case study for theory

An official website of the United States government

The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

• Publications
• Account settings

Preview improvements coming to the PMC website in October 2024. Learn More or Try it out now .

• Advanced Search
• Journal List
• BMC Med Res Methodol

The case study approach

Sarah crowe.

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

Kathrin Cresswell

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

Ann Robertson

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

Anthony Avery

Aziz sheikh.

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

Introduction

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

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

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

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

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

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

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

What is a case study?

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

Definitions of a case study

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

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

What are case studies used for?

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

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

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

How are case studies conducted?

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

Defining the case

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

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

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

Selecting the case(s)

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

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

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

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

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

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

Collecting the data

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

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

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

Analysing, interpreting and reporting case studies

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

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

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

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

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

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

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

Potential pitfalls and mitigating actions when undertaking case study research

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

Conclusions

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

Competing interests

The authors declare that they have no competing interests.

Authors' contributions

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

Pre-publication history

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

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

Acknowledgements

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

• Yin RK. Case study research, design and method. 4. London: Sage Publications Ltd.; 2009. [ Google Scholar ]
• Keen J, Packwood T. Qualitative research; case study evaluation. BMJ. 1995; 311 :444–446. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Sheikh A, Halani L, Bhopal R, Netuveli G, Partridge M, Car J. et al. Facilitating the Recruitment of Minority Ethnic People into Research: Qualitative Case Study of South Asians and Asthma. PLoS Med. 2009; 6 (10):1–11. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Pinnock H, Huby G, Powell A, Kielmann T, Price D, Williams S, The process of planning, development and implementation of a General Practitioner with a Special Interest service in Primary Care Organisations in England and Wales: a comparative prospective case study. Report for the National Co-ordinating Centre for NHS Service Delivery and Organisation R&D (NCCSDO) 2008. http://www.sdo.nihr.ac.uk/files/project/99-final-report.pdf
• Robertson A, Cresswell K, Takian A, Petrakaki D, Crowe S, Cornford T. et al. Prospective evaluation of the implementation and adoption of NHS Connecting for Health's national electronic health record in secondary care in England: interim findings. BMJ. 2010; 41 :c4564. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Pearson P, Steven A, Howe A, Sheikh A, Ashcroft D, Smith P. the Patient Safety Education Study Group. Learning about patient safety: organisational context and culture in the education of healthcare professionals. J Health Serv Res Policy. 2010; 15 :4–10. doi: 10.1258/jhsrp.2009.009052. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• van Harten WH, Casparie TF, Fisscher OA. The evaluation of the introduction of a quality management system: a process-oriented case study in a large rehabilitation hospital. Health Policy. 2002; 60 (1):17–37. doi: 10.1016/S0168-8510(01)00187-7. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Stake RE. The art of case study research. London: Sage Publications Ltd.; 1995. [ Google Scholar ]
• Sheikh A, Smeeth L, Ashcroft R. Randomised controlled trials in primary care: scope and application. Br J Gen Pract. 2002; 52 (482):746–51. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• King G, Keohane R, Verba S. Designing Social Inquiry. Princeton: Princeton University Press; 1996. [ Google Scholar ]
• Doolin B. Information technology as disciplinary technology: being critical in interpretative research on information systems. Journal of Information Technology. 1998; 13 :301–311. doi: 10.1057/jit.1998.8. [ CrossRef ] [ Google Scholar ]
• George AL, Bennett A. Case studies and theory development in the social sciences. Cambridge, MA: MIT Press; 2005. [ Google Scholar ]
• Eccles M. the Improved Clinical Effectiveness through Behavioural Research Group (ICEBeRG) Designing theoretically-informed implementation interventions. Implementation Science. 2006; 1 :1–8. doi: 10.1186/1748-5908-1-1. [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Netuveli G, Hurwitz B, Levy M, Fletcher M, Barnes G, Durham SR, Sheikh A. Ethnic variations in UK asthma frequency, morbidity, and health-service use: a systematic review and meta-analysis. Lancet. 2005; 365 (9456):312–7. [ PubMed ] [ Google Scholar ]
• Sheikh A, Panesar SS, Lasserson T, Netuveli G. Recruitment of ethnic minorities to asthma studies. Thorax. 2004; 59 (7):634. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Hellström I, Nolan M, Lundh U. 'We do things together': A case study of 'couplehood' in dementia. Dementia. 2005; 4 :7–22. doi: 10.1177/1471301205049188. [ CrossRef ] [ Google Scholar ]
• Som CV. Nothing seems to have changed, nothing seems to be changing and perhaps nothing will change in the NHS: doctors' response to clinical governance. International Journal of Public Sector Management. 2005; 18 :463–477. doi: 10.1108/09513550510608903. [ CrossRef ] [ Google Scholar ]
• Lincoln Y, Guba E. Naturalistic inquiry. Newbury Park: Sage Publications; 1985. [ Google Scholar ]
• Barbour RS. Checklists for improving rigour in qualitative research: a case of the tail wagging the dog? BMJ. 2001; 322 :1115–1117. doi: 10.1136/bmj.322.7294.1115. [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Mays N, Pope C. Qualitative research in health care: Assessing quality in qualitative research. BMJ. 2000; 320 :50–52. doi: 10.1136/bmj.320.7226.50. [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Mason J. Qualitative researching. London: Sage; 2002. [ Google Scholar ]
• Brazier A, Cooke K, Moravan V. Using Mixed Methods for Evaluating an Integrative Approach to Cancer Care: A Case Study. Integr Cancer Ther. 2008; 7 :5–17. doi: 10.1177/1534735407313395. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Miles MB, Huberman M. Qualitative data analysis: an expanded sourcebook. 2. CA: Sage Publications Inc.; 1994. [ Google Scholar ]
• Pope C, Ziebland S, Mays N. Analysing qualitative data. Qualitative research in health care. BMJ. 2000; 320 :114–116. doi: 10.1136/bmj.320.7227.114. [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Cresswell KM, Worth A, Sheikh A. Actor-Network Theory and its role in understanding the implementation of information technology developments in healthcare. BMC Med Inform Decis Mak. 2010; 10 (1):67. doi: 10.1186/1472-6947-10-67. [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Malterud K. Qualitative research: standards, challenges, and guidelines. Lancet. 2001; 358 :483–488. doi: 10.1016/S0140-6736(01)05627-6. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Yin R. Case study research: design and methods. 2. Thousand Oaks, CA: Sage Publishing; 1994. [ Google Scholar ]
• Yin R. Enhancing the quality of case studies in health services research. Health Serv Res. 1999; 34 :1209–1224. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Green J, Thorogood N. Qualitative methods for health research. 2. Los Angeles: Sage; 2009. [ Google Scholar ]
• Howcroft D, Trauth E. Handbook of Critical Information Systems Research, Theory and Application. Cheltenham, UK: Northampton, MA, USA: Edward Elgar; 2005. [ Google Scholar ]
• Blakie N. Approaches to Social Enquiry. Cambridge: Polity Press; 1993. [ Google Scholar ]
• Doolin B. Power and resistance in the implementation of a medical management information system. Info Systems J. 2004; 14 :343–362. doi: 10.1111/j.1365-2575.2004.00176.x. [ CrossRef ] [ Google Scholar ]
• Bloomfield BP, Best A. Management consultants: systems development, power and the translation of problems. Sociological Review. 1992; 40 :533–560. [ Google Scholar ]
• Shanks G, Parr A. Proceedings of the European Conference on Information Systems. Naples; 2003. Positivist, single case study research in information systems: A critical analysis. [ Google Scholar ]

• Privacy Policy

Home » Case Study – Methods, Examples and Guide

Case Study – Methods, Examples and Guide

Table of Contents

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

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

Types of Case Study

Types and Methods of Case Study are as follows:

Single-Case Study

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

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

Multiple-Case Study

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

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

Exploratory Case Study

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

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

Descriptive Case Study

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

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

Instrumental Case Study

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

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

Case Study Data Collection Methods

Here are some common data collection methods for case studies:

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

Observations

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

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

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

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

How to conduct Case Study Research

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

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

Examples of Case Study

Here are some examples of case study research:

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

Application of Case Study

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

Business and Management

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

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

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

Social Sciences

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

Law and Ethics

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

Purpose of Case Study

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

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

Case studies can also serve other purposes, including:

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

Advantages of Case Study Research

There are several advantages of case study research, including:

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

Limitations of Case Study Research

There are several limitations of case study research, including:

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

About the author

Muhammad Hassan

Researcher, Academic Writer, Web developer

You may also like

Questionnaire – Definition, Types, and Examples

Observational Research – Methods and Guide

Quantitative Research – Methods, Types and...

Qualitative Research Methods

Explanatory Research – Types, Methods, Guide

Survey Research – Types, Methods, Examples

Have a language expert improve your writing

Run a free plagiarism check in 10 minutes, automatically generate references for free.

• Knowledge Base
• Methodology
• 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.

Prevent plagiarism, run a free check.

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.

Cite this Scribbr article

If you want to cite this source, you can copy and paste the citation or click the ‘Cite this Scribbr article’ button to automatically add the citation to our free Reference Generator.

McCombes, S. (2023, January 30). Case Study | Definition, Examples & Methods. Scribbr. Retrieved 14 May 2024, from https://www.scribbr.co.uk/research-methods/case-studies/

Is this article helpful?

Shona McCombes

Other students also liked, correlational research | guide, design & examples, a quick guide to experimental design | 5 steps & examples, descriptive research design | definition, methods & examples.

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

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

Research question

• Conceptual framework
• Conceptual vs. theoretical framework

Data collection

• Qualitative research methods
• Focus groups
• Observational research

What is a case study?

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

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

Case studies

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

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

Definition of a case study

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

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

Characteristics of case studies

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

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

The role of case studies in research

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

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

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

What is the purpose of a case study?

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

Why use case studies in qualitative research?

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

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

The explanatory, exploratory, and descriptive roles of case studies

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

The impact of case studies on knowledge development

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

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

Types of case studies

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

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

Exploratory case studies

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

Descriptive case studies

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

Explanatory case studies

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

Intrinsic, instrumental, and collective case studies

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

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

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

Critical information systems research

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

Health research

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

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

Asthma research studies

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

Other fields

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

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

Whatever field you're in, ATLAS.ti puts your data to work for you

Download a free trial of ATLAS.ti to turn your data into insights.

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

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

Propositions

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

Units of analysis

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

Argumentation

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

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

Ready to jumpstart your research with ATLAS.ti?

Conceptualize your research project with our intuitive data analysis interface. Download a free trial today.

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

Defining the research question

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

Selecting and defining the case

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

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

Developing a detailed case study protocol

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

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

Collecting data

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

Analyzing and interpreting data

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

Writing the case study report

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

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

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

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

Observations

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

Documents and artifacts

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

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

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

Ensuring the quality of data collection

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

Data analysis

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

Organizing the data

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

Categorizing and coding the data

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

Identifying patterns and themes

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

Interpreting the data

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

Verification of the data

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

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

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

Benefits include the following:

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

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

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

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

Ready to analyze your data with ATLAS.ti?

See how our intuitive software can draw key insights from your data with a free trial today.

• Open access
• Published: 27 June 2011

The case study approach

• Sarah Crowe 1 ,
• Kathrin Cresswell 2 ,
• Ann Robertson 2 ,
• Guro Huby 3 ,
• Anthony Avery 1 &
• Aziz Sheikh 2  

BMC Medical Research Methodology volume  11 , Article number:  100 ( 2011 ) Cite this article

779k Accesses

1040 Citations

37 Altmetric

Metrics details

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

Peer Review reports

Introduction

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

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

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

What is a case study?

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

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

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

What are case studies used for?

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

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

How are case studies conducted?

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

Defining the case

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

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

Selecting the case(s)

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

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

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

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

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

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

Collecting the data

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

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

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

Analysing, interpreting and reporting case studies

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

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

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

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

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

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

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

Conclusions

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

Yin RK: Case study research, design and method. 2009, London: Sage Publications Ltd., 4

Google Scholar  

Keen J, Packwood T: Qualitative research; case study evaluation. BMJ. 1995, 311: 444-446.

Article   CAS   PubMed   PubMed Central   Google Scholar  

Sheikh A, Halani L, Bhopal R, Netuveli G, Partridge M, Car J, et al: Facilitating the Recruitment of Minority Ethnic People into Research: Qualitative Case Study of South Asians and Asthma. PLoS Med. 2009, 6 (10): 1-11.

Article   Google Scholar  

Pinnock H, Huby G, Powell A, Kielmann T, Price D, Williams S, et al: The process of planning, development and implementation of a General Practitioner with a Special Interest service in Primary Care Organisations in England and Wales: a comparative prospective case study. Report for the National Co-ordinating Centre for NHS Service Delivery and Organisation R&D (NCCSDO). 2008, [ http://www.sdo.nihr.ac.uk/files/project/99-final-report.pdf ]

Robertson A, Cresswell K, Takian A, Petrakaki D, Crowe S, Cornford T, et al: Prospective evaluation of the implementation and adoption of NHS Connecting for Health's national electronic health record in secondary care in England: interim findings. BMJ. 2010, 41: c4564-

Pearson P, Steven A, Howe A, Sheikh A, Ashcroft D, Smith P, the Patient Safety Education Study Group: Learning about patient safety: organisational context and culture in the education of healthcare professionals. J Health Serv Res Policy. 2010, 15: 4-10. 10.1258/jhsrp.2009.009052.

Article   PubMed   Google Scholar  

van Harten WH, Casparie TF, Fisscher OA: The evaluation of the introduction of a quality management system: a process-oriented case study in a large rehabilitation hospital. Health Policy. 2002, 60 (1): 17-37. 10.1016/S0168-8510(01)00187-7.

Stake RE: The art of case study research. 1995, London: Sage Publications Ltd.

Sheikh A, Smeeth L, Ashcroft R: Randomised controlled trials in primary care: scope and application. Br J Gen Pract. 2002, 52 (482): 746-51.

PubMed   PubMed Central   Google Scholar  

King G, Keohane R, Verba S: Designing Social Inquiry. 1996, Princeton: Princeton University Press

Doolin B: Information technology as disciplinary technology: being critical in interpretative research on information systems. Journal of Information Technology. 1998, 13: 301-311. 10.1057/jit.1998.8.

George AL, Bennett A: Case studies and theory development in the social sciences. 2005, Cambridge, MA: MIT Press

Eccles M, the Improved Clinical Effectiveness through Behavioural Research Group (ICEBeRG): Designing theoretically-informed implementation interventions. Implementation Science. 2006, 1: 1-8. 10.1186/1748-5908-1-1.

Article   PubMed Central   Google Scholar  

Netuveli G, Hurwitz B, Levy M, Fletcher M, Barnes G, Durham SR, Sheikh A: Ethnic variations in UK asthma frequency, morbidity, and health-service use: a systematic review and meta-analysis. Lancet. 2005, 365 (9456): 312-7.

Sheikh A, Panesar SS, Lasserson T, Netuveli G: Recruitment of ethnic minorities to asthma studies. Thorax. 2004, 59 (7): 634-

CAS   PubMed   PubMed Central   Google Scholar  

Hellström I, Nolan M, Lundh U: 'We do things together': A case study of 'couplehood' in dementia. Dementia. 2005, 4: 7-22. 10.1177/1471301205049188.

Som CV: Nothing seems to have changed, nothing seems to be changing and perhaps nothing will change in the NHS: doctors' response to clinical governance. International Journal of Public Sector Management. 2005, 18: 463-477. 10.1108/09513550510608903.

Lincoln Y, Guba E: Naturalistic inquiry. 1985, Newbury Park: Sage Publications

Barbour RS: Checklists for improving rigour in qualitative research: a case of the tail wagging the dog?. BMJ. 2001, 322: 1115-1117. 10.1136/bmj.322.7294.1115.

Mays N, Pope C: Qualitative research in health care: Assessing quality in qualitative research. BMJ. 2000, 320: 50-52. 10.1136/bmj.320.7226.50.

Mason J: Qualitative researching. 2002, London: Sage

Brazier A, Cooke K, Moravan V: Using Mixed Methods for Evaluating an Integrative Approach to Cancer Care: A Case Study. Integr Cancer Ther. 2008, 7: 5-17. 10.1177/1534735407313395.

Miles MB, Huberman M: Qualitative data analysis: an expanded sourcebook. 1994, CA: Sage Publications Inc., 2

Pope C, Ziebland S, Mays N: Analysing qualitative data. Qualitative research in health care. BMJ. 2000, 320: 114-116. 10.1136/bmj.320.7227.114.

Cresswell KM, Worth A, Sheikh A: Actor-Network Theory and its role in understanding the implementation of information technology developments in healthcare. BMC Med Inform Decis Mak. 2010, 10 (1): 67-10.1186/1472-6947-10-67.

Article   PubMed   PubMed Central   Google Scholar  

Malterud K: Qualitative research: standards, challenges, and guidelines. Lancet. 2001, 358: 483-488. 10.1016/S0140-6736(01)05627-6.

Article   CAS   PubMed   Google Scholar  

Yin R: Case study research: design and methods. 1994, Thousand Oaks, CA: Sage Publishing, 2

Yin R: Enhancing the quality of case studies in health services research. Health Serv Res. 1999, 34: 1209-1224.

Green J, Thorogood N: Qualitative methods for health research. 2009, Los Angeles: Sage, 2

Howcroft D, Trauth E: Handbook of Critical Information Systems Research, Theory and Application. 2005, Cheltenham, UK: Northampton, MA, USA: Edward Elgar

Book   Google Scholar  

Blakie N: Approaches to Social Enquiry. 1993, Cambridge: Polity Press

Doolin B: Power and resistance in the implementation of a medical management information system. Info Systems J. 2004, 14: 343-362. 10.1111/j.1365-2575.2004.00176.x.

Bloomfield BP, Best A: Management consultants: systems development, power and the translation of problems. Sociological Review. 1992, 40: 533-560.

Shanks G, Parr A: Positivist, single case study research in information systems: A critical analysis. Proceedings of the European Conference on Information Systems. 2003, Naples

Pre-publication history

The pre-publication history for this paper can be accessed here: http://www.biomedcentral.com/1471-2288/11/100/prepub

Download references

Acknowledgements

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

Author information

Authors and affiliations.

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

Sarah Crowe & Anthony Avery

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

Kathrin Cresswell, Ann Robertson & Aziz Sheikh

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

You can also search for this author in PubMed   Google Scholar

Corresponding author

Correspondence to Sarah Crowe .

Additional information

Competing interests.

The authors declare that they have no competing interests.

Authors' contributions

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

Rights and permissions

This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/2.0 ), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Reprints and permissions

About this article

Cite this article.

Crowe, S., Cresswell, K., Robertson, A. et al. The case study approach. BMC Med Res Methodol 11 , 100 (2011). https://doi.org/10.1186/1471-2288-11-100

Download citation

Received : 29 November 2010

Accepted : 27 June 2011

Published : 27 June 2011

DOI : https://doi.org/10.1186/1471-2288-11-100

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Case Study Approach
• Electronic Health Record System
• Case Study Design
• Case Study Site
• Case Study Report

BMC Medical Research Methodology

ISSN: 1471-2288

• General enquiries: [email protected]

• SUGGESTED TOPICS
• The Magazine
• Newsletters
• Managing Yourself
• Managing Teams
• Work-life Balance
• The Big Idea
• Data & Visuals
• Reading Lists
• Case Selections
• HBR Learning
• Topic Feeds
• Account Settings
• Email Preferences

What the Case Study Method Really Teaches

• Nitin Nohria

Seven meta-skills that stick even if the cases fade from memory.

It’s been 100 years since Harvard Business School began using the case study method. Beyond teaching specific subject matter, the case study method excels in instilling meta-skills in students. This article explains the importance of seven such skills: preparation, discernment, bias recognition, judgement, collaboration, curiosity, and self-confidence.

During my decade as dean of Harvard Business School, I spent hundreds of hours talking with our alumni. To enliven these conversations, I relied on a favorite question: “What was the most important thing you learned from your time in our MBA program?”

• Nitin Nohria is the George F. Baker Professor of Business Administration, Distinguished University Service Professor, and former dean of Harvard Business School.

Partner Center

A Real Case Application of Game Theoretical Concepts in a Complex Decision-Making Process: Case Study ERTMS

• Open access
• Published: 18 October 2021
• Volume 31 , pages 153–185, ( 2022 )

Cite this article

You have full access to this open access article

• Femke Bekius   ORCID: orcid.org/0000-0003-4357-7371 1 ,
• Sebastiaan Meijer 2 &
• Hugo Thomassen 3  

5619 Accesses

4 Citations

Explore all metrics

Engineering systems are complex, amongst others due to the interdependencies between actor and technical aspects. This complexity has consequences for the way of designing such systems and, in particular, for the decision-making process. Recognizing the impossibility of having an optimal system design in such complex systems, this article explores how a game theoretical characterization of a decision-making process assists in the organization and design of the process itself. In contrast to a game theoretical analysis, which results in optimal outcomes, the characterization is fed back to the designers of the decision-making process during the course of the process. The study analyses how the game concept characterization was used, i.e., which strategies were defined during the game theory interventions, and what the consequences of these strategies were for the design of the decision-making process. The design of a new safety system ERTMS for the Dutch railway sector is the context in which the study was performed. The contribution is a successful approach to complex decision-making in multi-actor systems by identification of multiple game concepts over time, with periodic feedback into the designing system, and not the actual decision-making itself. In short, it supported adapting to an actor focus on the process, it affected the role and responsibilities of the program management, it contributed to (de)coupling of issues, and it influenced the capability of creating awareness amongst actors of the urgency of the decision window. The paper ends with reflections on the experience of intervening in a decision-making process with game theoretical concepts.

Similar content being viewed by others

Exploring a Mixed Method Approach: Simulation Games and Q Methodology

A game-structuring approach applied to estuary management in south africa, a review and participatory extension of game structuring methods.

Avoid common mistakes on your manuscript.

1 Introduction

Large scale infrastructures in our society are associated with complex stakeholder constellations and equally complex technological challenges and interdependencies. It is well-known that an integrated management of both aspects is essential for the success of infrastructures and society at large.

Different perspectives on engineering systems exist, as they can be interpreted as a large technological system (Hughes 1987 ), as a Socio-Technical System (STS) (Trist and Bamforth 1951 ), as a System-of-Systems (SoS) (DeLaurentis 2005 ) or as a Complex Adaptive System (CAS) (Holland 1995 ; Miller and Page 2007 ).

Considering this evolution of system theories, we observe an increase in focus on the interactions between actor and technical aspects. According to a CAS perspective, systems consist of interdependent subsystems that need to be aligned to let the entire system function. The relations between subsystems are dynamic and evolving over time and, as a result, systems show emergent and chaotic behavior (Holland 1992 ). The increased understanding of the complexity of systems has consequences for the designing function. In traditional engineering design, one actor could decide on an optimal solution. Nowadays, multiple actors are involved, each responsible for their own subsystem with disjoint perspectives on optimality and incentives. This is embodied in the concept of Engineering Systems (De Weck et al. 2011 ).

To capture and address the uncertainties in decision-making processes, several types or levels of complexity have been proposed. System complexity is rooted in the engineering sciences (Hughes 1987 ) and actor complexity has its origins in the social sciences (Thissen and Walker 2013 ). This distinction provides insight into the different elements of the process, but the real complexity is represented by the interdependencies within and between complexity levels (De Bruijn and Herder 2009 ). According to De Bruijn and Ten Heuvelhof ( 2018 ), decision-making processes are complex due to three main characteristics: (i) unstructured problems: there are many technological uncertainties, problems and solutions; (ii) networks: multiple stakeholders with different incentives are interdependent; (iii) dynamics: context and environment continuously change. Therefore, we distinguish three levels of complexity: technical, actor and context complexity. Moreover, the theory on complex decision-making and multi-actor systems talks about games (Kickert et al. 1997 ; Scharpf 1997 ; Axelrod 1984 ).

Game concepts describe the behavior of and interaction between actors who have to make a decision. The concepts originate from different disciplines - ranging from formal game theory to public administration (Bekius et al. 2016 ; Rasmusen 2007 ). The game concept approach provides structure in the ill-structured decision-making process by making the game elements, such as actors, actions and strategies, precise and specify the type of game. Moreover, the game concepts allow for an analysis of different scenarios and possible outcomes which creates a perspective of action. Different from formal game theory the approach does not make the assumption of rationality explicit or specifies an optimal or right-versus-wrong outcome. Rather, the game concept approach focuses on incentive structures, responsibility and ownership of actors, i.e., actors’ agency, and dilemmas existing in the decision-making process (Bekius 2019 ).

In this paper, we explore how a game theoretical characterization of a decision-making process assists in the organization and design of the process itself. Describing decision-making situations in game theoretical terms is not new. This paper goes one step further: theoretical models are used to assist in the continuous design of a complex negotiation process. The exploratory nature of the paper allows us to assess the value of descriptive insights for a process without being prescriptive.

The objectives of this paper are (i) to apply game theoretical concepts in a real complex decision-making process, (ii) to give back the game theoretical characterization to the designers of the decision-making process and observe the impact on the process, and (iii) to provide lessons learned from the experience (intervening in a decision-making process with game theoretical concepts) for both researchers and practitioners. Our research question is: What are the effects of giving back a game theoretical characterization of a decision-making process to the designers of the process on the process itself?

The paper contributes to the theoretical framework on complex decision-making in multi-actor systems [among others De Bruijn et al. ( 2010 ); De Bruijn and Ten Heuvelhof ( 2018 ); Kickert et al. ( 1997 )]. We identify multiple game concepts, show how they interact and characterize the situation instead of finding an optimal outcome and defining the rules of the game. Moreover, we extend the framework by specifying particular game concepts instead of talking about the decision-making game in general terms.

Moreover, the paper contributes to the use of game theoretical models and formal models in general. It yields an example in which theoretical models are used to assist in a complex decision-making process. Opposed to the classical use of game theoretical concepts in a multi-actor setting which aims at an optimal outcome of a particular decision moment, the game theoretical characterization in this process describes a running process. Additionally, the characterization was given back to the designers of the process while the process was still going on. We explore the effects of periodic feedback to designers of the decision-making process on the process. In particular, we describe how the characterization is translated into strategies and present the consequences of these strategies for the design of the decision-making process.

The focus of this paper is to intervene in the design of the decision-making process without actively intervening in the behavior of actors. This is different from gaming simulation which is an active intervention in actor behavior and in which players are taken out of their usual context to play a game in a so-called safe environment. The use and effect of such interventions have been assessed in different studies (Bekebrede and Meijer 2009 ; Meijer 2012b ; Mayer et al. 2005 ; De Caluwé 1997 ), but an evaluation of the interventions in the design of decision-making processes is missing (Grogan and Meijer 2017 ).

Finally, we contribute to the decision support field by outlining lessons learned from the experience. In several interventions the game theoretical characterization is presented to and discussed with senior program managers. An analysis of the interventions provides insight into the consequences of giving back such information for the process of decision-making. Moreover, apart from a descriptive value at process level, the analysis resulted in learning points for us as researchers. The learning points are framed as points to consider when repeating this study in different organizations or domains to overcome the exploratory character of the current study.

1.1 Case Study: Railways

The European Rail Traffic Management System (ERTMS) is a European project to standardize control and improve safety of the railway system. The aim of the project is to “enhance cross-border interoperability and signaling procurement by creating a single Europe-wide standard for railways with the final aim of improving competitiveness of the rail sector” (Schuitemaker et al. 2018 ). For the Netherlands, it entails a major systems transition from an analogue to a digital system for the entire country. We will introduce the context of the case study using three complexity levels.

The technical complexity consists of the difficult content of the technical aspects and the multiple interdependencies that exist between theses technical aspects. For example, implementation strategies in the Netherlands have immediate consequences for the timing of replacing trains. There is uncertainty whether program goals regarding interoperability, capacity, speed, safety and reliability can be reached. The complexity of and interdependence between these goals makes it nearly impossible to translate them to technical specifications for all subsystems.

The complex multi-actor setting with many formal and informal rules, diffuse responsibilities towards the systems results in a complicated governance and is captured by the actor complexity . The actors (passenger and freight train operators, contractors, leasing companies, infrastructure manager, ministries, the Parliament, and European Union) have different incentives, are not hierarchically organized, but are mutually dependent and responsible for different parts of the system. The main actors, ProRail, NS, the Ministry of Infrastructure and Water management (I&W), and freight operators, have different perspectives on time lines.

The context complexity comprises different dynamics: other decisions made on the railway system such as storage of trains overnight are coupled to ERTMS decision-making, historical decisions which assume the implementation of ERTMS influence the current decision-making; political pressure from European Union requirements exists as well as decisions made by other European Union countries regarding ERTMS. Moreover, the technology is new and developing. Hence, the status of the technology today is not the status at the moment of implementation.

The complexities and interdependencies create an ill-structured, and sometimes messy, decision-making process with many uncertainties. The program management of ERTMS, responsible for the design of the decision-making process and advising on the decisions to be made, can impossibly oversee the entire process. There is thus a need to gain insight into the strategic behavior of actors, actors’ power and responsibilities and how both evolve in a dynamic environment. More understanding of the decision-making process and a perspective of action could help the program management in the design of the decision-making process. To address both points we propose the use of game theoretical concepts as further explored in this paper.

The paper is structured as follows: in Sect.  2 , we introduce the game concept approach and position the approach in the broader field of decision support methods. The methodology for this paper is outlined in Sect.  3 where we distinguish between a characterization of the decision-making process and returning the characterization into the designing system. In Sect.  4 , we present a timeline of events capturing the main elements of the decision-making process together with the game concept elements and interventions. The analysis of the four interventions is shown in Sect.  5 . Finally, we provide lessons learned from the series of interventions in Sect.  6 before we conclude the paper and discuss the results in Sect.  7 .

2 Game Concept Approach

In this paper, we use game concepts to characterize a complex decision-making process. Subsequently, the characterization is given to designers of the decision-making process in interventions to support the process. The game concept approach is introduced by presenting the theoretical framework in which the approach fits and positioning the approach in the broader field of decision support methods. Finally, we introduce the seven game concepts that are central in this paper.

2.1 Theoretical Framework

Complex decision-making in multi-actor systems is a broad field that has been studied by many researchers (among others De Bruijn et al. ( 2010 ); De Bruijn and Ten Heuvelhof ( 2018 ); Kickert et al. ( 1997 )). It goes beyond the scope of this paper to give a detailed overview of this literature. We have restricted ourselves to a couple of features that explain why decision-making processes in multi-actor systems are complex. They include: networks of multiple interdependent actors, wicked or unstructured problems, and a dynamic environment.

Actors perform strategies to deal with the complexity of a decision-making process. This can take place at (at least) two levels. First, at the level of individual actors and their strategies, for example, wait-and-see behavior or keeping-options-open. Second, at the process level actors develop strategies or interventions to deal with the unstructured process itself. For instance, share or hide information, or introduce new issues as an attempt to structure the process.

We consider the following three elements of the theoretical framework on complex decision-making in multi-actor systems to be relevant for the game concept approach: First, the decision-making process can be seen as a game. Actors perform strategic behavior and follow the rules of the game to reach an (optimal) outcome or consensus. Second, descriptive analysis of the decision-making process in terms of game elements takes into account the dynamics and context of the process. Third, the analysis of the decision-making process forms the basis for interventions in the behavior of actors.

In the remainder of this paper, we show how the game concept approach used in multiple interventions extends the theoretical framework by addressing the above mentioned elements.

2.2 Decision Support Methods

As the game concept approach is used to support decision-making processes, more precisely to support the design of the process, we present a selection of approaches and decision support methods applied in cases on large infrastructure systems. We show for each method how the game concept approach is different or complementary.

Many examples of formal applications of game theoretical models to support decision-making exist (Chen et al. 2012 ; Cantarelli et al. 2013 ; Hollander and Prashker 2006 ; Osman and Nikbakht 2014 ). Game theoretic modeling often simplifies the situation to one game and therefore explains only a small part of the process (Cohen 2015 ). In contrast, we identify multiple game concepts in a decision-making process and are interested in the interactions between identified game concepts to represent the dynamics of the process more accurately. Another feature of formal game theoretical modeling is that it usually aims at finding an optimal or stable outcome and thereby assumes the rationality of actors (Howard 1994 ). This assumption is quite strong, especially when we consider the fact that actors have different responsibilities and thus perceive an outcome differently. The game concept approach rather presents different scenarios and outcomes with potential risks. Moreover, game theoretical models are rarely presented to decision makers in their formal way (Camerer 1991 ). The game concept approach does not use the formal presentation of games which makes it suitable for use in interventions with decision makers.

Several design theory frameworks are available which aim to describe the design process of (engineering) systems (Reich 1995 ; Reich et al. 1996 ; Meijer et al. 2014 ). Such frameworks suggest that the components (e.g. product, actor, institution) need to be connected to or reflecting upon one another (Geels 2004 ; Hermans et al. 2013 ; Geyer and Davies 2000 ; Hardy et al. 2005 ). However, the problem with those methods, which is why they are less suitable for application to support decision-making, is that they either do not involve all components (Pluchinotta et al. 2019 ) or the framework is not fully operationalized. The game concept approach is applied to design processes to explain misalignments between different components in the process (Bekius and Meijer 2018 ).

Some well-known decision support models are Multi Criteria Decision Analysis (MCDA) (Ishizaka and Nemery 2013 ; Nikas et al. 2018 ), Cost-Benefit Analysis (CBA) (Flyvbjerg et al. 2008 ) and Analytical Hierarchy Process (AHP) (Ossadnik et al. 2016 ). The models compare different alternatives, or variants, based upon various evaluation criteria that can have different weights (Dodgson et al. 2009 ; Corsair et al. 2009 ). Group Decision Support Systems (GDSS) are specific Information and Communications Technology (ICT) applications for the support of group interaction and decision-making (Mayer and De Jong 2004 ; Eden 1992 ). De Vreede and Dickson ( 2000 ) use a Group Support System (GSS) to develop and evaluate a participatory design process. Their research approach to support the design of organizational processes relates to our study. However, the game concept approach particularly focuses on interactions between actors with selected game theoretical models. Moreover, we evaluate the use of the game concept approach in a running process compared to a complete redesign of a process. The context elements of a decision-making process, such as the impact of the political environment on the decision, are difficult to quantify and these elements are usually not covered by the decision-based models (Mayer et al. 2005 ). The game concept approach is able to reflect the political dimensions of a decision-making process by focusing on incentive structures of actors as shown in two case studies of the Dutch railway sector (Bekius et al. 2018 ).

Gaming simulations have been used in various studies to support decision-making on infrastructure systems (Mayer et al. 2004 ; Bekebrede and Meijer 2009 ), including the Dutch railway sector (Meijer 2012a , 2015 ; Lo et al. 2013 ). Which elements of the process to include in the game design is crucial for the success of a gaming simulation (Salen and Zimmerman 2004 ). The game concept approach helps in identifying the strategic games being played in the decision-making process in terms of actor constellation, its responsibilities and power relations and how the constellation evolves over time (Roungas et al. 2019 ). Gaming simulation is an active intervention in the behavior of actors. Participants are taken out of their usual context to participate in a game. The game concept approach targets a different type of participants and does not intervene directly in the decision-making process, but more indirectly in the design of the process.

Operational research is a discipline which has developed a plethora of methods and tools to support decision-making processes (De Gooyert 2016 ). Problem Structuring Methods (PSM) , and as subcategory Game Structuring Methods (GSM), are a collection of techniques to model a situation one want to change (Cunningham et al. 2014 ; Rouwette et al. 2009 ). Usually the model is applied by a group of people to structure a situation, to facilitate reaching consensus or to negotiate on what needs to change instead of making a decision (Mingers and Rosenhead 2001 ). Hermans and Thissen ( 2009 ) present an overview of actor analysis methods and their limitations and potentials by focusing on the trade-off between analytic quality and practical usability. Although features of the various stakeholder and actor analysis methods overlap with the game concept approach there are three important characteristics that distinguish them: (i) game concepts focus on the behavior of actors and interactions between them, including actor’s agency, i.e., responsibility and ownership of the system resulting in power relations; (ii) game concepts characterize the process of decision-making and thereby include the dynamics; and (iii) game concepts are developed in such a way that they can be used by decision makers themselves and eventually create a ‘perspective of action’ in the form of strategies.

So far, we introduced the theoretical framework in which we position the game concept approach and showed how the game concept approach relates to other methods investigating and supporting decision-making processes. In short, the game concept approach adds a structured way to address the constellation of actors including their responsibilities and power relations and the dynamics. Moreover, the approach is not only theoretical, but can be used with and by decision makers as we will show later in the paper. Next, we introduce the selection of game concepts which are central in this paper.

2.3 Game Concepts

In this paper, we use seven different game concepts to characterize a complex decision-making process. The selection of game concepts is based on characteristics of complex decision-making processes such as multiple actors forming a network of interdependencies and where reaching a collective decision is the aim of the process. A taxonomy of game concepts is provided in an earlier paper, and we refer to Bekius ( 2019 ) and Bekius and Meijer ( 2020 ) for a detailed explanation of the selection criteria. The game concepts are illustrated by an example and defined in terms of the context in which they appear, the process they characterize, their possible results, and potential risks in Table  1 .

The Multi-Issue game (M-I game) characterizes a situation with multiple actors having different incentives aim to reach consensus in a decision-making process that was in a deadlock in the first place (Winter 1997 ; De Bruijn and Ten Heuvelhof 2018 ; De Bruijn and Ten Heuvelhof 2002 ; Sebenius 1983 ).

Imagine you are part of a family (father, mother and three children) and the father sees the opportunity to have a summer holiday together. He decides on a destination and period in summer, but not everyone likes his idea. The family members have different preferences regarding the summer holiday issue and the situation gets stuck in a deadlock. How could the father resolve it? An option is to take control over the agenda and introduce new issues that matter to the family members, such as a skiing holiday during winter or having a pet. The new agenda creates a broadened solution space which enables the forming of coalitions within the family, the exchanging of issues, and the creation of a give-and-take game. As a result, the deadlock could be resolved and the family members could reach consensus on the larger set of issues. A serious risk is that too many issues are added to the agenda such that the game becomes over-complex.

The Principal-Agent game (P-A game) represents a hierarchical relation between a principal and an agent. The principal is dependent on the agent because of its knowledge and expertise regarding a certain decision. The game explains the power position of the subordinate, i.e., the agent (Stauvermann 2004 ; Gintis 2000 ; Braun and Guston 2003 ; Laffont and Martimort 2002 ; Cantarelli et al. 2013 ; Dodgson et al. 2009 ; Cole et al. 2014 ).

Suppose you are an employee in a company and your boss asks you to deliver a report before the deadline on the feasibility of a certain technique for measuring the well-being of elderly people (Roungas et al. 2019 ). Apart from the content of the report, you know it is important for the company to be able to report good results in order to be chosen by the regional government for implementing the technique. As employee, you are the agent in a principal-agent relation with your boss, i.e., the principal. The relation is asymmetrical since your boss puts pressure on the deadline and the content of the report, i.e., the principal has more power. On the other hand, you have more information and know the details of the technique. The information is the agent’s power to argue with or convince the principal.

The Cascade Game (CG) shows the tendency of intelligent actors, in case of uncertainties, to follow the decisions of others independently of the quality of the content of the decisions (Bikhchandani et al. 1992 ; Easley and Kleinberg 2010 ; Anderson and Holt 1996 ; Conradie et al. 2015 ).

Imagine you are in a new place and you want to make a roundtrip. Based on your own research you intent to go for operator A. However, when you arrive at the departure point you notice that it is completely empty, and operator B has a line of people waiting for tickets. At this point, it would make sense to have your private information, decide for operator A, to be outweighed by the public information you infer from others’ decision for operator B. The decision has an either-or character, it is either A or B, players make the decision sequentially, and each player can observe the choices made by those who acted earlier. The Cascade game makes clear that players tend to follow others and this creates a cascade-effect. It has an important implication: the actors who made their choice first have an impact on the following actors.

The Hub-Spoke game (H-S game) describes a situation with multiple actors (spokes) having different incentives who are steered by one actor (hub) via command-and-control. The game creates an incentive for inflated claims, the spokes can reach agreements among each other and create strategic issues for the hub (Elrod and Fortenberry 2017 ; Adler 2005 ; Adler and Smilowitz 2007 ; Adler et al. 2010 ; Takebayashi 2015 ; Markusen 1996 ; De Bruijn et al. 2010 ).

Suppose there is a company, called the hub, which wants to found a business unit in a certain area. To succeed it needs to deal with several parties, called the spokes, for example local companies and municipalities. The hub initiates the plan and starts negotiating with the spokes. The negotiations follow a plan and it can enact several strategies. The hub can make agreements with each spoke separately and propose a unique deal to each. Alternatively, it can propose the same deal to each of the spokes. A local company can try to block the plan of the hub by performing a wait-and-see strategy or exchanging information with other spokes. The communication between spokes can create strategic issues for the hub.

The Volunteers Dilemma (VD) explains why one or more actors take the responsibility for the group to prevent a worst-case scenario from happening. Performing wait-and-see behavior is beneficial, but increases the risk of a bad outcome of the decision-making process (Archetti 2009 ; Goeree and Holt 2000 ; Diekmann 1985 ).

Imagine a situation in which you live in a flat and suddenly the electricity fails. There are many people in your flat, but no one calls an electrician. Performing wait-and-see behavior, not calling the electrician, is beneficial, since it requires no effort and thus no cost. Moreover, there are so many others, why would you be the volunteer? No volunteer acting increases the time of being without electricity. A very bad outcome no one wants. The longer this dilemma, calling or not calling, is present, the higher the risk, and thus the more pressure exists for a volunteer to take action.

The Diners Dilemma (DD) represents a situation in which multiple actors come to an agreement about the process of decision-making, e.g. collaboration and mutual interaction. Due to the agreements made it becomes attractive to be the first one to violate the agreements (Teng et al. 2013 ; Gneezy et al. 2004 ; O’Donovan et al. 2013 ; De Bruijn and Ten Heuvelhof 2018 ).

Suppose you decide to have dinner with a group of people in a restaurant. You agree in advance that the costs of the dinner will be divided equally among the participants. Upon arrival, there appear to be two options: there is a cheap menu and an expensive menu. The participants come to an additional agreement to order the cheap menu. However, there is an incentive to be the first one to violate the collective agreement and order the expensive menu. The profit for this person is high, and there are limited additional costs for the other group members. However, the other group members seeing the bill will understand that the agreement has been violated. It becomes attractive for others to join the first mover and, in the end, the agreement will erode.

The Battle of the Sexes (BS) describes a case in which two actors are completely dependent upon each other. Moreover, they share the same goal, but have different incentives. In order to reach a decision one of the two actors needs to adopt the others’ idea (Shoham and Leyton-Brown 2008 ; Van Benthem 2014 ; Easley and Kleinberg 2010 ; Vollmer 2013 ; Goeree and Holt 1999 ; Camerer 1997 ; Binmore 2007 ; Rasmusen 2007 ).

A man and a woman share the same goal of going out together, but prefer a different destination. The woman prefers a baseball match and the man prefers the opera. The different preferences result in different strategies and create a ‘battle’. To reach a decision and achieve the shared goal they need to anticipate each other’s strategy. One of the two actors needs to adopt the other’s viewpoint and go to the baseball game instead of the opera or the other way around. However, given the complete dependency of actors and the fact that no one can overrule the other by using power or information this is unlikely to happen. The battle will thus continue, probably delay the process, and eventually one of the actors will be the winner and the other the loser, which results in sub-optimal decision-making.

3 Methodology

Action research was the research approach employed in this study. It aligned with the general definition that says “research leading to action” (Lewin 1946 ) and was intended to have a dual outcome of action (in the design of the decision-making process) and research (exploring how the game concept approach was used) (Argyris and Schön 1989 ). The game theoretical characterization of the decision-making process came about as an interplay between researchers and participants in interventions. In the interventions, the participants used the game concept characterization to reflect on the situation and formulated strategies. Moreover, we assessed the uptake from the formulated strategies for the design of the decision-making process.

In this study, we performed an iterative process from data collection to data structuring, data analysis and data validation through various methods such as participatory interventions, interviews and reconciliation meetings.

Important to mention is the dichotomy in this research between (i) characterizing the decision-making process using game concepts, and (ii) giving back the characterization to designers of the decision-making process. The latter always happened during the interventions and, apart from intervention 1, by the researcher. The first point, however, was sometimes performed by researchers beforehand, other times by participants during interventions, and at times by both researchers and participants. In Table  3 , we specified the role of researchers and participants during the interventions.

3.1 Data Collection

In this study, we collected different types of data. The reason why the data was collected varied.

Creation of an overview of decision-making process to understand the context, the actors involved and the issues present.

Identification of game concepts to characterize the decision-making process.

Presentation and discussion of game concepts with and by participants to come to strategies .

Estimate the uptake of defined strategies and its consequences for the design of the decision-making process.

Validation of results, in particular, validation of the overview and identification.

Table  2 lists the types of data collected and the above mentioned purposes. The order of the table does not correspond to the order in which data was collected. Since the interventions were an important part of this research we specify the details of the interventions in Table  3 .

3.2 Data Structuring, Analysis and Validation

To explain how we structured and analyzed the data we use the different purposes of data collection.

An overview of the decision-making process was created by a timeline of events. The timeline contained the important decision moments, the actors and their incentives, and the issues present. Both researchers and program managers contributed to the timeline. Program managers did this during intervention 2 and intervention 3. Researchers provided a timeline, based on documentation, interviews, memos of meetings and recordings of interventions, before interventions 3 and 4 and adapted these afterwards. The interventions together with the validation sessions served to check the details of the process overview.

Identification of game concepts was performed by both program managers and researchers. In intervention 1 program members identified the game concepts using a game concept identification tool (Bekius 2019 ). The tool consists of characteristics of the game concepts. These characteristics were translated to questions regarding the process of decision-making. By answering a sequence of questions the tool presented one or more game concepts. In intervention 3, the game concepts were identified using the descriptions of the game concepts (see Sect.  2 ). In interventions 2, 3 and 4, researchers identified the game concepts before the intervention based on data collected in interviews, meetings, and from documentation. Hence, those interventions were also a validation session for the game concept identification performed by the researchers. Moreover, during these interventions the identified game concepts were connected to the events on the timeline.

Formulation of strategies took place during the interventions. After the game concept characterization was presented to the participants, they discussed its meaning for the process of decision-making. The participants thought of ways to steer the game(s) identified and prevent the potential worst case scenarios from happening. More precisely, they defined strategies to (re)design the decision-making process. Researchers made notes during the interventions or coded the transcripts of the discussion afterwards.

Assessing the uptake from strategies formulated during the interventions happened both directly and indirectly. During validation sessions and meetings with program members we asked them which strategies were implemented and how they worked out. The program members formulated the strategies during the interventions and were able to assess to which extent these actions steered, changed, or contributed to the design of the decision-making process. Additionally, we questioned the consequences of strategies in an indirect way by interviewing different actors involved in the decision-making process. Questions during interviews concerned the quality of the decision-making process, the preparation of the decision weeks, the essential moments in the process, information and time available, and collaboration with other actors. Moreover, we followed the development of the process of decision-making using documentation and reconsolidation meetings with program members. In intervention 4, we described potential future game concept dynamics and interactions based on the previous collected information. Afterwards, we evaluated whether the dynamics and interactions of game concepts happened as expected by interviewing different program members. The interview questions concerned elements of the game concepts, and for each of these elements we questioned which strategies were performed to deal with that situation or what context prevented this situation from happening.

The methodology explained so far described how we accomplished the iterative process of collecting, analyzing, structuring and validating data. It showed how we applied game theoretical concepts in a real complex decision-making process, and returned the game theoretical characterization to the designers of the decision-making process and observed the impact on the process. The third objective, to provide lessons learned from the experience (interventions), is based on a reflection of the researchers and practitioners on the process afterwards.

4 Case Study ERTMS and Game Concepts

The case description considers a specific part of the decision-making process regarding the roll-out of ERTMS starting from the beginning of 2018, when preparations for a first decision week started, until mid-2019, when the Parliament decided on the implementation of ERTMS. This section gives an overview of the important moments in the decision-making process and highlights the elements and strategies of the game concepts present. Figure  1 provides an overview of the game concepts present throughout the decision-making process. Details about the role of the actors and strategies played in the game can be found in the text description.

Game concepts present throughout the decision-making process

Beginning 2018: Letter from freight operators to the Parliament The roll-out of ERTMS needed a timely and technically coordinated refurbishment of trains and infrastructure. Freight operators sent (separate) letters to the Parliament (a principal in the Principal-Agent game) about their worries regarding the process of introducing ERTMS. For the freight operators it was unclear which costs they needed to cover and no agreements were made regarding this issue. The need for investment in new trains by freight operators created a deadlock in the decision-making process (Multi-Issue game). Moreover, contractors wanted to confirm their position. As a result, freight and regional passenger operators started participating in the steering group of ERTMS which brought new perspectives to the decision table. New actors were introduced in the Multi-Issue game.

April 2018: Decision to start preparation phase of program ERTMS The first decision week concerned the approval of the ERTMS dossier for starting a BIT (Bureau ICT-Toetsing) test. Footnote 1 In preparation of this week, the actors of the steering group made process agreements which included finalizing the ERTMS dossier and investigating, and solving, a list of issues. The process agreements were an element of a Diners Dilemma. Final decisions regarding the list of issues needed to be made before summer 2018. The focus of the process so far had been mainly on content issues and new issues arose constantly because of the complexity of the system transition and the many uncertainties present. Content and context issues were on the agenda of the Multi-Issue game. The focus on content issues explained the over-complexity of the decision-making process. Moreover, technical uncertainties influenced the hierarchical relation between the Ministry (principal) and the railway sector: ProRail as infrastructure provider, NS as main operator, regional and freight operators (agents) in a Principal-Agent game.

Mid-May 2018: Intervention 1 “Workshop session Patterns in decision-making processes” Members of the central program management organization ERTMS (in Dutch: programmadirectie ERTMS) identified game concepts for the current stage of the decision-making process and discussed their different views. Moreover, they discussed a possible design of the decision-making process.

Beginning June 2018: Intervention 2 “Follow-up workshop session” Building on Intervention 1, a timeline of events, including actors involved, their incentives, and the main issues was constructed. The participants recognized a Multi-Issue game and discussed its potential effects on the process of decision-making.

End June 2018: Final preparations of the first decision week At this point in time, two main issues were present. The first issue concerned a discussion between the Ministry and freight operators about the Masterplan freight transport. Exchange of issues, such as track access charges and noise pollution, took place in return for freight operators being committed to ERTMS. It influenced their position in the decision-making process. The exchange of issues to broaden the solution space was a Multi-Issue game strategy performed by the Ministry. Moreover, agreements between freight operators and the Ministry in the Masterplan were an element of a Diners Dilemma. The second issue reflected the following situation: there was asymmetry of information between the Ministry (principal) and the ProRail (agent). The Ministry did not have sufficient railway knowledge to fully steer the technical part of the program. Given its knowledge and position, ProRail was the best candidate to take a larger responsibility in the governance of the ERTMS program by being responsible for the program management. Moreover, the principal assigned to the agent the role of referee in conflict situations and distributed its power to close information gaps. This was a Principal-Agent strategy and concerned the positioning of ProRail, and especially the program management, as hub in a Hub-Spoke game. Therefore, one of the main questions to be answered in the decision week was: do the other main actors agree with the steering of the program ERTMS by ProRail?

The decision week was prepared in a very short time, resulting in limited time for reflections on the decisions to be made and late communication of information. This affected the pressure on and quality of the decisions to be made. The program management and the Ministry put pressure on deadlines, heading for a freeze of the dossier for the BIT test. Its aim was to decide on the list of issues prepared and finally decide on starting the BIT test after summer 2018. Pressure to start the BIT test was forced by European Union agreements. The pressure from the European Union (principal) was part of another Principal-Agent game in which the Parliament, and indirectly the Ministry, was one of the agents.

9-13 July 2018: The first decision week The main goal of the first decision week was to decide on the readiness of the ERTMS dossier to start the BIT test. The decision week was set-up as a ‘cascade’ of decisions which needed to be made by the different layers of the organizations. First, the different organizations discussed the decisions internally within their own organization. Then, the actors met at the Director meeting (in Dutch: Directeuren Overleg (DO)) and discussed the list of decisions again. Subsequently, the DO-meetings provided input for the Board of Directors (in Dutch: Raad van Bestuur (RvB)) before the final decisions were made by the ERTMS steering committee at the end of the week. The decision week was organized as a Cascade game and as an effect the entire process before and after the decision week converged to and built on a Cascade game structure. The decisions needed to be adopted by the various predefined decision levels involving representatives of different organizations.

Decisions present in the decision week were connected to one another which is an element of a Multi-Issue game. For example, the issue concerning one or two system suppliers for implementing ERTMS was connected to the number of corridors which could be equipped with ERTMS given the available budget. Moreover, investing in a test corridor affected the number of corridors that could be included in the roll-out strategy. Starting the roll-out with corridor Kijfhoek-Roosendaal would give freight operators the burden of dealing with first-time issues. However, connecting this decision to the decision of assuring a test corridor resolved the issue. For the ATB-NG issue (an old safety system that needs to be replaced before ERTMS is implemented) no solution was found yet. ProRail as infrastructure provider wanted to introduce ERTMS immediately. However, this raised several new issues, contributing to the over-complexity of the process (Multi-Issue game), concerning the roll-out strategy that was decided upon and the need for investments in new trains earlier than expected.

Everyone was committed to provide clarity to the steering committee at the end of the week and postponing decisions until after summer was not challenged. The commitment showed that an agreement on the list of decisions and the shared goal to start the BIT test after summer was made (Diners Dilemma). Moreover, the Cascade game was not blocked by any actor at this point. After the decision week, the starting point for the introduction of ERTMS was clear, but certainly not everything was set. For instance, there were still no (formal) agreements with freight operators about the exact costs and the train specifications. Moreover, many issues remained and new issues were expected, therefore no consensus was reached in the Multi-Issue game.

End July 2018: Intervention 3 “Construct timeline of game concepts” The earlier constructed timeline was adapted and a game concept characterization was added to the timeline based on the dynamics of the first decision week.

Summer 2018: Completion of tasks after the first decision week Although freight operators agreed during the decision week on the list of decisions, afterwards they claimed that they needed more time and they actually disagreed with some decisions made. The freight operators, leasing companies, and contractors had different perspectives and were thus split-up. Additionally, ProRail, NS, and the Ministry sent letters to the program management with additional wishes and issues. The objections of actors after the decision week, due to the fact that time was limited and information was late, could be seen as a sub-optimal results of the Cascade game.

Some actors organized themselves and consulted political parties to influence the political level. This is an example of actors who were ‘freeriding’ (Diners Dilemma). It was in the freight operators’ interest to delay the process since investments in the future were necessary anyway. NS did not have an incentive to delay the process, but they wanted to have sufficient time to prepare the operation before introducing ERTMS and they wished to maintain their autonomy. This situation could eventually result in actors violating the agreements made (Diners Dilemma) and blocking the Cascade game or at least delaying the process. The program management was positioned as independent actor (the hub), i.e., separate from the organization ProRail itself (one of the spokes). Its role was to challenge project plans from different actors and departments (other spokes). The spokes in the Hub-Spoke game were not aligned, moreover, the exact responsibilities of the hub were not fully clear and if they were clear they were not fully accepted by the spokes. The result was that spokes created strategic issues easily which delayed the process and created chaos (Hub-Spoke strategy).

The period after the decision week and before the start of the BIT test appeared to be too short to address all remaining aspects of the decision week. NS was worried about aspects concerning the planning of infrastructure and the readiness of the test corridor. Both situations could lead to a blockade of the Cascade game.

October 2018: The BIT test officially started.

January 2019: Results BIT test The advice from the BIT test arrived and its main point concerned the position of the program management in the process of decision-making. The program should conduct a system engineering approach and provide guidance on technical content towards the main actors. The advice suggested to use additional methods for managing this program. It said to change the role of the hub (program management) to a more strict and controlling role that did not leave room for conflicts and issues between spokes to occur (following a client-contractor model), this was a Hub-Spoke game strategy.

An example of such a conflict was the technological issue of where to build an antenna: on the train (preferred by ProRail) or into the infrastructure (preferred by NS). Both actors shared a common goal of introducing ERMTS in a feasible and good way, however, on this issue their preferences were in conflict. Since no one could overrule the other actor with power or information and no compromise was possible the conflict appeared (Battle of the Sexes). The fact that institutional uncertainty existed, i.e., no one could decide on the issue alone, this resulted in a delay of the process and affected the (trust) relations between actors. A solution (Battle of the Sexes strategy) was to involve a referee, in this case the hub (program management), who decided upon the issue and resolved the conflict.

February 2019: Intervention 4 “Potential future game concepts” A timeline including the period until mid-2019 was presented to participants based on the previous constructed timelines (including events, actors and issues) and a game concept characterization of the process. The timeline also described potential future activation of and interaction between game concepts. Participants validated the timeline and discussed how to deal with the game concept dynamics in the process of decision-making.

March/April 2019: Towards the second decision week In preparation of the second decision week, the program management organized several meetings with directors to make sure that urgent issues were covered. The main issues were the delayed tendering process concerning the infrastructure, the connection of the budget of the high speed line (HSL) and ERTMS, and the fact that freight train operators searched for support from the political level.

Moreover, technical briefings with the Ministry were held to discuss the details of the dossier ERTMS and the role of freight train operators in the process. This was a Principal-Agent strategy to minimize information asymmetry between the Ministry (principal) and the program management (agent).

April 2019: The second decision week The goal of the second decision week was to decide whether the ERTMS program could move from the planning phase to the realization phase. Hence, the decision to be made was: Is the ERTMS dossier ready for the decision by the Council of Ministers in May 2019? Depending on their decision, the decision would be reconsidered by the Parliament. If the Parliament’s decision was positive, the tender process for new rolling stock and infrastructure could start, but only after an independent review approved that the recommendations of the BIT test were adequately implemented, as the Ministry promised to the Parliament. A third Principal-Agent game, the Parliament being the principal and the Ministry being the agent, was present.

During the second decision week the remainder of the decisions from the previous decision week and final points for finalizing the dossier were discussed. The decision week was organized similar to the first decision week starting with decision-making at the DO-level, then decision-making at the RvB level, and finally the steering committee ERTMS decided. Again a Cascade game was present since decisions needed to be adopted by the various predefined decision levels.

May 2019: Council of Ministers decision The Ministry of Infrastructure and Water management decided positively on the start of the implementation of ERTMS on 17th of May 2019.

June 2019: Parliament decision Despite the large budget allocated by the Parliament for implementation of ERTMS, the number of motions was relatively low and the decision of the Council of Ministers was adopted. Hereby, the principal in the second Principal-Agent game, i.e., the Parliament, finalized the cascade of decisions. During the process information asymmetry was minimized by the Ministry (agent) providing access to documentation, technical briefings, and progress reports (a Principal-Agent strategy). As a result, the principal and the agent shared the same incentives which meant that pressure for a certain outcome from the principal was not necessary.

5 Analysis of Interventions With Game Concepts

The previous section presented an overview of the ERTMS decision-making process and highlighted the elements of and strategies performed by actors in terms of game concepts. This section analyses the four intervention moments in which the game concept characterization was given back to designers of the decision-making process, i.e., program management ERTMS. For each intervention, we describe the main observation points by the participants of the intervention and explicate the strategies they formulated during the intervention. Subsequently, we present the consequences of those strategies for the design of the decision-making process. Notice that this section discusses game concept strategies at another level compared to the previous section. Where Sect.  4 characterized game concept strategies performed by actors in the decision-making process, in Sect.  5 , we discuss the game concept strategies (to be) performed by participants of the interventions as a result of the intervention.

5.1 Intervention 1: Workshop “Patterns in Decision-Making Processes”

Short summary: Participants identified the game concepts individually using a game concept identification tool (Bekius 2019 ). They discussed their view on which game concepts were present and reached consensus on two game concepts: the Multi-Issue game and the Cascade game. Additionally, they discussed potential next steps in the process of decision-making given the game concept context.

5.1.1 Observations and Strategies

Actors involved in the decision-making process brought up new content issues continuously, but most new issues were not that much relevant with respect to the overall program goals. There was a risk of creating an over-complex process (Multi-Issue game). The over-complexity could have resulted in no decision being made in the first decision week. Extension of the decision was an undesirable outcome and seen as a worst case scenario due to the planned external BIT-audit. It was unlikely that after all the engineering work new insights would occur. Strategy (1): Change the focus of the process, from content to actors, their incentives, and the process of decision-making.

The incentives of the different actors were not always clear, or at least not made transparent. Some actors could have retained the decision. This was something to pay attention to and affirmed that trust between actors played an important role. Strategy (2): Create an overview of actors’ preferences towards the issues of the Multi-Issue game. Focus on strengthening the trust relation with actors who can block the decision.

The aim of the decision-making process, consensus among actors (Multi-Issue game outcome) or sufficient actors on board regarding the weight of the program goals and design of solutions, changed over time due to politics. Strategy (3): Aim for sufficient support of actors, i.e., their agreement with the main or sufficient decisions, and particularly focus on the interests of potential blocking actors. More specifically, give actors the opportunity to put their final points on paper and discuss them in the steering group.

The process was not about one decision, but a sequence of decisions to be made in the coming years (Cascade game). The program management was part of a much larger game playing at different decision levels. Strategy (4): Create an overview for actors of those decision levels (Cascade game) and how the sequence of decisions evolves over time.

5.1.2 Consequences for the Design of the Decision-Making Process

Strategy (1) led to a focus on actors and the larger context in the process of decision-making. Together with strategies (2), (3) and (4) this resulted in the following: incentives of actors involved in the process were planned to be made explicit in the program plan, the next decision week as extension to make decisions was framed as no option, the number of issues was limited with support of actors, and the program specified a decision-making process as a sequence of decisions rather than as one decision.

In general, awareness of the Multi-Issue game and Cascade game, and how to use them explicitly in the decision-making process, increased. Based on these insights there was a need to further develop and investigate the game concepts identified. This was the motivation for a follow-up session on how to approach and organize the first decision week based on the Cascade game and the Multi-Issue game.

5.2 Intervention 2: Follow up “Patterns in Decision-Making Processes”

Short summary: Participants created a timeline of important events in the decision-making process. Attached to the events we specified the actors involved, their incentives and the main issues present. The discussion then focused on the Multi-Issue game and the Cascade game: How could the program management steer these games and thereby manage the process of decision-making, in particular, towards the first decision week?

5.2.1 Observations and Strategies

The program management had to manage the Multi-Issue game and the Cascade game to reach the desired outcome. Two risks were observed: i) an over-complex Multi-Issue game (more and more issues on the table) and ii) a Cascade game blocked by one or more actors.

There were two main issues: Masterplan freight train operators and the governance of the program ERTMS. Moreover, these two issues influenced decisions on other issues in the Multi-Issues game. In the decision week, decision makers needed to decide over the totality of issues. Strategy (1): Create an overview of the totality of issues and collect actors’ opinions on these issues.

The desired outcome of the process was a decision supported by the actors involved, i.e., consensus reached in the Multi-Issue game. An undesired outcome was no decision since this would delay the process. Strategy (2): Focus on actors who can potentially block the Multi-Issue game. Which issues can be added to the agenda to stimulate exchange of issues?

5.2.2 Consequences for the Design of the Decision-Making Process

Strategy (1) led to a collection of opinions (in favor, neutral, or against) of the actors regarding the issues (decisions) planned for the decision week. It resulted in a categorization of the decisions: decisions that were not ready and would be postponed to a later stage, decisions not objected to by any actor, content decisions with objections from at least one actor, financial decisions, and decisions regarding the roll out of ERTMS in the Netherlands. The categorization provided the basis for the agenda, i.e., the sequence of topics and issues, of the decision week. Apart from collecting opinions on single decisions, the program management questioned the dependencies between the two main issues and preferences for the other decisions. This provided an idea on how potential blocking actors could be kept in the game to support the total set of issues (strategy 2).

The program management used the information to decide on the order of decisions on the agenda and balance decisions that would take short time (since everyone agreed) with decisions that would need more time for discussion (since actors had opposing opinions). This process steered the way in which the cascade of decisions in the decision week was structured (Cascade game) while taking into account the multiple issues that played a role in the context (Multi-Issue game).

Actors involved in the decision-making process were informed about the agenda and the structure of the decision week by the program management before the decision week started. This helped in giving the program management a neutral position (as hub in the Hub-Spoke game) during the decision week in which the actors involved should come to an agreement. The position of the program management as such contributed to the level of trust between actors. It had been reported that the decision week was structured and well prepared, the right issues were discussed and there was room for all actors to present their opinions. Moreover, actors involved in the decision week reported a high level of trust.

5.3 Intervention 3: Analysis of Game Concepts Over Time

Short summary: Participants adapted and extended the timeline of events from Intervention 2 with future events, actors and issues. They were able to identify and describe the game concepts themselves in the process of decision-making. The intervention included the total set of game concepts instead of only focusing on the Multi-Issue and Cascade game. Moreover, the scope was broader since it considered future decisions until the year 2025 and its potential dynamics.

5.3.1 Observations and Strategies

The position and coordination role of the program management was crucial for the continuation of the process. There was an increased focus by the Ministry to strengthen the position of the program direction ERTMS in legal terms. Strategy (1): The Ministry positioned the program management as hub in the Hub-Spoke game and agent in the Principal-Agent game.

One could not change decisions at a later stage without risking a lot of budget to be spend. This is called the convergence of decisions in the Cascade game. Strategy (2): Create awareness of this aspect to prevent sub-optimal outcomes of the Cascade game.

Actors violating agreements (Diners Dilemma) or creating deadlocks (Multi-Issue game) would delay the process. Strategy (3): The Ministry connected ERTMS issues to context issues, i.e., they created a support package for freight train companies (Maatregelenpakket) and thereby broadened the agenda of the Multi-Issue game. Strategy (4): Moreover, the Ministry wanted to stimulate cooperation between operators to prevent violation of agreements in the Diners Dilemma.

5.3.2 Consequences for the Design of the Decision-Making Process

Positioning the program management as a hub (strategy 1) aimed at minimizing information asymmetry and confusion about incentives. The program management functioned as an intermediate actor between the other actors and the Ministry. As a result, the Ministry did not need to be involved in all technical discussions. Moreover, in case of conflicts between actors (the spokes) about system integration aspects, the program management (hub) had the power to decide in favor of one actor and provided the other actor with compensation. The Ministry had limited knowledge of these system aspects and could not make an objective decision. The formulation of the hub-position in legal terms in the governance led to situations in which conflict situations could be dealt with easier and faster.

To prevent sub-optimal outcomes of the decision week (strategy 2), the cascade of decisions was taking place in one week. During the decision week, both internal decision-making within organizations and decision-making between organizations was performed iteratively. The fact that decisions were made consecutively in a short time decreased the risk of forgetting or ignoring what had been decided upon previously and alerted decision makers to inconsistencies among decisions.

The connection between ERTMS issues and context issues (strategy 3) led to a broader agenda. The discussion between freight operators, program management and the Ministry created room for a give-and-take of issues eventually preventing a deadlock in the decision-making process. Together with stimulation of cooperation between operators (strategy 4) this reduced opposition during the decision week.

5.4 Intervention 4: Forecasting Future Game Concepts

Short summary: Participants discussed a characterization of the decision-making process based on Intervention 3. Researchers included a preview of the decision-making process and described potential future game concepts and their dynamics. The total set of game concepts was included. Participants explored options and solutions to prevent situations which could be destructive for or delay the process of decision-making.

5.4.1 Observations and Strategies

Given the game concept characterization over time of Intervention 3 we expected the multiple Principal-Agent games, Multi-Issue game, Cascade game and Hub-Spoke game to continue towards the second decision week. Moreover, a Battle of the Sexes, Volunteers Dilemma and Diners Dilemma could appear and be destructive for the process and its outcome. The program management recognized the game concepts presented and their potential risks. A worst-case scenario for them was the final decision being postponed by the Parliament which could happen for several reasons.

Actors who disagreed with the set of decisions started lobbying by the Parliament. Strategy (1): Show actors that cooperation is key for this process with financial incentives (prevent a Diners Dilemma), and invest in the trust relation between actors by recognizing their worries and providing solutions.

New issues emerged at the table and opened up a new area of issues to be resolved (over-complex Multi-Issue game). Strategy (2): Create a context in which actors are aware that this is the only moment for a decision by the Parliament to go from ERTMS plan to implementation. Focus on actors’ incentives instead of technical issues they bring up.

Actors could leave the process or block the cascade of decisions (Cascade game). Strategy (3): Provide information regarding the second decision week on time and give sufficient time for internal decision-making within organizations. Moreover, focus on the importance of the decision moment at the level of directors of organizations.

Pressure from European Union due to time, budget, and cooperation with other countries increased. Strategy (4): Manage the multiple Principal-Agent games by reducing information asymmetry and differences in incentives. This is crucial to prevent misalignment of actors, in particular between the Ministry and the Parliament.

Conflicts and dilemmas between actors on content issues delayed the process (Battle of the Sexes). Strategy (5): Position the program management as mediator and objective actor in conflict situations between actors (to resolve a Battle of the Sexes). Moreover, introduce an extra condition in the subsidy arrangements such that the program management has the mandate to decide on technical issues.

5.4.2 Consequences for the Design of the Decision-Making Process

In meetings with directors of organizations prior to the second decision week the decision makers accommodated to the message of the program management: “there is a single chance to get the ERTMS dossier from plan to implementation and the chance is now” (strategy 2 and 3). Decision makers came to a common understanding of this situation which helped the discussions and decreased the number of issues coming up. This prevented an over-complex Multi-Issue game. Moreover, it set the basis for actors not performing unexpected behavior in the final stage close to the decision week. For example, blocking a Cascade game or acting as a volunteer in a Volunteers Dilemma.

The Ministry took its role in decreasing the information asymmetry and minimizing power play with the Parliament (strategy 4). This helped in dealing with the limited number of motions and during technical briefing with the Ministry. Moreover, they addressed the urgent issues in the final stage and permitted the actors involved to negotiate about it. These issues therefore did not complicate the decision week or decision-making at the Parliament level.

In case of conflicts or issues such as with the HSL, the program management formulated one consistent answer. Its role as mediator and objective decision maker was to a certain extent accepted by the actors involved (strategy 5). The acceptance was caused by the shared understanding that a decision was needed (strategy 2) and thus actors kept their opinion to themselves and did not bring it up with others.

Freight train operators did not try to block the decision of the Parliament, since they realized that a broad support across the Parliament had emerged and wanted in an upcoming stage to fight again for more budget. The program management acknowledged the position of the freight operators and promised extra support for their issues (strategy 1).

To conclude this section, we summarize the main consequences for the design of the decision-making process as a result of the formulation of strategies based on the game concept characterization.

The program management shifted towards a focus on actors and their incentives instead of on new issues, and they adapted the decision-making process accordingly. A result was the implementation of two separate decision weeks. To prepare for the decision weeks the program management identified the incentive structures of actors. Moreover, the program management adapted its role and responsibility to resemble a client-contractor model in which they became the neutral organizer of the decision-making process. It had been reported that decision weeks were well structured with decisions clustered around themes and the ordering dependent on the incentive structures of actors. This contributed to the level of trust between actors.

We observed a strengthening of the program management to better deal with conflicts in and prevent delays of the decision-making process. As a neutral actor, close to the technical system integration issues, they were better able to make objective decisions than the Ministry. In the final stages, the initiated coupling of issues was prevented by the program management being more secure in its role.

Coupling of issues by the Ministry for the freight train operators resulted in a broader decision-making process. Due to this strategy, smaller freight train operators got involved, which had historically proven difficult. Moreover, the program management invested in the relation with freight train operators, all to prevent them from blocking the decisions.

The game concepts assisted in supporting a consistent communication of the main message: there is a single chance for a decision by Parliament and that is now. This consistency decreased the number of new issues and set the basis for actors not enacting unexpected behavior in the final stage close to the decision week.

Finally, we observed an effect in minimizing the information asymmetry between principal and agent when multiple Principal-Agent games were present. It has been reported that the decision by the Parliament after the decision of the Ministry went quite fast. Due to minimizing the information asymmetry and sharing the incentives a level of trust was created which helped adopting the final decision.

In the next section, we take a step back and provide lessons learned from the experience of intervening in a decision-making process with game concepts.

6 Reflection on Methodology

Pursuing a project like this brings with it a number of challenges, as is common for action research. This section provides some reflections from the experience of intervening in a decision-making process with game concepts. Initially, the lessons are framed as points to consider when repeating this study in different organizations or domains to overcome the exploratory character of the current study. However, these lessons could even be valuable for practitioners who are interested in approaches that assist in the design of a decision-making process.

The research design can be seen as a cycle: process analysis \(\rightarrow \) intervention with designers \(\rightarrow \) evaluation of strategies, and back to process analysis. Zuber-Skerritt ( 1991 ) distinguishes four phases: plan (analysis), act and observe (intervention), and reflect (evaluation). In this study, we performed the cycle four times. However, the phases (analysis, intervention, evaluation) are not always distinct. During interventions, so when one acts and observers, analysis as well as evaluation can take place.

Lesson 1: A rigid design of steps and cycles provides clarity, but requires flexible adjustment during the process.

As with the nature of action research, the role of researchers and participants in the research cycle is dynamic (Robertson 2000 ). The role of researchers and participants can vary between the phases of the cycle and can differ across cycles. In our study, the role of researchers and participants in the interventions was made explicit in Table  3 . We observed that participants had a larger role in the characterization of the process and game concepts in the earlier interventions and researchers were more dominant in giving the information in the later interventions. An explanation for the shift in roles could be that researchers gained more insight in the decision-making during the process and were therefore better able to characterize, and even forecast future dynamics of, the decision-making process. Given the information asymmetry between researchers and process designers, we experienced several moments of tension between roles.

Lesson 2: Be explicit about the role of researchers and participants in the different phases of the research cycles. In particular, regarding the use of game concepts. Questions to clarify are: Who identifies the game concepts? Who validates the identification? (process analysis); Who presents the game concept characterization? Who interprets the game concept characterization? (intervention); Who assesses the effect of the formulated strategies of the intervention? (evaluation).

Although the interventions took place at the level of the design of the decision-making process, i.e., with designers of the process, the perspectives of the other actors at different levels involved in the process needed to be included. This was necessary to obtain an overview of the process itself, but most importantly to evaluate the consequences of strategies formulated for the design of the decision-making process.

Lesson 3: Include information from actors involved at different levels of the decision-making process. This can be done in two ways: Indirectly, by asking the designers of the process to introduce the perspectives of different actors; and directly, by interviews with, observations of, or documentation from actors themselves.

It was crucial to be aware of the changing dynamics of the decision-making process to prevent the game theoretical characterization being inaccurate (or just wrong). Assuming a constant actor constellation is not reasonable for such processes.

Lesson 4: Find a way to keep track of changing dynamics between intervention cycles. There are a couple of solutions here: (i) let participants characterize the process themselves during the intervention; (ii) start the intervention with validating the characterization, or do this beforehand; (iii) have at least one linking actor, part of the design team, who can provide updates about the process and changing dynamics.

Similar strategies were formulated in different interventions. For example, strategy 2 of intervention 1 and strategy 1 of intervention 2 overlap. An explanation could be that different participants were involved in the interventions, but also that the observation of the situation preceding the formulated strategy was still present. During interventions, participants did not always come up with new strategies, but also re-articulated strategies that were formulated before. Sometimes the moment to put the strategy into action was not directly after the current intervention, but only after the next intervention.

Lesson 5: A suggestion for further research is to not only consider the interventions separately, but to view them as a whole and examine how strategies developed over time as well as the consequences of these strategies for the design of the decision-making process.

In all interventions, the participants used the game concepts, but the way in which they used them was different. In this study, the way in which game concepts were used was dependent on (i) the size and constellation of the group, (ii) previous experience with and thus existing knowledge of the game concepts, (iii) the time available for the intervention, and (iv) the information researchers had about the decision-making process beforehand.

Lesson 6: When repeating this study on a larger scale, align a number of those points such that the value of the way in which the game concept approach is used by participants can be better assessed.

7 Conclusion and Discussion

The objective of this paper was to explore the value of descriptive insights from game-theoretic analysis for dynamic interventions in the design of a process. The study applied game theoretical models to characterize a complex decision-making process and gave back the information to the designers of the process. The experience showed that the effects of such an approach could potentially make game theoretical models relevant to practical decision-making in a new way. Moreover, we provided lessons learned based on the experience for both researchers and practitioners. The context in which this research took place is the case of ERTMS in the Dutch railway sector.

First, we described the process of decision-making and highlighted the game concept elements. Second, we analyzed the four interventions with designers of the decision-making process. They used the game concept characterization to formulate strategies. Subsequently, we investigated the consequences of the strategies for the design of the decision-making process. The consequences for the process can be summarized as follows: an actively supported adaptation of an actor focus in the process, it affected the role and responsibilities of the program management, it contributed to the (de)coupling of issues, and it influenced the capability of creating awareness amongst actors of the urgency of the decision window. It also avoided the expected actor behavior of complicating the final stage of the decision-making process. Finally, we reflected upon the study as action research and drew six lessons learned for both researchers and practitioners.

The paper contributed to the theoretical framework on complex decision-making in multi-actor systems. We characterized the process by multiple game concepts instead of talking about a (single) game and an optimal outcome. Parallel interacting game concepts existed in the decision-making process which played at different levels of the organizations involved.

We showed how game theoretical models can assist in a complex decision-making process by giving back the game theoretical characterization to designers of the process. We provided a successful example of a case where a descriptive analysis led to the formulation of strategies instead of using the normative value of game theoretic models. This point is of interest for the broader use of game theory, or formal models in general, in the area of participatory decision-making and design of organizational processes.

Moreover, instead of actively intervening in behavior of actors outside their real context, these interventions targeted the design of the decision-making process. By investigation of the consequences of the formulated strategies in interventions, we contributed to the area of evaluation of participatory interventions. The game concept approach proved to be flexible in aligning with an ongoing process, and did not overtake the process as, for instance, decision-support systems do and to a certain extent also gaming does.

Finally, the paper contributed to the field of decision support and action research by providing methodological reflections on the use of the game concept approach as presented in the paper. The exploratory nature of the study makes it impossible to draw firm conclusions and shows its limitations, however, the reflections provide a starting point for further research in this area.

The BIT test is a necessary gateway test conducted by the Ministry of Internal Affairs for all major ICT programs of governmental organizations in the Netherlands.

Adler N (2005) Hub-Spoke network choice under competition with an application to western Europe. Transp Sci 39(1):58–72

Google Scholar  

Adler N, Smilowitz K (2007) Hub-and-spoke network alliances and mergers: price-location competition in the airline industry. Transp Res Part B 41(4):394–409

Adler N, Pels E, Nash C (2010) High-speed rail and air transport competition: game engineering as tool for cost-benefit analysis. Transp Res Part B Methodol 44(7):812–833

Anderson LR, Holt CA (1996) Classroom games: information cascades. J Econ Persp 10(4):187–193

Archetti M (2009) Cooperation as a volunteer’s dilemma and the strategy of conflict in public goods games. J Evolut Biol 22(11):2192–2200

Argyris C, Schön DA (1989) Participatory action research and action science compared: a commentary. Am Behav Scient 32(5):612–623

Axelrod R (1984) The evolution of co-operation. Basic Books, New York

Bekebrede G, Meijer S (2009) Understanding complex infrastructure systems: The case of SimPort-MV2. Second International Conference on Infrastructure Systems and Services, Developing 21st Century Infrastructure Systems. IEEE, Chennai, India, pp 1–6

Bekius F (2019) Towards Understanding and Supporting Complex Decision-Making by using Game Concepts: A Case Study of the Dutch Railway Sector. PhD thesis, Delft University of Technology

Bekius F, Meijer S (2018) The redesign process of the timetable for the Dutch railway sector: a theoretical approach. Int J Syst Syst Eng 8(4):330–345

Bekius F, De Bruijn H, Cunnighmam SW, Meijer S (2016) Structuring the Multi-Issue and Hub-Spoke games found in Public Administration. In: PICMET 2016, Portland International Conference for Management of Engineering and Technology, IEEE

Bekius F, Meijer S, De Bruijn H (2018) Collaboration patterns in the Dutch railway sector: using game concepts to compare different outcomes in a unique development case. Res Transp Econ 69:360–368

Bekius FA, Meijer SA (2020) Selecting the right game concept for social simulation of real-world systems. Springer Proceedings in Complexity, Springer

Bikhchandani S, Hirshlleifer D, Welch I (1992) A theory of fads, fashion, custom, and cultural change as informational cascades. J Political Econ 100(2):992–1026

Binmore K (2007) Game Theory. Oxford University Press, A Very Short Introduction

Braun D, Guston D (2003) Principal-agent theory and research policy: an introduction. Sci Public Policy 30(5):302–308

Camerer CF (1991) Does strategy research need game theory? Strat Manag J 12(S2):137–152

Camerer CF (1997) Progress in behavioral game theory. J Econ Perspect 11(4):167–188

Cantarelli CC, Chorus CG, Cunningham SW (2013) Explaining cost overruns of large-scale transportation infrastructure projects using a signalling game. Transportmetrica A Transp Sci 9(3):239–258

Chen TC, Lin YC, Wang LC (2012) The analysis of BOT strategies based on game theory - case study on Taiwan’s high speed railway project. J Civil Eng Manag 18(5):662–674

Cohen N (2015) Bargaining and informal interactions in the national budget: A game theory analysis of the Israeli case. Int Rev Administr Sci 81(1):58–78

Cole S, Izmalkov S, Sjo E (2014) Games in the Arctic: applying game theory insights to Arctic challenges. Polar Res 33(1):1–13

Conradie, Fritella, Palmigiano, Tzimoulis, Wijnberg (2015) The impact of informational cascades on competitive processes in creative industries

Corsair HJ, Ruch JB, Zheng PQ, Hobbs BF, Koonce JF (2009) Multicriteria decision analysis of stream restoration: potential and examples. Group Decis Negot 18(4):387–417

Cunningham S, Hermans L, Slinger J (2014) A review and participatory extension of game structuring methods. EURO J Decis Process 2(3):173–193

De Bruijn H, Herder PM (2009) System and actor perspectives on sociotechnical systems. IEEE Trans Syst Man Cybern Part A Syst Humans 39(5):981–992

De Bruijn H, Ten Heuvelhof E (2002) Policy analysis and decision making in a network: How to improve the quality of analysis and the impact on decision making. Impact Assess Project Appr 20(4):232–242

De Bruijn H, Ten Heuvelhof E (2018) Management in networks: on multi-actor decision making. Routledge, London

De Bruijn H, Ten Heuvelhof E, in ’t Veld R (2010) Process Management, Why Project Management Fails in Complex Decision Making Processes. Springer, Berlin

De Caluwé L (1997) Veranderen moet je leren. Een evaluatiestudie naar de opzet en effecten van een grootschalige cultuurinterventie met behulp van spelsimulatie. Delwel Uitgeverij, Den Haag

De Gooyert V (2016) Stakeholder Dynamics in the Dutch Energy Transition; towards a Shared Frame of Reference. PhD thesis, Radboud University Nijmegen, the Netherlands, 10.13140/RG.2.2.17417.08800

De Vreede GJ, Dickson G (2000) Using GSS to design organizational processes and information systems: an action research study on collaborative business engineering. Group Decis Negot 9(2):161–183

De Weck OL, Roos D, Magee CL (2011) Engineering systems: meeting human needs in a complex technological world. MIT Press, Camebridge

DeLaurentis DA (2005) Understanding transportation as system-of-systems design problem. In: 43rd AIAA Aerospace Sciences Meeting and Exhibit, pp 1–14

Diekmann A (1985) Volunteer’s dilemma. J Conflict Resol 29(4):605–610

Dodgson J, Spackman M, Pearman A, Phillips L (2009) Multi-criteria analysis: a manual. Department for Communities and Local Government, London

Easley D, Kleinberg J (2010) Information cascades. In: Networks, crowds, and markets: reasoning about a highly connected world, Cambridge University Press, chap 16

Eden C (1992) A framework for thinking about Group Decision Support Systems (GDSS). Group Decis Negot 1(3):199–218

Elrod JK, Fortenberry JL (2017) The hub-and-spoke organization design: an avenue for serving patients well. BMC Health Serv Res 17(1)

Flyvbjerg B, Priemus H, van Wee B (2008) Decision-making on mega-projects: cost-benefit analysis. Planning and Innovation, Edward Elgar, Cheltenham, UK and Northampton, MA

Geels FW (2004) From sectoral systems of innovation to socio-technical systems: insights about dynamics and change from sociology and institutional theory. Res Policy 33(6):897–920

Geyer A, Davies A (2000) Managing project—system interfaces: case studies of railway projects in restructured UK and German markets. Res Eng Des 29(7):991–1013

Gintis H (2000) Bosses and workers, landlords and peasants, and other principal-agent models. Game theory evolving: a problem-centered introduction to modeling strategic behavior, Princeton University Press, chap 14:357–369

Gneezy U, Haruvy E, Yafe H (2004) The inefficiency of splitting the bill. Econ J 114:265–280

Goeree J, Holt C (1999) Games: Coordination. In: Encyclopedia of Cognitive Science, American Cancer Society, pp 1–8

Goeree JK, Holt CA (2000) An explanation of anomalous behaviour in binary-choice games: Entry, voting, public goods and the volunteers’ dilemma. In: Virginia Economics Online Papers, University of Virginia, Department of Economics

Grogan PT, Meijer SA (2017) Gaming methods in engineering systems research. Syst Eng 20(6):542–552

Hardy C, Lawrence TB, Grant D (2005) Discourse and collaboration: the role of conversations and collective identity. Acad Manag Revg 30(1):58–77

Hermans F, van Apeldoorn D, Stuiver M, Kok K (2013) Niches and networks: explaining network evolution through niche formation processes. Res Policy 42(3):613–623

Hermans LM, Thissen WA (2009) Actor analysis methods and their use for public policy analysts. Eur J Oper Res 196(2):808–818

Holland JH (1992) Complex adaptive systems. Daedalus 121(1):17–30

Holland JH (1995) Hidden order: how adaptation builds complexity. Basic Books, New York

Hollander Y, Prashker JN (2006) The applicability of non-cooperative game theory in transport analysis. Transportation 33(5):481–496

Howard N (1994) Drama theory and its relation to game theory. part 1: dramatic resolution vs. rational solution. Group Decis Negot 3(2):187–206

Hughes T (1987) The evolution of large technological systems. In: Bijker W, Hughes T, Pinch T (eds) The social construction of technological systems: new directions in the sociology and history of technology. MIT Press, Cambridge, pp 51–82

Ishizaka A, Nemery P (2013) Multi-criteria decision analysis: methods and software. Wiley, Chichester

Kickert WJM, Klijn EH, Koppenjan JFM (1997) Managing complex networks. SAGE Publications Ltd, London

Laffont JJ, Martimort D (2002) The theory of incentives: the principal-agent model. Princeton University Press, Princeton and Oxford

Lewin K (1946) Action research and minority problems. J Soc Issues 2(4):34–46

Lo J, Van den Hoogen J, Meijer S (2013) Using gaming simulation experiments to test railway innovations: Implications for validity. In: Pasupathy R, Kim SH, Tolk A, Hill R, Kuhl ME (eds) Proceedings of the 2013 Winter Simulation Conference, IEEE Press, Washington, D.C., USA, pp 1766–1777

Markusen A (1996) Sticky places in slippery space: a typology of industrial districts. Econ Geogr 72(3):293–313

Mayer I, De Jong M (2004) Combining GDSS and gaming for decision support. Group Decis Negot 13(3):223–241

Mayer IS, Daalen CEV, Bots PW (2004) Perspectives on policy analyses: a framework for understanding and design. Int J Technol Policy Manag 4(2):169

Mayer IS, van Bueren EM, Bots PWG, van der Voort H, Seijdel R (2005) Collaborative decision-making for sustainable urban renewal projects: a simulation gaming approach. Environ Plan B Plan Des 32(3):403–423

Meijer S (2012a) Gaming simulations for railways: Lessons learned from modeling six games for the Dutch infrastructure management. In: Perpinya X (ed) Infrastructure Design, Signaling and Security in Railway, InTech, chap 11, pp 275–294, 10.5772/35864

Meijer S (2012) Introducing gaming simulation in the Dutch railways. Proc Soc Behav Sci 48:41–51

Meijer S (2015) The power of sponges: comparing high-tech and low-tech gaming for innovation. Simul Gaming 46(5):512–535. https://doi.org/10.1177/1046878115594520

Article   Google Scholar  

Meijer S, Reich Y, Subrahmanian E (2014) The future of gaming for designing complex systems. In: Duke R, Kriz W (eds) Back to the Future of Gaming, pp 154–167

Miller JH, Page SE (2007) Complex adaptive systems: an introduction to computational models of social life. Princeton University Press

Mingers J, Rosenhead J (2001) Rational analysis for a problematic world revisited. Wiley, Chichester

Nikas A, Doukas H, López LM (2018) A group decision making tool for assessing climate policy risks against multiple criteria. Heliyon 4(3):1–38

O’Donovan J, Jones RET, Marusich LR, Teng Y, Gonzalez C, Tobias H (2013) A model-based evaluation of trust and situation awareness in the diner’s dilemma game. In: 22nd Behaviour Representation in Modeling & Simulation (BRIMS) Conference, pp 11–14

Osman H, Nikbakht M (2014) A game-theoretic model for roadway performance management: a socio-technical approach. Built Enviro Project Asset Manag 4(1):40–54

Ossadnik W, Schinke S, Kaspar RH (2016) Group aggregation techniques for analytic hierarchy process and analytic network process: a comparative analysis. Group Decis Negot 25(2):421–457

Pluchinotta I, Kazakçi AO, Giordano R, Tsoukiàs A (2019) Design theory for generating alternatives in public decision making processes. Group Decis Negot 28(2):341–375

Rasmusen E (2007) Games and information: an introduction to game theory. Blackwell Publishing, Malden

Reich Y (1995) A critical review of general design theory. Res Eng Des 7(1):1–8

Reich Y, Konda SL, Monarch IA, Levy SN, Subrahmanian E (1996) Varieties and issues of participation and design. Des Stud 17(2):165–180

Robertson J (2000) The three r’s of action research methodology: Reciprocity, reflexivity and reflection-on-reality. Educat Action Res 8(2):307–326

Roungas B, Bekius F, Meijer S (2019) The game between game theory and gaming simulations: design choices. Simul Gaming 50(2):180–201. https://doi.org/10.1177/1046878119827625

Rouwette EA, Vennix JA, Felling AJ (2009) On evaluating the performance of problem structuring methods: an attempt at formulating a conceptual model. Group Decis Negot 18(6):567–587

Salen K, Zimmerman E (2004) Rules of play: game design fundamentals. MIT press, Cambridge

Scharpf FW (1997) Games real actors play, Actor-centered institutionalism in policy research. Westview Press, Oxford

Schuitemaker K, van Spaandonk H, Kuijsten M, Rajabalinejad M (2018) Evaluating key factors influencing ERTMS risk assessment: a reference model. Int J Adv Syst Meas 11(1):22–35

Sebenius JK (1983) Negotiation arithmetic: adding and subtracting issues and parties. Int Organ 37(2):281–316

Shoham Y, Leyton-Brown K (2008) Multiagent systems: algorithmic, game-theoretic, and logical foundations. Cambridge University Press, Cambridge

Stauvermann PJ (2004) Application of principal-agent models in science policy. In: Comparative Perspectives on Scientific Expertise for Public Policy, pp 1–13

Takebayashi M (2015) Multiple hub network and high-speed railway: connectivity, gateway, and airport leakage. Transp Res Part A Policy Pract 79:55–64

Teng Y, Jones R, Marusich L, O’Donovan J, Gonzalez C, Höllerer T (2013) Trust and situation awareness in a 3-player diner’s dilemma game. 2013 IEEE International Multi-Disciplinary Conference on Cognitive Methods in Situation Awareness and Decision Support, CogSIMA 2013 pp 9–15

Thissen WAH, Walker WE (2013) Public policy analysis: new developments. Springer, Boston

Trist EL, Bamforth KW (1951) Some social and psychological consequences of the Longwall method of coal-getting. Human Relat 4(1):3–38. https://doi.org/10.1177/001872675100400101

Van Benthem J (2014) Logic in games. MIT Press, Cambridge

Vollmer H (2013) What kind of game is everyday interaction? Rationality Soc 25(3):370–404

Winter E (1997) Negotiations in multi-issue committees. J Public Econ 65(3):323–342

Zuber-Skerritt O (1991) Action research for change and development. Gower Publishing, Alderschot

Download references

Acknowledgements

This research was funded by ProRail (Dutch Railway Infrastructure Manager) and Delft University of Technology. The authors especially thank Peter Scheffel for his input and time during this study. Moreover, we thank the editor and reviewers for the valuable comments which definitely improved the paper.

Author information

Authors and affiliations.

Nijmegen School of Management, Department of Methodology, Radboud University, Heyendaalseweg 141, Nijmegen, The Netherlands

Femke Bekius

Department of Health Informatics and Logistics, KTH Royal Institute of Technology, Halsovagen 11C, Stockholm, Sweden

Sebastiaan Meijer

Director Airport Coordination Netherlands, Former Director Program ERTMS, Ministry of Infrastructure and Watermanagement, Schiphol, The Netherlands

Hugo Thomassen

You can also search for this author in PubMed   Google Scholar

Corresponding author

Correspondence to Femke Bekius .

Additional information

Publisher's note.

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/ .

Reprints and permissions

About this article

Bekius, F., Meijer, S. & Thomassen, H. A Real Case Application of Game Theoretical Concepts in a Complex Decision-Making Process: Case Study ERTMS. Group Decis Negot 31 , 153–185 (2022). https://doi.org/10.1007/s10726-021-09762-x

Download citation

Accepted : 25 September 2021

Published : 18 October 2021

Issue Date : February 2022

DOI : https://doi.org/10.1007/s10726-021-09762-x

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Decision-making
• Game theoretical concepts
• Engineering design
• Decision support
• Railway system
• Find a journal
• Publish with us
• Track your research

• Instructors
• Institutions
• Teaching Strategies
• Higher Ed Trends
• Academic Leadership
• Affordability
• Product Updates

Case Studies: Bringing Learning to Life and Making Knowledge Stick

Learning by doing is a highly effective and proven strategy for knowledge retention. But sometimes, learning about others who have “done”—using case studies, for example—can be an excellent addition to or replacement for hands-on learning. Case studies―a vital tool in the problem-based learning toolkit—can turbocharge lessons in any subject, but they are particularly useful teaching aids in subjects like Medicine, Law or Forensic Science , where hands-on experiences may not initially be possible.

Here’s a look at how this type of problem-based learning functions to make learning stick and how any faculty member can use them to facilitate deeper, richer learning experiences:

Case studies complement theoretical information 

Reading about scientific principles in a textbook challenges students to think deductively and use their imagination to apply what they’re learning to real-world scenarios. It’s an important skill set. Not all information can or should be packaged up and handed to students, pre-formed; we want students to become critical thinkers and smart decision-makers who are capable of forming their own insights and opinions. 

However, the strategic use of case studies, as a companion to required reading, can help students see theoretical information in a new light, and often for the first time. In short, a case study can bring to life what is often dry and difficult material, transforming it into something powerful, and inspiring students to keep learning. Furthermore, the ability to select or create case studies can give students greater agency in their learning experiences, helping them steer their educational experiences towards topics they find interesting and meaningful. 

What does the research show about using case studies in educational settings? For one, when used in group settings, the use of case studies is proven to promote collaboration while promoting the application of theory. Furthermore, case studies are proven to promote the consideration of diverse cultures, perspectives, and ideas. Beyond that? They help students to broaden their professional acumen —a vitally necessary part of the higher education experience. 

Case studies can be what you want them to be, but they should follow a formula  

Faculty may choose to use case studies in any number of ways, including asking students to read existing case studies, or even challenging them to build their own case studies based on real or hypothetical situations. This can be done individually or in a group. It may be done in the classroom, at home, or in a professional setting. Case studies can take on a wide variety of formats. They may be just a few paragraphs or 30 pages long. They may be prescriptive and challenge readers to create a takeaway or propose a different way of doing things. Or, they may simply ask readers to understand how things were done in a specific case. Beyond written case studies, videos or slide decks can be equally compelling formats. One faculty member even asks students to get theatrical and act out a solution in their sociology class.  

Regardless of format, a case study works best when it roughly follows an arc of problem, solution and results. All case studies must present a problem that doesn’t have an immediately clear solution or result. For example, a medical student may read a case study detailing the hospital admission of a 42-year-old woman who presents to the emergency room with persistent and severe calf pain, but has normal blood tests and ultrasound imaging. What should the physician consider next? A law student might read a case study about an elderly man involved in a car accident who denies any memory of the event. What legal angles should be considered?

Case studies – get started

Are you eager to use case studies with your students? Cengage higher education titles typically contain case studies and real-world examples that bring learning to life and help knowledge stick. Below are some learning materials, spanning a range of subjects, that can help your students reap the proven benefits of case study learning:

Accounting, 29e

Award-winning authors Carl Warren, Jefferson P. Jones and William B. Tayler offer students the opportunity to analyze real-world business decisions and show how accounting is used by real companies.

Guide to Computer Forensics and Investigations, 7e

“Guide to Computer Forensics and Investigations” by Bill Nelson, Amelia Phillips, Christopher Steuart and Robert S. Wilson includes case projects aimed at providing practical implementation experience, as well as practice in applying critical thinking skills.

Business Ethics: Case Studies and Selected Readings, 10e

Marianne M. Jennings’ best-selling “Business Ethics: Case Studies and Selected Readings, 10e” explores a proven process for analyzing ethical dilemmas and creating stronger values.

Anatomy & Physiology, 1e

Author Dr. Liz Co includes a chapter composed entirely of case studies to give students additional practice in critical thinking. The cases can be assigned at the end of the semester or at intervals as the instructor chooses.

Psychopathology and Life: A Dimensional Approach, 11e

Christopher Kearney offers a concise, contemporary and science-based view of psychopathology that emphasizes the individual first. Geared toward cases to which most college students can relate, helping them understand that symptoms of psychological problems occur in many people in different ways.

Understanding Psychological Disorders Enhanced, 12e

In “Understanding Psychological Disorders Enhanced” by David Sue, Derald Sue, Diane M. Sue and Stanley Sue, students can explore current events, real-world case studies and the latest developments from the field.

Policing in the US: Past, Present, and Future, 1e

This comprehensive and timely text by Lorenzo M. Boyd, Melissa S. Morabito and Larry J. Siegel examines the current state of American policing, offering a fresh and balanced look at contemporary issues in law enforcement. Each chapter opens with a real-life case or incident.

Public Speaking: The Evolving Art, 5e

With a student-centered approach, “Public Speaking: The Evolving Art” by Stephanie J. Coopman and James Lull includes innovative solutions to current issues, including critically assessing the credibility of information sources. A diverse collection of sample student and professional presentations encourage students to consider chapter concepts in the context of real speeches.

Theory and Practice of Counseling and Psychotherapies, 11e

Dr. Gerald Corey’s best-selling text helps readers compare and contrast the therapeutic models expressed in counseling theories.

Related articles

• Liberty University
• Jerry Falwell Library
• Special Collections
• < Previous

Home > ETD > Doctoral > 5543

Doctoral Dissertations and Projects

Virtual coaching, self-directed learning, and the implementation of evidence-based practices: a single qualitative case study.

Elisabeth Myers , Liberty University Follow

School of Education

Doctor of Philosophy in Education (PhD)

Christine Saba

virtual coaching, self-directed learning, evidence-based practices, self-determination theory, sustained implementation

Disciplines

Education | Educational Leadership

Recommended Citation

Myers, Elisabeth, "Virtual Coaching, Self-Directed Learning, and the Implementation of Evidence-Based Practices: A Single Qualitative Case Study" (2024). Doctoral Dissertations and Projects . 5543. https://digitalcommons.liberty.edu/doctoral/5543

The purpose of this single instrumental case study was to understand how a virtual coaching program provides opportunities for self-directed learning during the implementation of evidence-based practices for adults at Navigator Coaching. The theory guiding this study was Deci and Ryan’s self-determination theory as conceptualizations of self-directed learning described in the literature mirror descriptions of self-determination. The central research question was: How does a virtual coaching program provide opportunities for self-directed learning during the implementation of evidence-based practices? As a single instrumental case, the setting for this study was one virtual life-coaching program in North America. The sample of participants included 12 adults who were currently enrolled in the program for a minimum of 6 months and participated in weekly program activities. Multiple data collection methods were employed to describe and understand the case: observations, audiovisual materials, and individual interviews. Interpretational analysis and a multistep data analysis process including direct interpretation, categorical aggregation, correspondence tables, and interpretive commentaries were utilized to develop the themes and overall synthesis of the case. Opportunities for self-directed learning were provided in weekly live sessions, modules in the program library, and in the Facebook group. Program members utilized instructional opportunities to satisfy their need for autonomy, thus becoming students of self. Participation in a purposeful community that was focused on solutions provided opportunities for program members to satisfy competence and relatedness needs. Program members implemented evidence-based practices and developed skills to create weekly learning plans, which assisted them in becoming agents of their highest selves.

Included in

Educational Leadership Commons

• Collections
• Faculty Expert Gallery
• Theses and Dissertations
• Conferences and Events
• Open Educational Resources (OER)
• Explore Disciplines

Advanced Search

• Notify me via email or RSS .

Faculty Authors

• Submit Research
• Expert Gallery Login

Student Authors

• Undergraduate Submissions
• Graduate Submissions
• Honors Submissions

Home | About | FAQ | My Account | Accessibility Statement

Privacy Copyright

Cookies on GOV.UK

We use some essential cookies to make this website work.

We’d like to set additional cookies to understand how you use GOV.UK, remember your settings and improve government services.

We also use cookies set by other sites to help us deliver content from their services.

You have accepted additional cookies. You can change your cookie settings at any time.

You have rejected additional cookies. You can change your cookie settings at any time.

• Education, training and skills
• Further and higher education, skills and vocational training
• Sector-based Work Academy Programme: qualitative case study research
• Department for Work & Pensions

SWAP Qualitative Case Study Research: Annexes

Updated 16 May 2024

© Crown copyright 2024

This publication is licensed under the terms of the Open Government Licence v3.0 except where otherwise stated. To view this licence, visit nationalarchives.gov.uk/doc/open-government-licence/version/3 or write to the Information Policy Team, The National Archives, Kew, London TW9 4DU, or email: [email protected] .

Where we have identified any third party copyright information you will need to obtain permission from the copyright holders concerned.

This publication is available at https://www.gov.uk/government/publications/sector-based-work-academy-programme-qualitative-case-study-research/swap-qualitative-case-study-research-annexes

Annex 1: SWAP Theory of Change Logic Model

The flow diagram presents the following information:.

Inputs mainly under the heading ‘Government (Continued benefits, training costs, barriers to participation, analytical resources)’:

‘Employer -Time for set up/management/ feedback’

‘Training Provider - Time for set up/management’

‘Employer Advisor’, ‘Work Coach’

These inputs flow into the following activities:

• ‘Local Labour market analysis’
• ‘Arrange SWAP ’
• ‘Disseminate available SWAP with JCP ’
• ‘Awareness of available SWAP ’
• ‘Sell SWAP to claimant’
• ‘Refer claimant’

These activities flow to the output: ‘Claimant agrees to participate in SWAP ’. The claimant agreement flows on to the claimant input: ‘Investment of time and initial travel costs (reimbursable)’ and the following work coach activities:

• ‘Barrier Assessment’
• ‘Record referral’

Then the following employer activities:

• ‘Background checks (if applicable)’
• ‘Workplace adjustment (if applicable)’ 

These all flow into the output ‘Claimant starts SWAP ’.

The main SWAP portion of the theory of change starts here with the activities:

• ‘Pre-employment Training’ (with side flow to ‘Claimant gains certification (if applicable)’)
• ‘Work placement’
• ‘Guaranteed Interview’

The main SWAP activities flow to the following three possible outputs:

• ‘Claimant completes SWAP : Interview successful’
• ‘Claimant completes SWAP : Interview unsuccessful’
• ‘Claimant does not complete SWAP ’)

Regardless of which output, the diagram shows a flow to the activity ‘WC completes SWAP Tracker’. 

If Claimant completes SWAP with an unsuccessful interview, or the Claimant does not complete the SWAP , these outputs flow into the short term outcome of ‘additional needs identified’. The unsuccessful interview also flows into the short term outcome ‘interview feedback from employer’.

Both of these short term outcomes flow into the activity ‘Reflection with WC’ and this can flow into the activity ‘Claimant applies for other jobs in sector’. Claimant applies for other jobs in sector can flow into a successful short term outcome ‘claimant gains employment in new sector’ or an unsuccessful short term outcome, in which case ‘claimant reengages with WC’. 

Claimants unsuccessful at SWAP or subsequent interviews (through engagement with WC activities) flow into either:

• the short-term outcome ‘Increased employability’
• the medium term outcome ‘improve claimants employability’.

Collectively the short and medium term outcomes flow into the impact ‘Value for unsuccessful claimants’. 

If the claimant is successful at either the guaranteed or subsequent interview, these flow into the output ‘ Claimant enters work in new sector’ which flows onto the following four short-term outcomes:

• ‘Change in attitude towards working in new sector’
• ‘Claimant has skills to succeed at new job’
• ‘Increased earning’
• ‘Reduced UC /benefit’

This may flow into the following medium term outcomes:

• ‘ UC ends (or is maintained at reduced level)’
• ‘Sustained employment (18 months)’
• ‘Career progression’

These medium term outcomes flow into the impacts:

• ‘Increased employment’
• ‘Reduced UC costs’

If the claimant is successful at the guaranteed interview, and subject to the assumption ‘Employer outputs and outcomes are dependent on the SWAP meeting employer expectations’, the following employer outputs are recorded:

• ‘Reduced vacancies’
• ‘Employer social responsibility goals met’
• ‘Development of local workforce’ 

‘Reduced vacancies’ and ‘Employer social responsibility goals met’ flow to the short-term outcome ‘Employer satisfied with SWAP experience’. This then flows to the activity ‘ DWP gathers feedback from claimants and employers’ and the short-term outcome ‘Collated employer success stories’.

These short-term outcomes flow to the medium term outcomes:

• ‘Businesses return for additional SWAP ’
• ‘Increased employer uptake in SWAP or other provisions’
• ‘Improved Attitudes towards hiring DWP claimants’
• ‘Employers approaching DWP with vacancies more readily’ 

‘Development of local workforce’ output flows to the following short-term outcomes:

• ‘ SWAP aligns with local market need including sector shortages’
• ‘Sector pathways identified’
• ‘Change in attitude towards working in new sector’, which flow to the medium term outcome ‘Improved fit between employers and claimants’. 

Medium term outcomes in this employer focussed part of the theory of change flow to the impacts ‘Improved DWP relationship with business sector’ and ‘increased employment’.

Annex 2: Participant characteristics

Table 3: employer, training provider and claimant participants by swap sector, table 4: claimant participant characteristics, annex 3: additional methodology details.

This annex includes additional information about how the case study research was conducted.

Contacting claimants

A random sample of 150 claimants was drawn for each case study area (600 claimants in total across the four areas) in order to achieve 10 claimant interviews in each district. This sample size was in line with previous, similar research (in terms of mode, length and recruitment approach), which achieved a response rate of approximately 1 in 15 claimants. The sample was sourced from the SWAP manual trackers completed by each district which detail which claimants are referred each week to the programme. Claimant identification numbers were then linked to centrally held contact information (for example, postal address and telephone number).

The stratification of the sample was limited by the quality of data DWP holds on certain claimant characteristics (for example, ethnicity and disability information was not available) as well as claimants’ SWAP journey (only claimant start dates on the pre-employment training ( PET ) were consistently recorded by all areas). As a result, it was impossible to identify in advance claimants who had dropped out of a SWAP part-way through, or claimants who were successful at the guaranteed interview stage, which limited the study’s ability to explore these aspects in detail. The sample drawn was, therefore, broadly reflective (rather than representative) of the claimant population who started on a SWAP in terms of gender and sector of SWAP , and consisted of individuals who had started the SWAP PET within the previous 12 weeks of the sample being drawn. This time period was agreed in order to ensure the feasibility of obtaining a sample of 150 claimants from each area, while minimising as much as possible the risk of recall bias within claimant accounts of their experience.

It is important to note the claimant sample was delivered in two separate stages, to reflect the gap in fieldwork between Area 2 and Area 3. The samples for Areas 3 and 4, was additionally stratified by age (18 to 24 years vs. 25+ years) to account for the small number of potential participants aged 18 to 24 years provided in the sample for Areas 1 and 2.

All claimants in the sample were sent an advance letter to the address held on DWP ’s central records. This letter provided further information about the research, what their participation would involve, data processing information and an email address to which they could write if they wanted to opt-out. Claimants were called using the telephone numbers provided in each sample, and while formal quotas for recruiting participants were not used, calls were targeted to achieve a spread in terms of claimant gender, age and sector of SWAP (the latter was obtained from the SWAP manual trackers and was therefore dependent on DWP staff interpretations of this at the local level). Claimants were called up to three times without a response before they were not contacted any further. During the calls, researchers emphasised their independence from benefits processing and that decisions regarding participation would not affect claimants’ benefits in any way. Each interview lasted approximately 30 to 45 minutes and claimants received a £20 voucher for their time.

In Area 4, fieldwork was terminated early due to an underlying issue with this sample in which few claimants could be contacted (many claimants did not pick up the phone) and of those who did, few recalled the programme or had actually started the SWAP to which they had been referred. Only two interviews were completed from 207 recruitment calls, compared to 10 interviews completed from 88 recruitment calls in Area 3. The study team attempted to unpick the reasoning for the issues with the underlying sample in subsequent meetings and interviews with the local operational contacts, however, it was difficult to pinpoint this exactly. The information gathered suggested that the issue was likely a result of error(s) completing the local manual SWAP trackers. As a result, fieldwork was terminated early so that the findings could be reported to the timetable agreed.

Contacting employers and training providers

As described in the main report, the study was reliant on the case study areas to supply the contact details of employers and training providers who had taken part in a SWAP in their districts, as there was no alternative way of identifying these organisations. Within each area, the study aimed to interview a total of 7 employers, and 3 training providers, and so local contacts were asked to provide approximately 15 to 20 employer contacts and 5 to 10 training provider contacts to account for uncertainty in likely response rates. Obtaining contacts was more difficult in some of the case study areas and was affected by factors such as local record keeping of this information (for example, some training providers were listed as employers, and other contact information was out of date), and busyness of the staff involved. In all areas, subsequent samples of employers were requested due to poor response rates for this participant group.

To counter the risk of staff supplying only contacts for similar organisations, and therefore similar experiences of the programme, contact information for a range of organisations in terms of key characteristics (size, sector of SWAP , length of SWAP , number of SWAPs involved in, and how the SWAP was initiated) was requested. Organisations were then approached by researchers to ensure a spread across these characteristics, although achieving this was limited by response rates, particularly among employers.

Organisations were initially emailed using a template which explained the purpose of the research and asked if they were able to participate. Where organisations agreed to take part, they were then sent an additional information sheet and booked in for an interview at a convenient date and time. Where no response was received, a follow-up email was sent a few days later prompting them about the study. Finally, where the target number of interviews had not yet been reached, organisations were contacted by telephone for up to a maximum of two attempts. Where this was the case, the researcher verbally communicated the key information about the study contained in the initial emails.

For most areas, the first time employers and training providers heard about the research was when they were contacted via email about the study. In Area 4, however, DWP staff approached employers in advance before handing contact details over to the study team. This approach was taken as DWP staff in this area felt it would be beneficial in securing employer participation and minimised any risk to their relationships with these contacts if the study team were to contact them without warning. It should be noted that this may have increased the risk that some employers may have felt obligated to take part in the research and/or restricted their feedback due to a perceived lack of separation between DWP researchers and operational staff leading on SWAPs . As with all areas, researchers in Area 4 emphasised their independence from jobcentres ( JCPs ) and SWAP policy decision-making during each contact with participants, and the questions asked during data collection were framed in a way to encourage and enable participants to be honest about their experience. Despite this, it’s likely that a certain level of bias related to this aspect remains in the dataset obtained.

Each interview lasted approximately 30 minutes to an hour, depending on how much each organisation wanted to share. To ensure the most appropriate person was spoken to, the information shared during the recruitment stages requested that the participant was an individual who had knowledge of, or was responsible for, the SWAP that their organisation had been involved in.

Contacting staff

Once JCP Service Leaders had agreed for fieldwork to take place in their district areas, the study team were signposted to operational staff who would be able to facilitate the research. These individuals became key contacts for the study team during fieldwork. In initial meetings, these local contacts provided a broad overview of the SWAP set-up in their district, and the types of staff involved in delivery, from which a list of different staff roles to speak to as part of the fieldwork was agreed. Due to the varying nature of the local staffing models, it was easier to understand how SWAP delivery was organised in some areas more than others.

The project manager and case study leads maintained regular contact with these local contacts while fieldwork took place in each area. In Areas 1 and 2 this mostly consisted of contact via email, whereas for Areas 3 and 4 this took the form of a weekly scheduled meeting. In Areas 2, 3 and 4, a follow-up meeting took place with the local contacts to check the study team’s understanding of local SWAP delivery obtained through data collection, and to clarify any aspects of delivery that remained unclear.

The local contacts provided a list of suggested staff who could be approached for the fieldwork based on their role and involvement in local SWAP delivery. The study team then arranged the interviews and focus groups for these staff around their availability. In setting up the interviews and focus groups, an information sheet was provided about the research, and it was emphasised that their participation was voluntary. Despite this, some staff may have only participated in the study because they felt obligated to. As with other participant groups, the independence of the study team was emphasised, and participants were offered the opportunity to withdraw from the study if they wanted to.

Piloting [footnote 1] interviews were conducted with two members of DWP staff, one employer and one training provider who agreed to this. These interviews were conducted to test the length and appropriateness of the topic guides for these participant groups, and the quality of the data obtained. These individuals were recruited from a separate JCP district to the case study areas and so the information collected was not used in the analysis and reporting of this study. The topic guides were amended following these pilots.

For claimants, the first week of fieldwork was considered a pilot. Minimal changes were made to the topic guide following these interviews, and so, unlike the other fieldwork strands, the data collected during these interviews was analysed and reported on. It should, however, be noted that the topic guides and fieldwork processes were continually reviewed and modified throughout the data collection periods to ensure they were as efficient and effective as possible. The study team met multiple times a week to reflect on interviews, and formal debrief sessions were held within the study team, and separately with wider supporting researchers, following the end of data collection in each study area. This process allowed learning from each area to be implemented in subsequent fieldwork.

Analysis and Reporting

Once all interviews had been conducted, the interview notes formed the final dataset. The dataset was explored using a thematic analysis approach. As there were multiple researchers involved in the coding of the data, a coding framework (Annex 4) was developed to ensure consistency in coding across the study team. The research questions were used as a guide to ensure the framework aligned with the objectives of the research, and the framework was tested with an initial sample of interviews before a final version was agreed for coding the rest of the data (although this was still subject to ongoing tweaks as coding progressed).

Members of the study team were paired up to code a specific strand of data (for example, employers) and each pair coded the same initial set of notes to check alignment in their coding approach, before separately coding the remaining data. A separate member of the study team then examined a selection of coded notes from each pair to quality assure the completed coding. Feedback on the coding approach, particularly inconsistencies within each pair, was provided to the coders so that this could be incorporated into the analysis of future notes.

The project team met multiple times to discuss and agree the themes identified within the coded data. The themes identified via this process of analysis structured the findings within this report. When analysing the data, findings were explored by participant group (for example, claimants vs. employers) as well as by case study area (for example, Area 1 vs. Area 2), and these were included in the reporting where relevant.

A Quality Assurance ( QA ) panel was established to review the work of the research team during the analysis stage. The panel included researchers external to the project, senior researchers, and a fieldworker external to the study team, who was involved in conducting the research. This panel was engaged to review the initial coding framework that had been developed, and again to review how the codes had been applied to a sample of the data collected. This ensured that the approach taken to analysis had been peer reviewed, and that the data analysis conducted was of good quality. The final report was separately quality assured by an academic on secondment to the In-House Research Unit ( IHRU ), as well as senior researchers in the unit.

Annex 4: Initial coding framework

A pilot is a small-scale, preliminary study that is used as a test run for a particular research instrument to ensure its efficacy.  ↩

Is this page useful?

• Yes this page is useful
• No this page is not useful

Help us improve GOV.UK

Don’t include personal or financial information like your National Insurance number or credit card details.

To help us improve GOV.UK, we’d like to know more about your visit today. Please fill in this survey (opens in a new tab) .

• Open access
• Published: 11 May 2024

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

255 Accesses

12 Altmetric

Metrics details

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.

Peer Review reports

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.

Dhawan D, Bekalu M, Pinnamaneni R, McCloud R, Viswanath K. COVID-19 news and misinformation: do they matter for public health prevention? J Health Commun. 2021;26:799–808.

Article   PubMed   Google Scholar  

Janmohamed K, Walter N, Nyhan K, Khoshnood K, Tucker JD, Sangngam N, et al. Interventions to mitigate COVID-19 misinformation: a systematic review and meta-analysis. J Health Commun. 2021;26:846–57.

Cheng Y, Chen ZF. The influence of presumed fake news influence: examining public support for corporate corrective response, media literacy interventions, and governmental regulation. Mass Commun Soc. 2020;23:705–29.

Article   Google Scholar  

Earnshaw VA, Katz IT. Educate, amplify, and focus to address COVID-19 misinformation. JAMA Health Forum. 2020;1:e200460.

Bautista JR, Zhang Y, Gwizdka J. Healthcare professionals’ acts of correcting health misinformation on social media. Int J Med Inf. 2021;148:104375.

O’Doherty D, Lougheed J, Hannigan A, Last J, Dromey M, O’Tuathaigh C, et al. Internet skills of medical faculty and students: is there a difference? BMC Med Educ. 2019;19:39.

Article   PubMed   PubMed Central   Google Scholar  

Davison WP. The third-person effect in communication.

Koo AZ-X, Su M-H, Lee S, Ahn S-Y, Rojas H. What motivates people to correct misinformation? Examining the effects of third-person perceptions and perceived norms. J Broadcast Electron Media. 2021;65:111–34.

Oktavianus J, Bautista JR. Motivating healthcare professionals to correct online health misinformation: the roles of subjective norm, third-person perception, and channel differences. Comput Hum Behav. 2023;147:107839.

Tang S, Willnat L, Zhang H. Fake news, information overload, and the third-person effect in China. Glob Media China. 2021;6:492–507.

Chapin J. Third-person perception and facebook. Int J Cyber Behav Psychol Learn. 2014;4:34–44.

Wei R, Lo V-H, Lu H-Y. Reconsidering the relationship between the third-person perception and optimistic bias. Commun Res. 2007;34:665–84.

Weinstein ND. Unrealistic optimism about future life events. J Pers Soc Psychol. 1980;39:802–20.

Liu X. Media exposure and third-person perception: the mediating role of social realism and proxy efficacy. 2021.

Yang J, Tian Y. “Others are more vulnerable to fake news than I Am”: Third-person effect of COVID-19 fake news on social media users. Comput Hum Behav. 2021;125:106950.

Sun Ye, Shen L, Pan Z. On the behavioral component of the third-person effect. Commun Res. 2008;35:257–78.

Article   CAS   Google Scholar  

Wei R, Lo V-H. The third-person effects of political attack ads in the 2004 U.S. Presidential election. Media Psychol. 2007;9:367–88.

Duck JM, Hogg MA, Terry DJ. Social identity and perceptions of media persuasion: are we always less influenced than others? 1. J Appl Soc Psychol. 1999;29(9):1879–99.

Eveland WP, Nathanson AI, Detenber BH, McLEOD DM. Rethinking the social distance corollary: perceived likelihood of expsoure and the third-person perception. Commun Res. 1999;26:275–302.

Scharrer E. Third-person perception and television violence: the role of out-group stereotyping in perceptions of susceptibility to effects. Commun Res. 2002;29:681–704.

Brownlee K, Halverson G, Chassie A. Multiple relationships: maintaining professional identity in rural social work practice. J Compar Soc Work. 2012;7(1):81–91.

Hogg MA, Reid SA. Social identity, self-categorization, and the communication of group norms. Commun Theory. 2006;16:7–30.

Lee B, Tamborini R. Third-person effect and internet pornography: the influence of collectivism and internet self-efficacy. J Commun. 2005;55:292–310.

Wei R, Golan G. Political advertising on social media in the 2012 presidential election: exploring the perceptual and behavioral components of the third-person effect. Electron News. 2013;7:223–42.

Dong E, Du H, Gardner L. An interactive web-based dashboard to track COVID-19 in real time. Lancet Infect Dis. 2020;20:533–4. 

Jun Z, Weili W, Xin Z, Wei Z. Recommended psychological crisis intervention response to the 2019 novel coronavirus pneumonia outbreak in China: a model of West China Hospital. Precis Clin Med. 2020;3(1):3–8.

Shi Y, Zhang S, Fan L, Sun T. What motivates medical students to engage in volunteer behavior during the COVID-19 Outbreak? A large cross-sectional survey. Front Psychol. 2021;11:569765.

Passemard S, Faye A, Dubertret C, Peyre H, Vorms C, Boimare V, ... & Ricard JD. Covid-19 crisis impact on the next generation of physicians: a survey of 800 medical students. BMC Med Educ. 2021;21(1):1–13.

Tempski P, Arantes-Costa FM, Kobayasi R, Siqueira MA, Torsani MB, Amaro BQ, Martins MA. Medical students’ perceptions and motivations during the COVID-19 pandemic. PLoS ONE. 2021;16(3):e0248627.

Article   CAS   PubMed   PubMed Central   Google Scholar  

Perloff RM. Third-person effect research 1983–1992: a review and synthesis. Int J Public Opin Res. 1993;5:167–84.

Chen L, Fu L. Let’s fight the infodemic: the third-person effect process of misinformation during public health emergencies. Internet Res. 2022;32:1357–77.

Lee T. How people perceive influence of fake news and why it matters. Commun Q. 2021;69:431–53.

Liu PL, Huang LV. Digital disinformation about COVID-19 and the third-person effect: examining the channel differences and negative emotional outcomes. Cyberpsychol Behav Soc Netw. 2020;23:789–93.

Gunther AC, Thorson E. Perceived persuasive effects of product commercials and public service announcements: third-person effects in new domains. Commun Res. 1992;19:574–96.

Gunther A. What we think others think: cause and consequence in the third-person effect. Commun Res. 1991;18:355–72.

Reid SA, Hogg MA. A self-categorization explanation for the third-person effect. Hum Commun Res. 2005;31:129–61.

Cao B, Chen Z, Huang Y, Lo WH. Conflict between Mainland Chinese and Hong Kongers: a social identity perspective in explaining the hostile media phenomenon and the third-person effect. J Appl J Media Stud. 2014;3:225–40.

Google Scholar  

Tajfel H. Experimental studies of intergroup behaviour. In: Cognitive analysis of social behavior: Proceedings of the NATO advanced study Institute on “The cognitive analysis of socio-psychological processes”, Aix-enProvence, France, July 12–31, 1981 Dordrecht: Springer Netherlands; 1982. p. 227–46.

Chapter   Google Scholar  

Tajfel H, Turner JC, Austin WG, Worchel S. An integrative theory of intergroup conflict. Organizational Identity. 1979;56(65):9780203505984–9780203505916.

Crocker J, Luhtanen R. Collective self-esteem and ingroup bias. J Pers Soc Psychol. 1990;58(1).

Singelis TM. The measurement of independent and interdependent self-construals. Pers Soc Psychol Bull. 1994;20(5):580–91.

Cho H, Lee JS. The influence of self-efficacy, subjective norms, and risk perception on behavioral intentions related to the H1N1 flu pandemic: a comparison between K orea and the US. Asian J Soc Psychol. 2015;18(4):311–24.

Bandura A, Freeman WH, Lightsey R. Self-efficacy: the exercise of control. J Cogn Psychother. 1999;13:158–66.

Bandura A, Guide for constructing self-efficacy scales. Self-efficacy beliefs of adolescents. 2006;5(1):307–37.

Pajares F. Self-efficacy beliefs in academic settings. Rev Educ Res. 1996;66:543–78.

Park JS, Ahn HY, Haley EJ. Optimistic bias, advertising skepticism, and consumer intentions for seeking information about the health risks of prescription medicine. Health Mark Q. 2017;34(2):81–96.

Hofstede GH. Culture’s consequences: comparing values, behaviors, institutions, and organizations across nations. 2nd ed. Thousand Oaks: Sage Publications; 2001.

Triandis HC. Individualism and Collectivism. 1st ed. New York: Routledge; 2018.

Wated G, Sanchez JI. Managerial tolerance of nepotism: the effects of individualism-collectivism in a Latin American Context. J Bus Ethics. 2015;130:45–57.

Markus HR, Kitayama S. Culture and the self."Implications for cognition, emotion, and motivation.

Sullivan D, Landau MJ, Kay AC, Rothschild ZK. Collectivism and the meaning of suffering. J Pers Soc Psychol. 2012;103:1023–39.

Lo V, Wei R. Third-person effect, gender, and pornography on the lnternet. J Broadcast Electron Media. 2002;46:13–33.

Barnidge M, Rojas H. Hostile media perceptions, presumed media influence, and political talk: expanding the corrective action hypothesis. Int J Public Opin Res. 2014;26:135–56.

Wintterlin F, Frischlich L, Boberg S, Schatto-Eckrodt T, Reer F, Quandt T. Corrective Actions in the information disorder. the role of presumed media influence and hostile media perceptions for the countering of distorted user-generated content. Polit Commun. 2021;38:773–91.

Wei R, Lo V-H, Lu H-Y, Hou H-Y. Examining multiple behavioral effects of third-person perception: evidence from the news about Fukushima nuclear crisis in Taiwan. Chin J Commun. 2015;8:95–111.

McLEOD DM, Eveland WP, Nathanson AI. Support for censorship of violent and misogynic rap lyrics: an analysis of the third-person effect. Commun Res. 1997;24:153–74.

Nathanson AI, Eveland WP Jr, Park H-S, Paul B. Perceived media influence and efficacy as predictors of caregivers’ protective behaviors. J Broadcast Electron Media. 2002;46:385–410.

McLeod DM, Detenber BH, Eveland WP. Behind the third-person effect: differentiating perceptual processes for self and other. J Commun. 2001;51:678–95.

Rojas H. “Corrective” Actions in the public sphere: how perceptions of media and media effects shape political behaviors. Int J Public Opin Res. 2010;22:343–63.

Chung M, Munno GJ, Moritz B. Triggering participation: exploring the effects of third-person and hostile media perceptions on online participation. Comput Hum Behav. 2015;53:452–61.

Zhao L, Yin J, Song Y. An exploration of rumor combating behavior on social media in the context of social crises. Comput Hum Behav. 2016;58:25–36.

Sherman DK, Updegraff JA, Handy MS, Eom K, Kim HS. Beliefs and social norms as precursors of environmental support: the joint influence of collectivism and socioeconomic status. Pers Soc Psychol Bull. 2022;48:463–77.

Zhu Y, Wei R, Lo V-H, Zhang M, Li Z. Collectivism and altruistic behavior: a third-person effect study of COVID-19 news among Wuhan residents. Glob Media China. 2021;6:476–91.

Yang F, Horning M. Reluctant to share: how third person perceptions of fake news discourage news readers from sharing “real news” on social media. Soc Media Soc. 2020;6:205630512095517.

Adams K, Hean S, Sturgis P, Clark JM. Investigating the factors influencing professional identity of first-year health and social care students. Learn Health Soc Care. 2006;5(2):55–68.

丁汉青, 王军. 冲突与协调: 传媒从业者后备军职业认同状况研究——以北京某高校新闻学院在校生为例. 国际新闻界, 2019;2 :113–131.

Yoo B, Donthu N, Lenartowicz T. Measuring Hofstede’s five dimensions of cultural values at the individual level: development and validation of. J Int Consum Mark. 2011;23(3-4):193-210.

Tandoc EC, Lim D, Ling R. Diffusion of disinformation: how social media users respond to fake news and why. Journalism. 2020;21:381–98.

Tan ASL, Lee C, Chae J. Exposure to health (Mis)Information: lagged effects on young adults’ health behaviors and potential pathways. J Commun. 2015.

Tully M, Bode L, Vraga EK. Mobilizing users: does exposure to misinformation and its correction affect users’ responses to a health misinformation post? Soc Media Soc. 2020;6:205630512097837.

Arbuckle JL. Full information estimation in the presence of in complete data. In: Marcoulides GA, Schumaker RE, editors. Advanced structural equation modeling: issues and techniques. Mahwah: Erlbaum; 1996. p. 243–77.

Narayanan A. A review of eight software packages for structural equation modeling. Am Stat. 2012;66(2):129–38.

Sakaria D, Maat SM, Mohd Matore MEE. Examining the optimal choice of SEM statistical software packages for sustainable mathematics education: a systematic review. Sustainability. 2023;15(4):3209.

Fornell C, Larcker DF. Evaluating structural equation models with unobservable variables and measurement error. J Mark Res. 1981;18(1):39–50.

Wheaton B, Muthen B, Alwin DF, Summers GF. Assessing reliability and stability in panel models. Sociol Methodol. 1977;8:84–136.

Hu LT, Bentler PM. Cutoff criteria for fit indexes in covariance structure analysis: conventional criteria versus new alternatives. Struct Equ Modeling. 1999;6(1):1–55.

Ho SS, Goh TJ, Leung YW. Let’s nab fake science news: predicting scientists’ support for interventions using the influence of presumed media influence model. Journalism. 2022;23:910–28.

Bhagavathula AS, Aldhaleei WA, Rahmani J, Mahabadi MA, Bandari DK. Knowledge and perceptions of COVID-19 among health care workers: cross-sectional study. JMIR Public Health Surveill. 2020;6(2):e19160.

Jung EH, Zhang L, Nekmat E. SNS usage and third-person effects in the risk perception of Zika virus among Singaporean Women. J Health Commun. 2020;25:736–44.

Stavrositu CD, Kim J. Social media metrics: third-person perceptions of health information. Comput Hum Behav. 2014;35:61–7.

Wei R, Lo VH, Lu HY. Third-person effects of health news: exploring the relationships among media exposure, presumed media influence, and behavioral intentions. Am Behav Sci. 2008;52:261–77.

Hong SC. Presumed effects of “fake news” on the global warming discussion in a cross-cultural context. Sustainability. 2020;12(5).

Neuwirth K, Frederick E. Extending the framework of third-, first-, and second-person effects. Mass Commun Soc. 2002;5:113–40.

Bastick Z. Would you notice if fake news changed your behavior? An experiment on the unconscious effects of disinformation. Comput Hum Behav. 2021;116.

Harff D, Bollen C, Schmuck D. Responses to social media influencers’ misinformation about COVID-19: a pre-registered multiple-exposure experiment. Media Psychol. 2022;25:831–50.

Download references

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).

Author information

Authors and affiliations.

Journalism and Information Communication School, Huazhong University of Science and Technology, Wuhan, Hubei, China

Zongya Li & Jun Yan

You can also search for this author in PubMed   Google Scholar

Contributions

Zongya Li wrote the main manuscript and Jun yan collected the data. All authors reviewed the manuscript.

Corresponding author

Correspondence to Jun Yan .

Ethics declarations

Ethics approval and consent to participate.

This study was approved by the Medical Ethics Committee of Union Hospital Affiliated to Tongji Medical College, Huazhong University of Science and Technology (approval number: 2022S009). All the participants provided informed consent to engage in this research.

Consent for publication

The authors give their consent for the publication of identifiable details, which can include photograph(s) and/or videos and/or case history and/or details within the manuscript to be published in the BMC Public Health.

Competing interests

The authors declare no competing interests.

Additional information

Publisher’s note.

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/ . The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/ ) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Cite this article.

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

Download citation

Received : 08 December 2023

Accepted : 02 May 2024

Published : 11 May 2024

DOI : https://doi.org/10.1186/s12889-024-18763-9

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Digital misinformation
• Third-person perception
• Pre-professionals
• Professional identification

BMC Public Health

ISSN: 1471-2458

• Submission enquiries: [email protected]
• General enquiries: [email protected]

• Open supplemental data
• Reference Manager
• Simple TEXT file

People also looked at

Original research article, local perspectives on marine ecotourism development in a water-insecure island region: the case of bocas del toro, panama.

• 1 Ocean Nexus, Dalhousie University, Marine Affairs Program, Halifax, NS, Canada
• 2 Center for Tropical Island Biodiversity Studies, The School for Field Studies, Bocas del Toro, Panama

As a dimension of a blue economy, marine ecotourism should, in theory, not only increase economic viability and environmental sustainability but, most importantly, pursue socially equitable outcomes. In tropical and sub-tropical island regions, where substantial tourism development is often coupled with widespread strains on public infrastructure and services, including water access, there exists a need to better understand the expansion of this industry is felt at the community level; more importantly by individuals who are reliant on these infrastructures and services. Through a case study of the Bocas del Toro Archipelago, where water insecurity is becoming acute, we draw on and mobilize stories from local community members, alongside non-participant observations and document collection, to 1) document the experience of some community members with water insecurity and shortages, including how they perceive the roles played by the central government and marine ecotourism sector, and 2) examine how community members feel about how communities feel about policies and investment priorities of the central government regarding water insecurity, including the extent to which they view marine ecotourism development as undermining or promoting local needs. Our results underline the complex nature of marine ecotourism governance and infrastructure development outcomes in a resource-insecure island region, demonstrating that current issues are greatly impacted by historical and social underpinnings of neo-colonialism and systemic racism, misalignments of community vs. government development priorities, and eroded political trust, that shape local experiences with sustainable development and local residents’ perceptions of the ability of marine ecotourism to address issues of water insecurity. Moreover, while our focus is on the marine ecotourism industry, the significance of these findings contributes to a growing body of literature that places local experiences at the forefront of research into the implications of sustainable development in island regions.

Introduction

The marine ecotourism industry is considered to be a dimension of a ‘blue economy’; an ocean-wide sustainable development strategy proposed by Small Island Developing States (SIDS) in 2012 to “promote economic growth, social inclusion, and preservation or improvement of livelihoods, while at the same time ensuring environmental sustainability” ( World Bank and UN DESA, 2017 , p.1). In theory, marine ecotourism should not only increase economic viability and environmental sustainability but, most importantly, pursue social equity—a “distinctive system of individualized justice” ( Minow, 2021 , p.173). In island regions, where substantial tourism appeal is often coupled with widespread issues of water insecurity ( Cole, 2012 ; Gössling et al., 2012 ; Gossling, 2015 ), this study explores questions regarding the ability of a blue economy strategy, rooted in marine ecotourism, to equitably address both development and well-being in the eyes of those local to island regions. In this paper, we refer exclusively to tropical and sub-tropical islands when discussing ‘islands’ or ‘island regions.’

In island regions, local blue economies are often heavily reliant on the marine tourism industry ( UNWTO, 2023 ). However, as per Leposa (2020) , large volumes of tourists, and the services required to support them (e.g., transportation, accommodation, food and beverage, recreation, etc.), can exacerbate existing issues of local public utility access, often due to infrastructural deficiencies or inherent vulnerabilities to climate change. Important to this study, in particular, is the relationship between the marine ecotourism industry and the availability and management of water resources.

To our knowledge there exist few studies that sit at the intersection of marine ecotourism and water insecurity in island regions specifically; less so those that are guided by, and draw conclusions from, the experiences of those individuals that most closely feel their impacts. As the push for blue economic development continues to grow ( Cisneros-Montemayor et al., 2021 ; Pace et al., 2023 ), and water insecurity becomes increasingly prevalent in climate-vulnerable regions ( Winters et al., 2022 ; Crisman and Winters, 2023 ), failing to capture how the two intersect and are felt at the community level could pose risks of conducting research with communities as the ‘subject’ rather than active participants and beneficiaries of the research process ( Israel et al., 2019 ), and/or informing policies that do not capture the nuances of community interests and needs ( Freudenberg and Tsui, 2014 ; Cisneros-Montemayor et al., 2019 ).

Marine ecotourism can be described as a “nature-based; environmentally educated; and sustainably managed” ocean tourism industry involving activities such as recreational fishing, snorkelling, whale watching, and SCUBA diving, for example ( Blamey, 2001 , p.6). Modern definitions also include dimensions of local benefits ( Sakellariadou, 2014 ; Das and Chatterjee, 2015 ; Ramos-García et al., 2017 ; Tuwo et al., 2021 ). This can entail increasing market demand for locally produced goods, the use of, and investment in, local facilities and infrastructure, opportunities for local entrepreneurship, and the generation of new revenue streams that remain within a community, for example ( Sakellariadou, 2014 ).

Unlike traditional mass tourism models, marine ecotourism adopts aspects of environmental conservation and promotes community involvement. However, when these tenets are not upheld, due to a variety of reasons (e.g., poor management, lack of community involvement, limited enforcement regimes, etc.), the industry can promote unsustainable practices on all fronts—economic, social, and environmental ( Hoyman and McCall, 2013 ; Rahman et al., 2022 ; Zeng et al., 2022 ). As such, recent scholarship has called for a re-prioritization of social sustainability within blue economic development ( Pascual et al., 2014 ; Bennett et al., 2019 ; Leposa, 2020 ; Nugraheni et al., 2020 ; Osterblum et al., 2020 ; Campbell et al., 2021 ; Cisneros-Montemayor et al., 2021 ), with concerns raised regarding the implication of developing marine industries in areas where there is significant need to consume and manage resources sustainably.

The United Nations (UN) refers to water security as the ability of a population to safeguard sustainable access to adequate quantities and quality of water for the support of livelihoods, human well-being and socio-economic development ( UN Water, 2013 ). In this sense, water in security is the condition in which at least one of the above variables (i.e., quantity, quality, or accessibility) is not met, threatening human well-being. While many island regions have some degree of established water infrastructure, the coincidence of ‘dry season’ and peak tourist landings can perpetuate regional instabilities in water security, where local residents compete for this essential yet scarce resource; both with tourists and between communities ( Gheuens et al., 2019 ).

In this study, we draw on and mobilize stories of local residents in a heavily touristed island to better understand how the relationship between marine ecotourism and water insecurity manifests at the community level. We explore the case of Panama’s Bocas del Toro Archipelago (henceforth referred to as ‘Bocas del Toro’ or ‘the archipelago’), where substantial tourism appeal and infrastructural issues coexist, as a microcosm of the paradox of pursuing a marine ecotourism-based blue economy in a water insecure island region. Through integrating non-participant observations and collected documents with a series of semi-structured interview responses we aim to 1) document the experience of some community members with water insecurity and shortages, including how they perceive the roles played by the central government and marine ecotourism sector, and 2) examine whether community members feel as though water insecurity and shortages have influenced policies and economic investment and the extent to which marine ecotourism development may undermine or promote changes.

Our results underline the dynamic and complex nature of marine ecotourism governance and infrastructure development outcomes in a resource-insecure island region, highlighting the historical, political, and social underpinnings that shape perceptions of, and poor experiences with, blue economic. While our focus is on the marine ecotourism industry, the significance of these findings contributes to a growing body of literature that places local experiences at the forefront of research into the implications of sustainable development in island regions.

Island development and marine ecotourism

Although often associated with ‘paradise’ ( Baldacchino, 2012 ), island nations are considered, by the UN, to be some of the world’s ‘least developed’ nations (UN, n.d.), with island regions often referred to as ‘vulnerable,’ given their narrow resource bases, remoteness, and susceptibility to natural hazards and external economic shocks ( Baldacchino, 2012 ; Belmar et al., 2016 ; Lucas et al., 2017 ; Nunn and Kumar, 2017 ). That said, it is important to note that this explicitly reflects the barriers that may limit attempts to garner increased economic prosperity and/or development capacity rather than island societies as a whole.

As described by ( Grydehøj et al., 2021 , p.4), in reflecting upon Hau’ofa (1994) , the modern development and governance of island resources is also often heavily steeped in colonialism, where Western standards for ‘successful’ development are far too narrow in their economic, geographic, and cultural views. Dating back to the 15th century, island states have faced oppression from the United States, France, Spain, England, and the Netherlands ( Keegan and Diamond, 1987 ; Leposa, 2020 ). While there remain proponents of some aspects of the colonial legacy ( Feyrer and Sacerdote, 2009 ), Kay (2010) maintains that colonialism, in Latin America specifically, has led to harmful endo -colonial relations that sit at the root of present-day developmental inequities. In the Caribbean, Sealy (2018) notes that colonization has not only impacted the regional ethnic makeup, but that the perpetuation of globalization as a neo-colonial structure has created a larger dependence on investments from the Global North. Overall, there exists a small body of literature that discusses the role of the blue economy in perpetuating or combating neo-colonialism. However, scholarship surrounding the colonization of islands maintains that neo-colonialism can propagate harmful outcomes of sustainable development projects such as marine ecotourism ( Heim, 2017 ; Durokifa and Ijeoma, 2018 ; Grydehøj et al., 2021 ).

Typically, ‘tourism intensive’ island regions derive a substantial proportion of their economic development from the marine ecotourism industry ( Adamiak and Szyda, 2022 ). McElroy (2006) refers to tourist-driven island economies as SITES (‘Small Island Tourist Economies’), describing the expansion of tourism as a prominent development strategy for small economies, where there exist large dependencies on the industry. While, marine ecotourism can lead to a host of benefits, research in the island context specifically, more often notes the potential consequences of such development in destinations considered to be on the ‘global periphery’ ( Dodds and Graci, 2012 ). For example, while ecotourism may produce local job opportunities, Das and Chatterjee (2015) posit that community members are more often placed in low-skill and/or low-pay roles. Moreover, Harrison and Prasad (2011) found that in Fiji, for example, there exist high levels of benefit leakages to foreign investors. In Bocas del Toro, specifically ( Scott et al., 2024 , p.2), explain that tourism-related development can lead to inequitable impacts through the promotion of real estate ventures in culturally significant areas, like mangroves, where investors may view the local environment as “obstacles to achieving ‘paradise.’”

Bocas del Toro, Panama

Located off the Caribbean coast of Panama, Bocas del Toro is one of the country’s top ecotourism destinations. It consists of approximately nine islands and 200 islets and is home to a population of approximately 22,500 across the larger Bocas del Toro district ( INEC, 2021 ). Attributable to a history of colonialism, the construction of the Panama Canal, and the cultivation of a plantation economy, among other reasons, the region is also home to a variety of distinct racial and cultural groups including Ngäbe peoples (those indigenous to present-day Panama and Costa Rica), Panamanians, Afro-Antilleans, and Chinese individuals, for example ( Guerrón-Montero, 2006 ; Carse, 2014 ; Suman and Spalding, 2018 ). Moreover, Bocas del Toro’s most developed islands have become increasingly inhabited by lifestyle migrants—relatively affluent individuals with the capacity to move to destinations, typically in the Global South, with warmer climates, a lower cost of living, and a seemingly higher quality of life—from the United States ( Benson, 2013 ; Spalding, 2013 ).

Although not formally considered an autonomous state, Bocas del Toro displays many of the hallmark characteristics of a SIDS as per the UN Office of the High Representative for the Least Developed Countries, Landlocked Developing Countries and Small Island Developing States ( UN-OHRLLS, 2022 ). It is home to both a distinct societal makeup and unique marine ecosystems ( Seemann et al., 2014 ; Pleasant and Spalding, 2021 ), and faces documented issues of infrastructural development and geographic isolation from larger global markets ( Tilmans et al., 2014 ; Pleasant and Spalding, 2021 ).

Bocas del Toro’s economy is predominantly supported by the tourism industry; across the larger Bocas del Toro province, tourism makes up 95% of all economic activity, greatly exceeding the national average ( Klytchnikova and Dorosh, 2013 ). The most lucrative form of tourism is referred to by the Autoridad de Turismo de Panama (Tourism Authority of Panama; ATP) as ‘island ecotourism’ ( ATP, 2020 ), with the most popular destinations being Starfish Beach, Red Frog Beach, and Isla Bastimentos National Marine Park ( Camarca de Turismo de Bocas del Toro, 2022 ). While the ATP does not explicitly refer to ‘marine ecotourism’ in their reporting, for the purposes of this study, ‘island ecotourism’ and ‘marine ecotourism’ will be considered synonymous, as their accepted definitions align greatly.

Common marine ecotourism-based businesses in the region include boat tours and taxis, restaurants, hostels, and gift shops, with much of the region’s tourism development concentrated in Bocas Town, Isla Colón, where an average of 150,000 tourists visited annually pre-COVID-19 pandemic ( Gray et al., 2015 ). Strikingly, although Bocas del Toro now sees approximately 225,000 tourists per year, the Bocas del Toro province remains one of the poorest in the nation ( CECOMRO, 2018 ; ATP, 2020 ).

Moreover, to appreciate the nuances of Bocas del Toro’s current socioeconomic landscape, one must also understand its economic history, which is closely tied to colonial resource extraction. In the early 20 th century, the construction of the Panama Canal and the establishment of the U.S. Canal Zone cemented the United States as a major player in the Panamanian economy. In Bocas del Toro, specifically, this presence was predominantly felt through the establishment of the United Fruit Company (UFC), an American-owned corporation trading in Latin American-grown fruit, namely bananas ( Pleasant and Spalding, 2021 ). Typically supporting the UFC’s operations were Afro-Caribbean and Ngäbe workers, as well as labour migrants from China and Italy ( Spalding, 2011 ). This created harmful shifts in power, as Black and Indigenous individuals were often exploited and marginalized through the imposition of a globally capitalistic system ( Amin, 1978 ). While small-scale operations remain (now Chiquita Brands International), the UFC’s presence in the archipelago declined greatly by 1990 due to war, crop diseases, and labour losses (as a result of poor pay and working conditions) ( Guerrón-Montero, 2006 ), making way for a burgeoning tourism industry by the 2000s, as many large-scale housing developments were left vacant and global interest in the region increased following the 1991 earthquake.

Today, the archipelago’s socioeconomic and environmental systems are inextricably linked to the marine ecotourism industry, attracting individuals looking to experience its vibrant culture, beautiful beaches, and ocean life ( Klytchnikova and Dorosh, 2013 ; Spalding et al., 2015 ; Lucas, 2019 ; ATP, 2020 ; Mach and Vahradian, 2021 ; Pleasant and Spalding, 2021 ; Bocas del Toro Tourism, 2023 ). That said, tourism infrastructure across Bocas del Toro has been deemed ‘suboptimal’ by the ATP, specifically as it pertains to the limitation of physical space and the overload of basic services, such as water provisioning ( ATP, 2020 ). Critical to this study, Bocas del Toro is also home to widespread issues of water insecurity; the majority of households across archipelago do not have access to running water supplied by the Instituto de Acueductos y Alcantarillados Nacionales (Institute of Aquaducts and Sewers; IDAAN), with 23% of the population instead turning to bottled water or drinking unfiltered rainwater respectively ( CNA, 2016 ) ( Figure 1 ). In fact, just 1.9% of the total residences connected to IDAAN’s services reside in the Bocas del Toro province ( IDAAN, 2022 ). As such, water insecurity is among the region’s most precarious issues.

Figure 1 Regional water insecurity across the Bocas del Toro Archipelago represented by the percentage of households in each census region without access to running water. The population density of each region in relation to the archipelago’s total population is also represented. Uncoloured areas represent regions outside of the archipelago or those not captured by the Panamanian Census. Created using the 2010 Panamanian Census Data, accessed from the STRI GIS Data Portal (2019) .

In this study we employ a multi-method approach—the combining of two or more methods to expand one’s research base when investigating a research question or phenomenon ( Roller and Lavrakas, 2015 )—that is firmly rooted in local experiences and perceptions. This includes the use of semi-structured interviews, non-participant observation, and document collection. While our approach pulls from that of political ecology, we do not attempt to formally mobilize methods typically used in such studies (e.g., Cole, 2012 ), but rather utilize participant responses to deduce the governance processes, historical events, etc., that frame their experiences with marine ecotourism and water insecurity. It should be noted that the data collection period in Bocas del Toro (May 25 th , 2023 to June 27 th , 2023) also coincided with a water shortage; declared an environmental emergency on June 9 th , 2023.

Semi-structured interviews

A member of our research team travelled to Bocas del Toro from May 25 th , 2023 to June 9 th , 2023 to conduct semi-structured interviews; asking participants open-ended questions to elicit information regarding one’s research topic ( Adeoye-Olatunde and Olenik, 2021 ). During this time, a total of 16 individuals, including members of the Bocas del Toro Chamber of Tourism, property owners, business owners, tour guides, labourers, and concerned citizens, were interviewed. Participants in this process—those older than 18 years of age and who have lived in the region for over 5 years—were identified through a purposive snowball method ( Weiss, 1994 ), beginning with contacts provided by a local informant.

Topics discussed (i.e., water shortages, infrastructure, economic and tourism development, and overall welfare) were drawn from a pre-determined interview guide developed through preliminary document collection and with guidance from researchers in the region (see Supplementary Table 3 ). While the guide was used to facilitate conversation, it adapted as more information was provided and new events occurred (i.e., the onset of an environmental emergency during the interview period). Interviews lasted an average of one hour and, depending on the participant’s level of comfort, were conducted in both English and Spanish (with an interpreter translating responses). Due to participant location and the accessibility of each island, interviews took place across three of Bocas del Toro’s nine main islands—Isla Colón, Isla Carenero, and Isla San Cristóbal ( Table 1 ).

Table 1 Socioeconomic and geographic description of interview locations/study sites.

Non-participant observation

To support responses collected during interviews, non-participant observation—observing and documenting an event without actively participating in activities ( Becker and Geer, 1957 )—was used to explore how ecotourist attractions function across the archipelago and further understand how communities respond to, and navigate, water shortages. Observed events were identified through community contacts established during the interview period as well as local WhatsApp groups; typically used to share important information across the region. They included waiting in line at public wells, visiting an ecotourist attraction, observing protests regarding water access, and attending a public meeting with IDAAN (further event details available in Supplementary Table 4 ). The average observation process lasted approximately one hour and involved taking notes regarding what did and did not occur, what demographic of individuals were present, and the overall tone of those present.

Document collection

Given that this is the first study to investigate topics of marine ecotourism and water insecurity in Bocas del Toro, supplementary grey literature was sought out to provide wider context and breadth to the study. Documents were found by searching for qualitative phrases related to drought, water, and tourism in Bocas del Toro in Google and the Bocas Breeze Newspaper database. Documents collected include government policies, local news articles, and regional reports.

The analysis of the data was guided by an inductive, constant comparative approach, as per Hodkinson (2008) and Glaser (1965) , whereby we sought to increase our understanding of potential underlying theories and identify emergent themes through a constant back-and-forth engagement with the data. In practice, this first involved transcribing and digitizing interview responses and observation notes. The data was then coded categorically (e.g., the codes ‘GOV-TOURISM’ and ‘GOV-WATER’ were utilized whenever a participant described how they felt about and experienced tourism and water governance respectively), and supplemental documents were reviewed to compare and contrast with interview and observational data.

In an effort to mirror the anecdotal nature of the data collected, here we weave together interview responses, observational notes, and document insights to describe how the economic development of Bocas del Toro, governance processes, experiences with water shortages, and future development in the region, shape local experiences with, and perceptions of, marine ecotourism and water insecurity. Figure 2 demonstrates a timeline of events and governance developments described by participants, as well as relevant events to contextualize the case.

Figure 2 Timeline of events and developments regarding ecotourism and water security in Bocas del Toro, Panama. The timeline presented is not exhaustive of all related moments in history, but rather those relevant to this particular study. Entries on the left of the timeline represent historical events, while those on the left represent policies and plans. ATP refers to the Tourism Authority of Panama; IDAAN refers to the Institute of Aquaducts and Sewers.

Beaches as the new bananas–shifting to a tourism-based economy

With increased neoliberal capital interest, government incentives to purchase land for tourism, and an abundance of global interest, tourism in Bocas del Toro effectively ‘exploded’ by the year 2000, signifying, as put by Pleasant and Spalding (2021) , a shift from a banana-based export economy created by the UFC to a tourism-centric economy based on the region’s beaches and biodiversity. Despite this shift, the UFC’s presence in Bocas del Toro remains prominent, as it had become integrated into the region’s social and infrastructural fabric (e.g., the creation of communication networks, railway systems, power plants, medical facilities, and housing developments) (United Fruit Historical Society, n.d.). Furthermore, when asked about the UFC in Bocas del Toro, participants described how a dependency on a singular industry and foreign entity resulted in harmful losses of traditional livelihoods, such as fishing and agriculture—”we used to be farmers who could feed ourselves, now we’ve lost this completely,” said one property owner.

Among those participants directly employed by the tourism industry, all spoke positively about the renewed economic benefit it brings. As one tour operator put it, “the money is in tourism, the experiences.” Of those participants situated outside of the industry, a majority also acknowledged that marine ecotourism does play a major role in supporting the local economy— “tourism is good,” noted a construction worker we spoke with, “yeah it’s good because it makes work and brings in money to us when it’s done right.”

That said, there remains great skepticism across all participants surrounding the industry’s future in Bocas del Toro:

“I used to fully believe that tourism was the key to successful cities with no opportunities.

But then we have fragile societies like we have in Latin America, and there’s not a strong

government that actually tries to implement human development. It is not taking us to the

right place,” said a member of the Bocas del Toro Chamber of Tourism.

When asked what she believes to be the largest development project in the community, one business owner responded:

“Tourists. But it grew alone. It grows alone … It’s incredible. Bocas [del Toro] has been developed in many ways, but not in basic things. It keeps growing, growing, growing, and I don’t see [public utilities] growing with it.”

Navigating an era of sustainable development – tourism and water governance

In contextualizing participant responses, we offer a brief exploration of relevant actors, plans, and policies as they pertain to marine ecotourism and water governance in Bocas del Toro. The overarching development of Panama’s marine sector is directed by the Ministerio de Relaciones Exteriores (Ministry of Foreign Affairs), Ministerio de Ambiente (Ministry of the Environment; MiAMBIENTE), and the UN Development Programme via the Política Nacional de Océanos de Panamá ( National Ocean Policy of Panama; NOP). Ratified in 2022, the goal of the NOP is to pursue a ‘Blue Panama,’ where “marine and coastal resources are protected, conserved, valued, and used sustainably, positively impacting the quality of life of citizens in an inclusive and participatory manner” ( MiAMBIENTE, 2022 , p.13). To do so, blue economic development, internally defined as the “sustainable use of marine and coastal resources…, approaching marine-coastal activities under the prism of balance between the three social, economic and environmental dimensions,” is prioritized as one of 4 strategic axes ( MiAMBIENTE, 2022 , p.21). Central to this, under Goal M. 27, is the “promotion of sustainable tourism development linked to the oceans” ( MiAMBIENTE, 2022 , p.21), where the NOP yields much of the responsibility around this directive to the ATP.

Since 2008, the ATP has been responsible for “the development, promotion, and regulation of tourism as an activity”; maintaining tourist resources, protecting the ecological balance of the land, and respecting the customs of its inhabitants ( Decreto Ley No.4, 2008 , p.1). When asked about their feelings towards the ATP, virtually all participants expressed concern regarding tourism governance in Bocas del Toro, and its ability to “make things happen.” According to one individual, tourism in Bocas del Toro is “governed by people who don’t have morals, they are just selfish. If it doesn’t make them money, they don’t do it.” At the community level, tourism in Bocas del Toro is monitored by the Cámara Turismo Bocas del Toro (Bocas del Toro Chamber of Tourism), a non-profit community organization that works to organize the local tourism sector and protect its longevity ( CTB, 2023 ). Nonetheless, the Chamber of Tourism is not afforded government funds or jurisdiction to carry out and/or enforce such endeavours and does not play a large role in high-level decision-making regarding tourism in the archipelago ( ATP, 2020 ). According to a member of the Chamber of Tourism, this creates issues surrounding community input, whereby the community is neither adequately consulted nor are their ideas accurately integrated into development plans:

“We are a private sector, but we have no say or worth in the final decision. [The ATP] says: ‘We met with the Chamber of Tourism and the chamber is approving [the development]’. But later, when we come and tell you all the things wrong with the plan, they say ‘Oh no, you came up with this idea, the Chamber approved it’…We don’t want that; we don’t need that. We need real things.”

At large, plans for tourism development in Bocas del Toro are organized under the Plan Maestro de Desarrollo Turístico Sostenible 2020-2050 (Master Plan for Sustainable Tourism Development 2020-2050; MPSTD), with goals to promote Panamanian tourism, improve global competitiveness, decentralize tourism operations, and develop state tourism policies ( ATP, 2020 ). In Bocas del Toro, the MPSTD’s Action Plan includes a total of 19 actions and 75 projects. Of this, 6 projects fall under Action 2.4.4. Improvement of Basic Infrastructures, including a project to, in tandem with IDAAN, “improve the drinking water supply system on Isla Colón” by 2022 ( ATP, 2020 , p.316). Despite this, participants were wary as to whether these plans would ever “hit the ground,” as put by one individual. “The [MPSTD] is a plan,” said a member of the Chamber of Tourism, “but if you do nothing to implement it, it’s not going to change. I haven’t seen any real action.” “You don’t need the government. The government is not going to do it. Because the government has no brain to think,” expressed another member of the community.

The implementation of these projects is largely overseen by IDAAN, with more specific water infrastructure improvement plans for Bocas del Toro listed in Panama’s Plan Nacional de Seguridad Hídrica 2015-2050 (National Plan for Water Security 2015-2050; NPWS). The NPWS serves as a roadmap for ensuring that “every person in [Panama] has sustained access to quality water and basic sanitation,” with a focus on “eliminating inequalities of access in an inclusive and equitable manner” ( CNA, 2016 , p.65). In pursuit of this, the NPSW budgets 3.3 billion USD to address issues of drinking water in Isla Colón exclusively, including improvements to catchments and sewage systems ( CNA, 2016 ). However, while the NPSW projects that all individuals in the Bocas del Toro province will have access to drinking water by 2025, as will be described in subsequent sections, participants note that, as of 2023, they are skeptical as to whether this goal will ever be reached. As one business owner put it, “it’s only plans plans. But when you go to practice? No, nothing happens.”

Accessing water in Bocas del Toro – a myriad of methods

Very limited formal documentation on water infrastructure and distribution processes in Bocas del Toro is publicly available; as put by one participant, “nobody really knows exactly how the water works [in Bocas del Toro].” Despite this, with insights from community members, we attempt here to establish a clearer picture of water distribution across the study sites ( Figure 3 ), highlighting the intensity of water insecurity in Bocas del Toro and inform how marine ecotourism might impact water access.

Figure 3 Maps of approximate locations of examples of water infrastructure across Isla Colón/Isla Carenero (A) , and Isla San Cristóbal (B) as described by participants. Image 1—a newly constructed water reserve tank. Image 2—a typical public well in Isla Colón. Image 3—Big Creek Reservoir. Image 4—IDAAN water processing station. Image 5—a typical rain catchment system in Isla Colón. Image 6—a water tanker deployed during water shortages. Image 7—water line that connects Isla Colón and Isla Carenero. Image 8—a typical rain catchment system in Isla Carenero. Image 9—water catchment station in Isla San Cristóbal. Image 10—underground pipe system in Isla San Cristóbal. Images 1-3 and 5-10 were taken by Abigael Kim. Image 4 is reprinted from the IDAAN Water Treatment Plant Database ( https://sig-idaan.hub.arcgis.com/apps/0a722564d72f421798b33b902ebef781/explore ).

Residents of Isla Colón typically access water through IDAAN’s public distribution system, and/or via public or private wells. IDAAN services over 9,000 individuals across the southern region of Isla Colón through an underground pipe system powered by gravity and a select number of pumps. While it is widely understood this water, supplied by a local reservoir (‘Big Creek’) ( Figure 3 , Point 3), is filtered at a nearby plant ( Figure 3 , Point 4), the efficacy of this process remains highly debated ( Corea, 2016 ; Telemetro, 2022 ; Albaez, 2023 ; Godoy, 2023 ; Ortiz, 2023 ). When asked whether she would drink water from her tap, one shop owner responded, “I’m not gonna do that,” while her partner added that the water is often “yellow or brown” in colour. This system is also subject to the impacts of ‘dry season’ in the Caribbean (October to April), when services are often limited by IDAAN to two hours in the morning and evening. Regions of the island not serviced by IDAAN rely on rainwater collection ( Figure 3 , Point 5) or the use of public or private wells ( Figure 3 , Point 2). As of today, there exist eight IDAAN wells in Isla Colón, with only four in constant operation, while private wells on the island are typically located in regions populated by lifestyle migrants and affluent families. That said, virtually all wells across the archipelago require electricity, of which the local supply is highly unpredictable.

In Isla Carenero, those residing along the island’s perimeter typically rely on underwater pipes that distribute water sourced from IDAAN’s system in Isla Colón ( Figure 3 , Point 7). That said, participants noted that this process is unreliable, as there is often not enough water pressure from Big Creek to reach the shores of Isla Carenero. According to a local restaurant owner, “[Isla] Carenero has huge water problems. When there is no water there, [they] struggle the most.” Participants from Isla Carenero also noted that it is common to utilize rain collection systems ( Figure 3 , Point 8) or to travel to Isla Colón to purchase jugs of water. Furthermore, many restaurants and tourist operations on the island utilize private wells to service their patrons, while lifestyle migrants are also known to have access to private wells.

Isla Colón and Isla Carenero are the only islands (out of nine that are inhabited) to have direct access to IDAAN’s services. Other islands, like Isla San Cristóbal, rely on community-led initiatives or the purchasing of water jugs from Isla Colón. As described by a local tour guide, approximately 600 individuals on Isla San Cristóbal access water via a natural catchment system and man-made storage and distribution point developed through a fundraising project by local and international organizations ( Figure 3 , Point 9). The storage point collects water from the island’s northern mountain region, filters it for solids, and distributes it to the community via gravity and underground pipes ( Figure 3 , Point 10). According to a local tour guide, this process is quite reliable; during times of drought, residents of other islands have looked to him for water.

Frustrations run high – a history of water shortages

Bocas del Toro has faced (documented) water shortages in 2016, 2017, 2019, 2022, and 2023. One restaurant owner noted that, while “water has always been an issue in [Bocas del Toro],” the problem “has never been this bad.” Following a prolonged period of drought and water restrictions, as well as pressure from MiAMBIENTE, a State of Environmental Emergency was declared by the Cabinet of Panama in both 2022 (November 8 th ) and 2023 (May 30 th ) ( Resolución de Gabinete No. 127, 2022 ; Resolución de Gabinete No. 48, 2023 ). Doing so authorizes IDAAN to enact the region’s ‘Contingency Plan’, involving the assignment of water trucks to distribute potable water to affected businesses and residences on Isla Colón and Isla Carenero, the increase of water conduction line diameters, the activation of additional wells, and the increase of regional technical support ( IDAAN, n.d. ).

During this type of Environmental Emergency, those without private well access typically purchase water jugs from local shops, fill their household tanks at public wells, or fill up smaller jugs from IDAAN trucks ( Figure 3 , Point 6). However, participants mentioned that such alternative methods are not sufficient, leaving many without water for days on end. One souvenir vendor, for example, mentioned that she had not been able to shower in “over 8 days.” Moreover, as lines for local wells grow, business owners mentioned that these trucks are extremely challenging to access, having to “choose between running [their] shops and getting water.”

Overall, aside from climate change as a catalyst, there is no largely agreed-upon answer or government consensus as to why water management and infrastructure are so precarious or why Bocas del Toro feels droughts so intensely. However, participants speculated that they have something to do with the coinciding of ‘dry season’ and tourist season in the fall. As mentioned in the Bocas Breeze Newspaper in response to the 2016 shortage:

“In recent years, sometimes it doesn’t rain for a while or excited tourists flood the island in

record numbers and when you turn the faucet, you are met with the depressing sound of a

‘drip, drip, (silence)…’ Maybe you left your toilet running and your tank has gone empty, or

perhaps the town reservoir has gone dry” (2016).

Undoubtedly at the center of these frustrations is IDAAN, more specifically as it pertains to the uneven distribution of water and lack of government accountability. According to IDAAN, water trucks are to deliver water to both city centres and residential areas. However, almost all participants mentioned that this system is not well executed, citing disparities in where water was being delivered during the 2023 shortage. “Unfortunately, there is a bad distribution of the water and trucks,” one tour operator said, “they don’t have a good plan for giving out the water, so they pass me by.” More specifically, many participants mentioned that hotels are often prioritized, and speculated that truck drivers were being paid a premium by these establishments to visit them first. “A government truck should be for the community,” said one community member, “but it doesn’t happen in Panama.”

Participants also expressed frustration with IDAAN’s accountability during these shortages. “I don’t look to the government for water,” said one individual, “I pray to God.” During the 2023 shortage, in particular, many community members were left with unanswered questions, as the regional IDAAN phone line for Bocas del Toro was disconnected, and public meetings with IDAAN were continuously cancelled. As was seen on multiple occasions during the 2023 shortage, such feelings often led to public displays of frustration, in the form of road blockades and protests; “we don’t just wait for water, we have to block the streets for water,” said one shop owner.

In June 2023, after over a month without reliable access to running water, IDAAN announced the connection of two additional wells to supplement Big Creek while precipitation levels remained low ( Ortiz, 2023 ). Despite these developments, residents of both Isla Colón and Isla Carenero still face water insecurity at large, with water remaining a contentious issue across the archipelago.

A potential paradox? – Future plans for water infrastructure and marine ecotourism

Looking towards 2050, Bocas del Toro is the topic of numerous development projects in both marine ecotourism and water infrastructure. However, participants expressed disappointment about the priorities of the central government’s plans and were skeptical of their potential outcomes.

In 2022, under the NPSW, IDAAN announced a 10 million USD investment in the “study, design, construction, operation, and maintenance of improvements to the components of the aqueduct in Isla Colón” ( Ortiz, 2023 , p.1). According to Albaez (2023) , this includes a 3-Phase Plan to develop a more reliable 24-hour public, potable water supply system:

● Phase 1—Well drilling/maintenance and construction of a water storage tank with a 700,000-gallon capacity.

● Phase 2—Construction of well-housing units and pumping equipment.

● Phase 3—Construction of supplementary desalinization plant and improvements to water treatment plant and dispensers.

Despite reports that 60% of the project has been completed as of May 2023 ( Ortiz, 2023 ), including the totality of Phase 1 and the maintenance of public well systems from Phase 2, none of the participants indicated that they had seen improvements in their water supply, but instead questioned the efficacy of IDAAN’s projects. For example, one participant referred to the early release of 5 million USD of the 3-Phase Plan investment during the 2022 shortage to rapidly increase water infrastructure quality and capacity ( Resolución de Gabinete No. 127, 2022 ), of which they had yet to see the effects of:

“They would come around and promise us that they would solve the problem, and it never

happened … They released 5 million dollars. Where does it go? It’s like ice in the sun, nobody knows where it goes … A week after they got the money the water came like lemonade, and we got it once a day”.

All participants were critical of where the Government of Panama’s plans for the development of water infrastructure sit on the list of priorities, as compared to tourism. Those directly employed by the tourism industry made note of the Urban Development of Cities with a Tourist Vocation Plan; a 6-year 100 million USD loan (2019-2023) for the development of tourism infrastructure, management, and governance, including that of public utilities in Isla Colón ( Inter-American Development Bank , n.d.). However, when asked whether they had seen any benefits from this investment, all pointed to the development of more hotels, attractions, and restaurants rather than improvements to existing infrastructure. “When I see that [investment] here, it’s in building hotels,” mentioned one property owner, “but they’re not building up the community with it, you know? ‘Why is that?’ I ask all the time”. Another participant mentioned that “[Bocas del Toro] is so marketed as a tourism place that there is nothing else [the government] does. We have culture and needs but they don’t see.”

While not explicitly discussed with participants, an important development in this case came in July of 2023, when Panama signed on to the UN’s Water Capacity Development Initiative (CDI) for SDG 6; the first country in the world to do so. The CDI serves as a vehicle for inter-agency cooperation on capacity development related to freshwater, sanitation, and hygiene ( UN Water, 2021 , p.1). Its goal is to enable the UN system, and its partners, to coordinate support for participating countries based on their unique needs. While it is too early to predict the efficacy of this initiative, it does indeed promote “national-level ownership” and capacity building, rather than a “simple transfer of mechanisms” ( UN Water, 2021 , p.1). As Panama continues to pursue a blue economy rooted in marine ecotourism as well as improved water security, questions remain as to whether there is indeed a balance to be struck between the two; one that aligns government aspirations for development with the realities and needs of those living in Bocas del Toro.

Contextualized around the potential paradox of developing a blue economy in a resource-insecure island region, this study examines how the relationship between marine ecotourism and water insecurity, in particular, manifests at the community level through a case study of Bocas del Toro, Panama. Guided by local experiences and perceptions, our findings highlight the role that socio-historical shifts, central plans and policies, and ongoing crises play in shaping the realities of local residents and their attitudes toward sustainable development and the government as a whole. In this section, we situate key findings within the literature, teasing out applicable lessons learned, making inquiries into the reasoning behind our results, and contemplating areas for future research.

The role of colonialism and race in marine ecotourism and water governance

Our results further perpetuate the widely accepted notion that issues of island development and resource governance must be considered within the context of colonization and systemic racism. In particular, studies in the ‘island tourism’ field (e.g., Cywiński (2015) ; Guerrón-Montero (2006) ; Grydehøj et al. (2021) ) would describe the lasting impacts of losses in traditional livelihoods at the hands of the UFC, and its role in directing Bocas del Toro’s economic development, as a function of neo -colonialism. Along this vein, Grimwood et al ( Grimwood et al., 2019 , p.1) posit that the production and consumption of tourism have the propensity to “(re)inscribe colonizing structures, systems, and narratives across time and space,” while ( Eyisi et al., 2024 , p.154) note that the pace and manner of tourism development is often an artifact of “tourists from colonizers becoming the source market for the colonized”. For example, a study of wildlife tourism by ( Mach et al., 2023 , p.1474) found that wildlife tourism boat guides learned what tourists (many being from Europe and North America) “wanted to see and seemed to enjoy most (e.g. pretty beaches and charismatic wildlife) and itineraries evolved accordingly,” often changing the actual names of destination, commonly used between locals to simple English, in order attract more tourists (e.g., ‘Sloth Island’).

A discussion of colonialism in this context, that being inherently racially formed, also brings us to the role of systemic racism. While the Panamanian government has enacted laws surrounding racial discrimination, in an effort to reconcile past and present harms [e.g., the dispossession of Afro-Caribbean farming communities ( Chapman, 2014 ), infringements upon Ngäbe land rights ( Finley-Brook and Thomas, 2010 ), and the attempted assimilation of Afro-Caribbean identity into mestizo society ( Corinealdi, 2022 )], Afro-Panamanians and Ngäbe individuals still make up some of the poorest groups in the nation, often residing in some of the least invested-in regions, with limited access to social services, water included ( INEC, 2021 ). While drawing a causal relationship between race and water insecurity is not within the scope of this research, the 2020 UN World Water Report does explicitly relate water insecurity and intersectionality, especially regarding race and class ( UN Water, 2020 ). Peer-reviewed studies on this issue, however, overwhelmingly exist in the North American context (e.g., Deitz and Meehan, 2019 ; Dickin and Gabrielsson, 2023 ; Harrington et al., 2023 ; Méndez-Barrientos et al., 2023 ; Workman and Shah, 2023 ). For example, a spatial analysis of water insecurity across the United States by Deitz and Meehan (2019) found that deficiencies in household water infrastructure are concentrated in regions typically inhabited by racialized groups. Specific to Bocas del Toro, our research highlights disparities in access to water between social and racial groups, as determined by foreign and ethno-racial status. For example, participants note that, during water shortages, wealthier lifestyle migrants and hotel operators have the financial capital to purchase water and/or pay truck drivers to deliver it.

The government-community disconnect

Central to this case is an evident disconnect between the Government of Panama’s aspirations for marine ecotourism development in Bocas del Toro and the needs of those living in the region, with many participants believing the government to be prioritizing marine ecotourism development over plans to improve water infrastructure. While a more intensive study, one which highlights the interconnectedness of climate change impacts and water management within larger government policies, is required to support this notion, our findings suggest that local realities may perpetuate the narrative that the government is ‘leaving behind’ social sustainability in pursuit of a viable marine ecotourism industry. In the Caribbean context, Peterson ( Peterson, 2020 , p.20) argues that “growth, rather than development, remains the overriding focus,” whereby “the quality of life for residents and, in turn, the quality of experience for visitors have not always met the various principles of sustainable tourism.” Furthermore, Srivastava and Mehta (2023) and Scott et al. (2024) propose that this outcome can indeed be “further exacerbated by neoliberal development policies and the notion of [Bocas del Toro] as a ‘resource frontier.’

As found by Wortman et al. (2016) ’s examination of local opinions on foreign tourism investment in Mauritius, our results suggest that the sheer profitability of the marine ecotourism sector may incentivize governments to continue to pursue its growth in terms of investment and future planning. They describe the tourism industry as “a variant of outward-oriented development strategies,” where the services required to host a successful industry may eclipse the services required by the local population. This is of extreme relevance in island regions, where tourism is a major contributor to national economies, motivating governments to continue to pursue ‘tourism-led growth,’ as put by Lee and Chien (2008) , and attracting increasing amounts of foreign direct investment ( Tecel et al., 2020 ; Broner et al., 2023 ).

If Bocas del Toro’s marine ecotourism sector continues to grow without the development of essential infrastructure alongside it, the region may indeed hit the point of ‘over-tourism’, where the arrival of excessive numbers of tourists at a destination imposes negative impacts on local communities ( Dioko, 2017 ). Peterson (2023) notes that over-tourism, in the Caribbean specifically, is often an artifact of “neo-liberal outward-oriented tourism policy., largely based on private and political interests to the exclusion of societal values and community interests.” Notably, reaching this point may, in fact, incentivize governing bodies to prioritize the development of public utility infrastructure to ensure that marine ecotourism remains an economically viable industry.

The importance of trust

The prevalence of mistrust in the Government of Panama expressed by participants can be described as a lack of ‘political trust’; trust in institutions and governance actors stemming from group membership, government policies, and/or general political support or satisfaction ( Bauer and Freitag, 2016 ). Our results demonstrate that local perceptions of corruption can mold residents’ opinions of marine ecotourism development, and its ability to act on issues of water insecurity. While we are not aware of any studies that explore the role of government corruption in affecting local perceptions of sustainable development, more broadly, Karst and Nepal (2022) note that a lack of established trust between communities and actors that oversee ecotourism development can lead to an array of management challenges and stakeholder conflicts.

Political trust is also often tied to the ability of actors to deliver quality public services and respond to citizen demands ( Murtin et al., 2018 ). In this study, participant responses indicate skepticism regarding the effectiveness and accountability of government actors and policies. As described by Fragkou and McEvoy (2016) , in an investigation of community attitudes surrounding water scarcity in Latin America, traumatic and frequent experiences with water scarcity can foster concerns regarding political accountability, further erode trust in utility providers, and perpetuate poor opinions of future developments that could potentially improve water access, like desalinization plants. Enqvist and Ziervogel (2019) also found that when compounded with historically tense relationships between communities and policymakers, the mishandling of water shortages can signal to local residents that government action is ineffective and subsequently untrustworthy. Eyisi et al. (2024) review of tourism in Nigeria also found that negative opinions of tourism development can be tied to a history of unfulfilled government promises. In the case of Bocas del Toro, participants often pointed out a lack of follow-through on the MPSTD. Nilsen et al. (2023) describe what it means to be a ‘periphery’ region on an intra -national scale, where the development of rural or isolated regions may fall victim to an ‘urban bias’ ( Lipton, 1977 ). We witness this in Bocas del Toro as participants note that management schemes from the national level often overlook their interests as compared to more urbanized provinces closer to the core of Panama City.

Study limitations and future research avenues

While we believe the stories and perceptions shared with us to be of the utmost value to understanding our research questions, we acknowledge that our results represent the experiences of 16 individuals across the archipelago. Although a smaller sample size can enhance the validity of an in-depth inquiry ( Crouch and McKenzie, 2006 ), a larger sample size can better account for diversity within and between stakeholder groups ( Boddy, 2016 ). As the pool of research in this field begins to expand, we recommend that not only do future studies adequately account for community experiences and perceptions, but that they aim to include a variety of stake- and rights-holders, determining sample size as a “matter of judgment and experience … evaluating the quality of the information collected against the uses to which it will be put,” as per Sandelowski ( Sandelowski, 1995 , p.179).

This research begins to fill knowledge gaps in the literature surrounding marine ecotourism development and access to water in island regions. To ensure that community realities and interests do not effectively ‘fall through the cracks,’ there exists a need to pursue community-centric research on the impact of a blue economic agenda on a variety of essential public utilities and human needs (e.g., electricity, food, housing). Furthermore, valuable insights can be drawn from studies that compare and contrast, in-depth, cases across island regions to better understand the norms of the community impacts of blue economic development in resource-scarce societies. Concerning Bocas del Toro specifically, there is a great need for continued research into all areas of marine ecotourism development and the equitable distribution of resources (both in relation to one another and independently), as ours is one of a handful of studies within the region (e.g., Spalding, 2013 ; Spalding et al., 2015 ; Spalding, 2017 ; Mach and Vahradian, 2021 ; Pleasant and Spalding, 2021 ; Mach et al., 2023 ; Sandelowski, 1995 ; Pigram, 2000 ; McElroy, 2006 ; Pascual et al., 2014 ; Sakellariadou, 2014 ; Roller and Lavrakas, 2015 ; Pierskalla, 2016 ; Nunn and Kumar, 2017 ; Ramos-García et al., 2017 ; Murtin et al., 2018 ; Nugraheni et al., 2020 ; Osterblum et al., 2020 ; Peterson, 2020 ; Phelan et al., 2020 ; Mach and Vahradian, 2021 ; Minow, 2021 ; Pleasant and Spalding, 2021 ; Ministerio de Ambiente de Panamá, 2022 ; Rahman et al., 2022 ; Resolución de Gabinete No. 127, 2022 ; Méndez-Barrientos et al., 2023 ; Nilsen et al., 2023 ; Ortiz, 2023 ; Pace et al., 2023 ; Resolución de Gabinete No. 48, 2023 ; Scott et al., 2024 ).

In this study, we mobilize local experiences with marine ecotourism and water insecurity to better understand how the relationship between the two manifests at the community level. Our results highlight issues, of colonialism and systemic racism, misalignments of development priorities, and eroded trust, that shape local experiences with sustainable development, and residents’ perceptions of the ability of marine ecotourism to address issues of water insecurity.

Moving forward, as the Government of Panama pursues a ‘Blue Panama,’ and the global community continues to adopt the blue economy as a framework for sustainable ocean development, there exists a need to re-center and internalize social sustainability, primarily issues of equity, as the leading goal of blue economic development. More specifically, in order to adhere to the original intent of a blue economy, this must not only include the prioritization of social equity throughout marine ecotourism and water governance, but also address the issues that underpin such misalignments, as found in this study. This can include an approach that focuses on the power disparities between groups through a socio-historical lens. Singh et al. (2023) refer to this as an ‘anti-inequity’ approach, whereby it is critical to investigate and understand the processes that perpetuate inequities in, in this case, water security.

Overall, this research has demonstrated that the ‘balance’ between community well-being and development in the pursuit of a blue economy in island regions is a matter far greater than ‘growth,’ ‘infrastructure,’ or ‘development’. There exist important historical and social underpinnings that define the relationship between decision-makers and the communities in which they make decisions for, who proves to benefit from a blue economy, and perceptions of sustainable development as a whole. Ultimately, marine ecotourism cannot be considered part of a blue economy strategy if it does not prioritize social equity. As such it is pivotal that future research within this field understand how relevant plans and policies may manifest at the community level, directly from those communities that may face existing barriers to social well-being and sustainability.

Data availability statement

The original contributions presented in the study are included in the article/ Supplementary Material . Further inquiries can be directed to the corresponding author.

Ethics statement

The studies involving humans were approved by Marine Affairs Program Ethics Review Standing Committee, Dalhousie University. The studies were conducted in accordance with the local legislation and institutional requirements. The participants provided their written informed consent to participate in this study.

Author contributions

AK: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Visualization, Writing – original draft, Writing – review & editing. CS: Conceptualization, Funding acquisition, Investigation, Project administration, Resources, Supervision, Writing – review & editing. WS: Conceptualization, Funding acquisition, Investigation, Project administration, Resources, Supervision, Writing – review & editing.

The author(s) declare financial support was received for the research, authorship, and/or publication of this article. This study was funded by the Nippon Foundation, Ocean Nexus.

Acknowledgments

We sincerely thank the communities and participants of Bocas del Toro for allowing, actively participating in, and supporting the data collection for this study. We also thank the staff of The School for Field Studies, Panama, for hosting us during our time in the field, as well as Laura Bruce and Sydney Rubinstein for their support as interpreters. Commentary and edits on the original manuscript were also provided by Ricardo de Ycaza (Oregon State University). We are grateful for the time and input from the reviewers of this paper, which have greatly improved the manuscript.

Conflict of interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher’s note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

Supplementary material

The Supplementary Material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/fmars.2024.1377053/full#supplementary-material

Adamiak C., Szyda B. (2022). Combining conventional statistics and big data to map global tourism destinations before COVID-19. J. Travel Res. 6, 1848–1871. doi: 10.1177/00472875211051418

CrossRef Full Text | Google Scholar

Adeoye-Olatunde O. A., Olenik N. L. (2021). Research and scholarly methods: Semi- structured interviews. J. Am. Coll. Clin. Pharm. 4, 1358–1367. doi: 10.1002/jac5.1441

Albaez A. (2023) IDAAN advances in the contingency plan for water supply in Isla Colón (province of Bocas del Toro: Radio Panama). Available online at: https://radioPanama.com.pa/idaan-avanza-en-plan-de-contingencia-de-abastecimiento-de-agua-en-isla-colon-provincia-de-bocas-del-toro/ (Accessed July 22, 2023).

Google Scholar

Amin S. (1978). Unequal development: An essay on the social formations of peripheral capitalism. Sci. Soc. 42, 219–222.

ATP (2020) Plan Maestro de Turismo Sostenible (Panama City: Autoridad de Tourismo de Panama). Available online at: https://www.atp.gob.pa/Plan_Maestro_de_Turismo_Sostenible_2020-2025.pdf (Accessed May 8, 2023).

Baldacchino G. (2012). The Lure of the island: A spatial analysis of power relations. J. Mar. Island Cultures 1, 55–62. doi: 10.1016/j.imic.2012.11.003

Bauer P. C., Freitag M. (2016). ““Measuring trust,”,” in The Oxford Handbook of Social and Political Trust . Ed. Uslaner E. (Oxford University Press, New York).

Becker H. S., Geer B. (1957). Participant observation and interviewing: A comparison. Hum. Organ. 16, 28–32. doi: 10.17730/humo.16.3.k687822132323013

Belmar Y. N., McNamara K. E., Morrison T. H. (2016). Water security in small island developing states: The limited utility of evolving governance paradigms. WIREs Water 3, 181–193. doi: 10.1002/wat2.1129

Bennett N. J., Cisneros-Montemayor A. M., Blythe J., Silver J. J., Singh G., Andrews N., et al. (2019). Towards a sustainable and equitable blue economy. Nat. Sustainability. 2, 1665–1685. doi: 10.1038/s41893-019-0404-1

Benson M. C. (2013). Postcoloniality and privilege in new lifestyle flows: The case of north Americans in Panama. Mobilities 8, 313–330. doi: 10.1080/17450101.2013.810403

Blamey R. K. (2001). ““Principles of ecotourism,“,” in The Encyclopedia of Ecotourism . Ed. Weaver D. B. (New York: CABI Publishing), 5–22.

Bocas del Toro Tourism (2023) Isla Colón . Available online at: https://go.bocasdeltoro.travel/es/destinos/isla-colon/ (Accessed May 3, 2023).

Boddy C. R. (2016). Sample size for qualitative research. Qual. Market Res. 19, 426–432. doi: 10.1108/QMR-06-2016-0053

Broner F., Didier T., Schmukler S. L., von Peter G. (2023). Bilateral international investments: The big sur? J. Int. Economics 145, 103795. doi: 10.1016/j.jinteco.2023.103795

Camarca de Turismo de Bocas del Toro (2022). Estudio del Destino 2020 Bocas del Toro, Panama. Available at: https://camaraturismobocas.org/estudio-del-destino-2020/ .

Campbell L. M., Fairbanks L., Murray G., Stoll J. S., D’Anna L., Bingham J. (2021). From Blue Economy to Blue Communities: Reorienting aquaculture expansion for community wellbeing. Mar. Policy 124, 104361. doi: 10.1016/j.marpol.2020.104361

Carse A. (2014). Beyond the big ditch : politics, ecology, and infrastructure at the Panama Canal. (Massachusetts: The MIT Press). doi: 10.7551/mitpress/9780262028110.001.0001

CECOMRO (2018) Visiones Regionales al 2050 de Bocas del Toro (Centro de Competitividad de la Región Occidental: David). Available online at: https://www.cecomro.com/wp-content/uploads/2020/03/VISION-2050-REGION-OCCIDENTAL.pdf (Accessed May 3, 202).

Chapman P. (2014). Bananas: How the United Fruit Company Shaped the World (Scotland: Open Road + Grove/Atlantic).

Cisneros-Montemayor A. M., Moreno-Báez M., Reygondeau G., Cheung W. W. L., Crosman K. M., González-Espinosa P. C., et al. (2021). Enabling conditions for an equitable and sustainable blue economy. Nature. 591, 396–401. doi: 10.1038/s41586-021-03327-3

PubMed Abstract | CrossRef Full Text | Google Scholar

Cisneros-Montemayor A. M., Moreno-Báez M., Voyer M., Allison E. H., Cheung W. W. L., Hessing-Lewis M., et al. (2019). Social equity and benefits as the nexus of a transformative Blue Economy: A sectoral review of implications. Mar. Policy. 109, 103702. doi: 10.1016/j.marpol.2019.103702

Cole S. (2012). A political ecology of water equity and tourism. Ann. Tourism Res. 39, 1221–1241. doi: 10.1016/j.annals.2012.01.003

CNA. (2016). Plan Nacional de Seguridad Hídrica 2015-2050 (Panama City: Republic of Panama). Available online at: https://www.undp.org/es/Panama/publications/plan-nacional-de-seguridad-h%C3%ADdrica-2015-2050-agua-para-todos (Accessed August 9, 2023).

Corea N. (2016). Moving 55,000 Cubic Meters of Sediment Means More Water for Bocas Town (The Bocas Breeze Newspaper). Available online at: https://thebocasbreeze.com/community/moving-55000-cubic-meters-sediment-means-water-bocas-town/ (Accessed July 30, 2023).

Corinealdi K. (2022). Panama in Black: Afro-Caribbean World Making in the Twentieth Century (North Carolina: Duke University Press). doi: 10.1215/9781478023128

Crisman T. L., Winters Z. S. (2023). Caribbean small island developing states must incorporate water quality and quantity in adaptive management of the water-energy-food nexus. Front. Environ. Sci. 11. doi: 10.3389/fenvs.2023.1212552

Crouch M., McKenzie H. (2006). The logic of small samples in interview-based qualitative research. Soc. Sci. Inf. 45, 483–499. doi: 10.1177/0539018406069584

CTB (2023) Sobre Nosotros . Available online at: https://camaraturismobocas.org/sobre-nosotros/ (Accessed May 3, 2023).

Cywiński P. (2015). Tourist neo-colonialism as an indication of the future of islands. The example of borobodur (Central Java). Miscellanea Geographica 19, 21–24. doi: 10.1515/mgrsd-2015-0011

Das M., Chatterjee B. (2015). Ecotourism: A panacea or a predicament? Tourism Manage. Perspect. 14, 3–16. doi: 10.1016/j.tmp.2015.01.002

Decreto Ley No.4 (2008). Available online at: https://www.atp.gob.pa/wp-content/uploads/2020/11/decretoley_atp2008.pdf (Accessed March 25, 2023).

Deitz S., Meehan K. (2019). Plumbing poverty: Mapping hot spots of racial and geographic inequality in U.S. Household water insecurity. Ann. Am. Assoc. Geographers 109, 1092–1109. doi: 10.1080/24694452.2018.1530587

Dickin S., Gabrielsson S. (2023). Inequalities in water, sanitation and hygiene: Challenges and opportunities for measurement and monitoring. Water Secur. 20, 100143. doi: 10.1016/j.wasec.2023.100143

Dioko L. A. (2017). The problem of rapid tourism growth—An overview of the strategic question. Worldwide Hospitality Tourism Themes 9, 252–259. doi: 10.1108/WHATT-02-2017-0005

Dodds R., Graci S. (2012). Sustainable Tourism in Island Destinations (New York: Routledge). doi: 10.4324/9781849776660

Durokifa A. A., Ijeoma E. C. (2018). Neo-colonialism and Millennium Development Goals (MDGs) in Africa: A blend of an old wine in a new bottle. Afr. J. Science Technology Innovation Dev. 10, 355–366. doi: 10.1080/20421338.2018.1463654

Enqvist J. P., Ziervogel G. (2019). Water governance and justice in Cape Town: An overview. WIREs Water 6, 1354. doi: 10.1002/wat2.1354

Eyisi A. P., Ololo N. G., Aruomah M. O. (2024). The impacts of colonialism on residents’ perceptions of tourism in Southeastern Nigeria. Tourism Hospitality Res. 24, 152–165. doi: 10.1177/14673584221128139

Feyrer J., Sacerdote B. (2009). Colonialism and modern income: Islands as natural experiments. Rev. Economics Stat 91, 245–262. doi: 10.1162/rest.91.2.245

Finley-Brook M., Thomas C. (2010). Treatment of displaced indigenous populations in two large hydro projects in Panama. Water Alternatives 3, 269–290.

Fragkou M. C., McEvoy J. (2016). Trust matters: Why augmenting water supplies via desalination may not overcome perceptual water scarcity. Desalination 397, 1–8. doi: 10.1016/j.desal.2016.06.007

Freudenberg N., Tsui E. (2014). Evidence, power, and policy change in community-based participatory research. Am. J. Public Health (1971) 104, 11–14. doi: 10.2105/AJPH.2013.301471

Gheuens J., Nagabhatla N., Perera E. D. P. (2019). Disaster-risk, water security challenges and strategies in small island developing states (SIDS). Water 11, 637. doi: 10.3390/w11040637

Glaser B. G. (1965). The constant comparative method of qualitative analysis. Soc. Problems 12, 436–445. doi: 10.2307/798843

Godoy Y. (2023) Panama will develop water and sanitation project (Telemetro). Available online at: https://www.telemetro.com/nacionales/Panama-desarrollara-proyecto-agua-y-saneamiento-n5902526 (Accessed July 22, 2023).

Gossling S. (2015). New performance indicators for water management in tourism. Tourism Manage. (1982) 46, 233–244. doi: 10.1016/j.tourman.2014.06.018

Gössling S., Peeters P., Hall C. M., Ceron J.-P., Dubois G., Lehmann L. V., et al. (2012). Tourism and water use: Supply, demand, and security. An international review. Tourism Manage. (1982) 33, 1–15. doi: 10.1016/j.tourman.2011.03.015

Gray E., Burke L., Lambert J. (2015). Valuing the costs and benefits of improved wastewater management: An economic valuation resource guide for the wider caribbean region (World Resource Institute). Available at: https://clmeplus.org/app/uploads/2020/04/CReW_C2_WRI_Valuing_Wastewater_PART_I_-Summary_Revised_April16.pdf .

Grimwood B. S. R., Stinson M. J., King L. J. (2019). A decolonizing settler story. Ann. Tourism Res. 79, 102763. doi: 10.1016/j.annals.2019.102763

Grydehøj A., Bevacqua M. L., Chibana M., Nadarajah Y., Simonsen A., Su P., et al. (2021). Practicing decolonial political geography: Island perspectives on neocolonialism and the China threat discourse. Political Geogr. 85, 102330. doi: 10.1016/j.polgeo.2020.102330

Guerrón-Montero C. (2006). Racial democracy and nationalism in Panama. Ethnology 45, 209–228. doi: 10.2307/20456595

Harrington C., Montana P., Schmidt J. J., Swain A. (2023). Race, ethnicity, and the case for intersectional water security. Global Environ. Politics 23, 1–10. doi: 10.1162/glep_a_00702

Harrison D., Prasad B. (2011). “The contribution of tourism to the development of Fiji and other pacific island countries,” in Handbook of Tourism Economics (Queensland: WORLD SCIENTIFIC), 741–761. doi: 10.1142/9789814327084_0032

Hau’ofa E. (1994). Our sea of islands. Contemp. Pacific 6, 148–161.

Heim O. (2017). Island logic and the decolonization of the pacific. Interventions 19, 914–929. doi: 10.1080/1369801X.2017.1401945

Hodkinson P. (2008). “Grounded Theory and inductive research,” in Researching Social Life , vol. 5. (London: SAGE Publications Ltd), 80–100.

Hoyman M. M., McCall J. R. (2013). Is there trouble in paradise? The perspectives of Galapagos community leaders on managing economic development and environmental conservation through ecotourism policies and the Special Law of 1998. J. Ecotourism 12, 33–48. doi: 10.1080/14724049.2012.749882

IDAAN IDAAN maintains a contingency plan for water supply on Isla Colón (IDAAN). Available online at: https://www.idaan.gob.pa/idaan-mantiene-plan-de-contingencia-de-abastecimiento-de-agua-en-isla-colon/ (Accessed July 22, 2023).

IDAAN (2022) Facturcion Total Clientes Medidos, Medidor Promediado y no Medidos en Balboas y Volumen en Galones (No. 2) . Available online at: https://www.idaan.gob.pa/wp-content/uploads/2022/04/FACTURACION-TOTAL-CLIENTES-MEDIDOS-MEDIDOR-PROMEDIADO-Y-NO-MEDIDOS-EN-BALBOAS-Y-VOLUMEN-EN-GALONES.pdf .

INEC. (2021). Population . Available online at: https://www.inec.gob.pa/publicaciones/Default3.aspx?ID_PUBLICACION=1196andID_CATEGORIA=17andID_SUBCATEGORIA=45 (Accessed October 11, 2023).

Inter-American Development Bank Comprehensive urban development program with tourist vocations . Available online at: https://www.iadb.org/en/whats-our-impact/PN-L1154 (Accessed October 15, 2023).

Israel B. A., Schulz A. J., Coombe C. M., Parker E. A., Reyes A. G., Rowe Z., et al. (2019). Community-based participatory research. Urban Health 272, 272–282. doi: 10.1093/oso/9780190915858.003.0029

Karst H. E., Nepal S. K. (2022). Social-ecological wellbeing of communities engaged in ecotourism: Perspectives from Sakteng Wildlife Sanctuary, Bhutan. J. Sustain. Tourism 30, 1177–1199. doi: 10.1080/09669582.2021.1913500

Kay C. (2010). Latin American Theories of Development and Underdevelopment (New York: Routledge). doi: 10.4324/9780203835418

Keegan W. F., Diamond J. M. (1987). Colonization of islands by humans: A biogeographical perspective. Adv. Archaeological Method Theory 10, 49–92. doi: 10.1016/B978-0-12-003110-8.50005-0

Klytchnikova I., Dorosh P. (2013). Tourism sector in Panama: Regional economic impacts and the potential to benefit the poor. Natural Resour. Forum 37, 70–79. doi: 10.1111/1477-8947.12019

Lee C.-C., Chien M.-S. (2008). Structural breaks, tourism development, and economic growth: Evidence from Taiwan. Mathematics Comput. Simulation 77, 358–368. doi: 10.1016/j.matcom.2007.03.004

Leposa N. (2020). Problematic blue growth: A thematic synthesis of social sustainability problems related to growth in the marine and coastal tourism. Sustainability Sci. 15, 1233–1244. doi: 10.1007/s11625-020-00796-9

Lipton M. (1977). ““Why poor people stay poor: A study of urban bias in world development,”,” in Milestones and Turning Points in Development Thinking . Ed. Jolly R. (Palgrave Macmillan, London), 148.

Lucas A. (2019) Tourism in Bocas del Toro, contradictory paths (Alba Sud). Available online at: https://www.albasud.org/noticia/es/1111/turismo-en-bocas-del-toro-caminos-contradictorios (Accessed May 3, 2023).

Lucas H., Fifita S., Talab I., Marschel C., Cabeza L. F. (2017). Critical challenges and capacity building needs for renewable energy deployment in Pacific Small Island Developing States (Pacific SIDS). Renewable Energy 107, 42–52. doi: 10.1016/j.renene.2017.01.029

Mach L., McPherson B., Hayes R. (2023). Wildlife tourism maps and the governance of environmental collapse. Tourism Geographies 25, 1465–1482. doi: 10.1080/14616688.2023.2231423

Mach L., Vahradian D. (2021). Tourists want to be spooked, not schooled: Sustaining indigenous tourism in the Bastimentos Island National Marine Park, Bocas del Toro, Panama. J. Ecotourism 20, 130–144. doi: 10.1080/14724049.2019.1585439

McElroy J. L. (2006). Small island tourist economies across the life cycle. Asia Pacific Viewpoint 47, 61–77. doi: 10.1111/j.1467-8373.2006.00303.x

Méndez-Barrientos L. E., Fencl A. L., Workman C. L., Shah S. H. (2023). Race, citizenship, and belonging in the pursuit of water and climate justice in California. Environ. Plann. E: Nat. Space 6, 1614–1635. doi: 10.1177/25148486221133282

MiAMBIENTE. (2022). Política Nacional de Océanos de Panamá (Panama City: MiAmbiente). Available online at: https://www.undp.org/sites/g/files/zskgke326/files/2023-03/UNDP-PA-Politica-Oceanos-Documento.pdf (Accessed October 15, 2023).

Minow M. (2021). Equality vs. equity. Am. J. Law Equality 1, 167–193. doi: 10.1162/ajle_a_00019

Murtin F., Fleischer L., Siegerink V., Aassve A., Algan Y., Boarini R., et al. (2018) Trust and its determinants: Evidence from the Trustlab experiment (OECD Working Paper). Available online at: https://www.oecd-ilibrary.org/economics/trust-and-its-determinants_869ef2ec-en (Accessed October 10, 2023).

Nilsen T., Grillitsch M., Hauge A. (2023). Varieties of periphery and local agency in regional development. Regional Stud. 57, 749–762. doi: 10.1080/00343404.2022.2106364

Nugraheni A. I. P., Priyambodo T. K., Sutikno B., Kusworo H. A. (2020). The social dimensions’ Aspects of sustainable tourism development analysis: A systematic literature review. Digital Press Soc. Sci. Humanities 4, 1. doi: 10.29037/digitalpress.44348

Nunn P., Kumar R. (2017). Understanding climate-human interactions in Small Island Developing States (SIDS): Implications for future livelihood sustainability. Int. J. Climate Change Strategies Manage. 10, 245–271. doi: 10.1108/IJCCSM-01-2017-0012

Ortiz N. (2023) From Crises To Solutions: Tackling The Water Challenges Of An Island Paradise (The Bocas Breeze Newspaper). Available online at: https://thebocasbreeze.com/community/water-solutions/ (Accessed August 30, 2023).

Osterblum H., Wabnitz C. C., Tladi D., Allison E., Arnaud-Haond S., Bebbington J., et al. (2020) Towards Ocean Equity. High Level Panel for a Sustainable Ocean Economy Working Paper . Available online at: https://digitalarchive.worldfishcenter.org/handle/20.500.12348/4486 (Accessed January 1, 2023).

Pace L. A., Saritas O., Deidun A. (2023). Exploring future research and innovation directions for a sustainable blue economy. Mar. Policy 148, 105433. doi: 10.1016/j.marpol.2022.105433\

Pascual U., Phelps J., Garmendia E., Brown K., Corbera E., Martin A., et al. (2014). Social equity matters in payments for ecosystem services. BioScience. 64, 1027–1036. doi: 10.1093/biosci/biu146

Peterson R. R. (2020). Over the caribbean top: Community well-being and over-tourism in small island tourism economies. Int. J. Community Well-Being 6, 89–126. doi: 10.1007/s42413-020-00094-3

Peterson R. R. (2023). Over the caribbean top: Community well-being and over-tourism in small island tourism economies. Int. J. Community Well-Being 6, 89–126. doi: 10.1007/s42413-020-00094-3

Phelan A., Ruhanen L., Mair J. (2020). Ecosystem services approach for community-based ecotourism: towards an equitable and sustainable blue economy. J. Sustain. Tourism 28, 1665–1685. doi: 10.1080/09669582.2020.1747475

Pierskalla J. H. (2016). The politics of urban bias: Rural threats and the dual dilemma of political survival. Stud. Comp. Int. Dev. 51, 286–307. doi: 10.1007/s12116-015-9194-2

Pigram J. (2000) Water Resources Management: In Island Environments: The Challenge of Tourism Development (Wisconsin: Centre for Water Policy Research). Available online at: https://mail.perfectbg.com/TouristDocuments.nsf/0/9a3404dbc7a13563c2257061003bc83f/$FILE/waterresourse.pdf (Accessed October 7, 2023).

Pleasant T., Spalding A. (2021). Development and dependency in the periphery: From bananas to tourism in Bocas del Toro, Panama. World Dev. Perspect. 24, 100363. doi: 10.1016/j.wdp.2021.100363

Rahman M. K., Masud M. M., Akhtar R., Hossain M. M. (2022). Impact of community participation on sustainable development of marine protected areas: Assessment of ecotourism development. Int. J. Tourism Res. 24, 33–43. doi: 10.1002/jtr.2480

Ramos-García J., Ibarra-Michel J. P., Velarde-Valdez M. (2017). Community-based ecotourism management: the case of a cooperative in Mazatlán, Sinaloa, Mexico. Czech J. Tourism 6, 155–170. doi: 10.1515/cjot-2017–0008

Resolución de Gabinete No. 127 (2022). Available online at: https://www.gacetaoficial.gob.pa/pdfTemp/29660_A/GacetaNo_29660a_20221109.pdf .

Resolución de Gabinete No. 48 (2023). Available online at: https://www.gacetaoficial.gob.pa/pdfTemp/29793/GacetaNo_29793_20230531.pdf .

Roller M. R., Lavrakas P. H. (2015). “A multi-method approach in qualitative research,” in Applied Qualitative Research Design: A Total Quality Framework Approach (New York: Guilford Publications), 288–289.

Sakellariadou F. (2014). The concept of marine ecotourism: A case study in a mediterranean island. Int. J. Climate Change: Impacts Responses 6, 33–39. doi: 10.18848/1835-7156/CGP/v06i01/37218

Sandelowski M. (1995). Sample size in qualitative research. Res. Nurs. Health 18, 179–183. doi: 10.1002/nur.4770180211

Scott C. P., Mach L., Lucas K. M., Myers A. E. (2024). Whose cultural ecosystem service values matter? Exploring power inequities in diverse mangrove communities. Hum. Ecology : Interdiscip. J . 52, 81–97. doi: 10.1007/s10745-023-00462-5

Sealy W. (2018). From colonialism to transnationalism: The neo-colonial structure of caribbean tourism. J. On Tourism Sustainability 1, 81–92.

Seemann J., González C. T., Carballo-Bolaños R., Berry K., Heiss G. A., Struck U., et al. (2014). Assessing the ecological effects of human impacts on coral reefs in Bocas del Toro, Panama. Environ. Monit. Assessment. 186, 1747–1763. doi: 10.1007/s10661-013-3490-y

Singh G. G., Keefer J., Ota Y. (2023). An inequity assessment framework for planning coastal and marine conservation and development interventions. Front. Mar. Sci. 10. doi: 10.3389/fmars.2023.1256500

Spalding A. K. (2017). Exploring the evolution of land tenure and land use change in panama: Linking land policy with development outcomes. Land Use Policy 61, 543–552. doi: 10.1016/j.landusepol.2016.11.023

Spalding A. K. (2011). Re-Making Lives Abroad: Lifestyle Migration and Socio-Environmental Change in Bocas del Toro (Panama: [Alberta]: University of Lethbridge).

Spalding A. K. (2013). Lifestyle Migration to Bocas del Toro, Panama: Exploring migration strategies and introducing local implications of the search for paradise. Int. Rev. Soc. Res. 3, 67–86. doi: 10.1515/irsr-2013-0005

Spalding A. K., Suman D. O., Mellado M. E. (2015). Navigating the evolution of marine policy in Panama: Current policies and community responses in the Pearl Islands and Bocas del Toro Archipelagos of Panama. Mar. Policy 62, 161–168. doi: 10.1016/j.marpol.2015.09.020

Srivastava S., Mehta L. (2023). The social life of mangroves: Neoliberal development and mangrove conservation in the changing landscape of Kutch. Environ. Planning. E Nat. Space (Print) 6, 2229–2248. doi: 10.1177/25148486211045360

STRI GIS Data Portal (2019). Available online at: https://stridata-si.opendata.arcgis.com/datasets/e9b8ba21a21d4ac7be98bbff2c67d3f2_0/explore .

Suman D. O., Spalding A. K. (2018). Coastal Resources of Bocas del Toro, PANAMA: Tourism and Development Pressures and the Quest for Sustainability (Miami: University of Miami).

Tecel A., Katircioğlu S., Taheri E., Victor Bekun F. (2020). Causal interactions among tourism, foreign direct investment, domestic credits, and economic growth: Evidence from selected Mediterranean countries. Portuguese Economic J. 19, 195–212. doi: 10.1007/s10258-020-00181-5

Telemetro (2022) State of Environmental Emergency declared on Colón and Carenero islands due to lack of water (Telemetro). Available online at: https://www.telemetro.com/nacionales/declaran-estado-emergencia-ambiental-islas-colon-y-carenero-falta-agua-n5799895 (Accessed July 22, 2023).

Tilmans S., Diaz-Hernandez A., Nyman E., Davis J. (2014). The potential for financing small-scale wastewater treatment through resource recovery: Experience from Bocas del Toro, Panama. J. Water Sanitation Hygiene Dev. 4, 449–459. doi: 10.2166/washdev.2014.138

Tuwo A., Yunus M., Aprianto R., Tresnati J. (2021). Marine ecotourism development in South Sulawesi, Indonesia. IOP Conf. Series. Earth Environ. Sci. 763, 12068. doi: 10.1088/1755-1315/763/1/012068

UN Water (2013) What is Water Security (Geneva: UN Water). Available online at: https://www.unwater.org/sites/default/files/app/uploads/2017/05/unwater_poster_Oct2013.pdf (Accessed October 16, 2023).

UN Water (2020) Water and Climate Change: United Nations World Water Development Report 2020 (UNESCO). Available online at: https://unesdoc.unesco.org/ark:/48223/pf0000372985.locale=en (Accessed October 16, 2023).

UN Water (2021) SDG 6 Capacity Development Initiative: Concept Note (Geneva: UN Water). Available online at: https://sdgs.un.org/partnerships/un-water-sdg-6-capacity-development-initiative#:~:text=The%20SDG%206%20Capacity%20Development%20Initiative%20supports%20coordination%20on%20SDG,the%20SDG%206%20Global%20Acceleration (Accessed July 23, 2023).

UNWTO. (2023). Inbound tourism expenditure over exports of goods and services. Available online at https://www.unwto.org/news/international-tourism-to-reach-pre-pandemic-levels-in-2024 .

UN-OHRLLS. (2022). List of LDCs. In: Office of the high representative for the least developed countries, landlocked developing countries and small island developing states . Available at: https://www.un.org/ohrlls/content/list-ldcs (Accessed November 8, 2023).

Weiss R. S. (1994). Learning from strangers : The art and method of qualitative interview studies (New York: Free Press).

Winters Z. S., Crisman T. L., Dumke D. T. (2022). Sustainability of the Water-energy-food nexus in caribbean small island developing states. Water (Basel) 14, 322. doi: 10.3390/w14030322

Workman C. L., Shah S. H. (2023). Water infrastructure as intrusion: race, exclusion, and nostalgic futures in North Carolina. Ann. Am. Assoc. Geographers 113, 1639–1651. doi: 10.1080/24694452.2022.2149461

World Bank and UN DESA (2017) The Potential of the Blue Economy—Increasing Long- term Benefits of the Sustainable Use of Marine Resources for SIDS and Coastal Least Developed Countries (Washington: World Bank). Available online at: https://openknowledge.worldbank.org/server/api/core/bitstreams/cee24b6c-2e2f-5579-b1a4-457011419425/content (Accessed November 9, 2023).

Wortman T., Donaldson R., van Westen G. (2016). “They are stealing my island”: Residents’ opinions on foreign investment in the residential tourism industry in Tamarin, Mauritius. Singapore J. Trop. Geogr. 37, 139–157. doi: 10.1111/sjtg.12151

Zeng X., Chen M., Zeng C., Cheng S., Wang Z., Liu S., et al. (2022). Assessing the management effectiveness of China’s marine protected areas: Challenges and recommendations. Ocean Coast. Management. 224, 106172. doi: 10.1016/j.ocecoaman.2022.106172

Keywords: marine ecotourism, water security, blue economy, island systems, Bocas del Toro, sustainable development

Citation: Kim A, Scott CP and Swartz W (2024) Local perspectives on marine ecotourism development in a water-insecure island region: the case of Bocas del Toro, Panama. Front. Mar. Sci. 11:1377053. doi: 10.3389/fmars.2024.1377053

Received: 26 January 2024; Accepted: 02 May 2024; Published: 17 May 2024.

Reviewed by:

Copyright © 2024 Kim, Scott and Swartz. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Abigael Kim, [email protected]

† These authors have contributed equally to this work

This article is part of the Research Topic

The Potentials and Pitfalls from National Blue Economy Plans Towards Sustainable Development

• Shop to Support Independent Journalism
• We Have Issues
• Investigations
• Ethics Policy
• Ad-Free Login

Special counsel accused of 'grotesquely dishonest' exhibits in Hunter Biden case

Sarah K. Burris

Senior editor, sarah burris is a long-time veteran of political campaigns, having worked as a fundraiser and media director across the united states. she transitioned into reporting while working for rock the vote, future majority and wiretap magazine, covering the millennial generation's perspective during the presidential elections. as a political writer, burris has had bylines at cnn, salon.com, bnr, and alternet and serves as a senior digital editor for rawstory.com..

Women in Media Cente

National security expert Marcy Wheeler has been closely following the Hunter Biden case while the world is captivated by the ongoing Donald Trump saga unfolding in Manhattan.

Wheeler argued that special counsel David Weiss is continuing to try to block Biden's full book from being admitted into evidence. Instead, he wants only certain excerpts admitted — and that, she says, twists the narrative.

Biden stands accused of violating laws that restrict drug users from purchasing a gun. He allegedly checked a box saying he was not on drugs while making a purchase — and later wrote in his book that he was.

Weiss submitted a motion to admit only portions of the book and audiobook and to exclude what he characterized as "self-serving statements," court documents show.

"The selections are not surprising. But in two ways, they are grotesquely dishonest. First, the chosen excerpts misleadingly lead from something that happened in August 2018," wrote Wheeler.

Read Also: Hunter Biden wants to testify openly — but Republicans won’t let him

The excerpt talks about how things were going well until Biden relapsed in Aug. 2018. Weiss then jumps to a story of Biden staying in a number of seedy motels off of I-95. As Wheeler explained, one would assume that these two events happened directly after each other.

The reality is that in the book, they're six months apart, and Weiss takes an excerpt from another part of the book, putting in an ellipsis.

Weiss included the excerpt: “I returned [to the East Coast] that fall of 2018, after my most recent relapse in California, with the hope of getting clean through a new therapy . . . Neither happened.”

The reality is that Biden's comment, "neither happened," came before he said he was going to try a new therapy and related to his reconciliation with his wife after the relapse.

"Next on my agenda was getting clean," the book says. "I drove up to Newburyport, Massachusetts, an old New England shipbuilding-turned-tourist town thirty-five miles north of Boston. A therapist ran a wellness center where he practiced a drug addiction therapy known as ketamine infusion. I would make two trips up there, staying for about six weeks on the first visit, returning to Maryland, then heading back for a couple weeks of follow-up in February of the new year."

At another point, Weiss misrepresents the timeline again, saying that it was the fall of 2018 when Biden was smoking crack in a Massachusetts Super 8 motel room . It was in Feb. 2019.

According to Wheeler, at no point in the book does Biden describe his "state of mind when he was in Delaware, when he owned the gun."

Weiss also wants to exclude a part of the book that talks about the "new therapy" making his condition much worse.

"The therapy’s results were disastrous," Biden says. "I was in no way ready to process the feelings it unloosed or prompted by reliving past physical and emotional traumas. So I backslid."

Wheeler assessed, "I get what self-serving hearsay is. This is not it (though Judge Noreika has thus far been wildly favorable to Weiss’ misrepresentations)."

Read her full details here.

Stories Chosen For You

Should trump be allowed to run for office, fury hits gop as it claims democratic ex-soldier with jewish children is backing hamas.

The Republican congressional committee that supports incumbent GOP members has accused a Democratic former soldier of supporting Hamas.

Due to redistricting, Rep. Pat Ryan (D-NY) is now in a race against a colleague, Rep. Anthony D’Esposito (R-NY) In a post, the GOP is claiming that Ryan said, "I support Hamas."

The Friday blog post from the National Republican Campaign Committee attributes the statement as a direct quote from Ryan, and tries to justify it by saying that Ryan voted against a bill that would condemn President Joe Biden for pausing the aid package to ensure human rights laws are being followed.

Only 16 Democrats voted for the bill. Ryan supported the funding and arms package for Israel in the April vote.

Read Also: 'Pretty dismissive': Republican says most House colleagues don't back MTG's speaker fight

But the NRCC claims that voting against the GOP's condemnation bill is the same as saying he supports Hamas.

The GOP's problem is that Ryan, a West Point graduate, has a history of fighting antisemitism because his children have been raised Jewish.

Eight months before Hamas kidnapped and killed hundreds of people in Israel, Ryan was talking to Jewish Insider in Feb. 2023 about his efforts "to combat antisemitism, counter Iranian malign activities and support the U.S.-Israel relationship."

Ryan explained on X that, beyond the love of his family, he fought groups like Hamas directly. The New York lawmaker served two tours in Iraq as a military intelligence officer and spent two years in Afghanistan working for a military subcontractor.

For him, comments like these are personal because terrorist groups like Hamas killed friends and colleagues while he was in combat, his congressional biography says .

"I put my life on the line for our country, and lost friends and fellow soldiers in combat to Iran-backed terror groups like Hamas. I read their names daily on the memorial bracelet I wear," Ryan wrote.

He then called on D’Esposito, "If you have any respect for our veterans," that he demanded the "shameful lie" be taken "down immediately" by the Republican Party site.

D’Esposito never served in the military, but he was a New York Police Department officer, where he received complaints of excessive force and had charges filed against him for an improper search, ProPublica reported .

Nancy Pelosi pleads for 'very long' prison sentence for husband's hammer attacker

Rep. Nancy Pelosi (D-CA) is asking a court to impose a "very long" sentence of the conspiracy theorist who broke into her home and brutally attacked her elderly husband.

The former House speaker's husband Paul Pelosi says he still suffers from dizziness, headaches, balance problems, nerve pain and walking challenges after David DePape attacked him with a hammer in October 2022, just before the midterm elections, reported CBS News .

"A violent man broke into our home, threatened to kidnap me and – in his own words – made my husband Paul 'take the punishment' in my absence with a near-fatal attack with a hammer," the veteran lawmaker wrote to the court. "Paul and I have not discussed the events of that horrible night. Paul doesn't want to undergo revisiting it, and the doctors' advice is that discussing the vicious assault would only renew his trauma."

Her chief of staff Terri McCollough wrote a separate letter reminded the sentencing judge that rioters had broken into the U.S. Capitol on Jan. 6, 2021, and many of them can be heard chanting, "Where's Nancy?" as they sought to prevent the certification of Joe Biden's election win over Donald Trump .

ALSO READ: Federal Election Commission kills anonymous donor proposal

"We could not imagine anything worse could happen in our world," McCullough wrote. "Yet I did, because of this defendant's actions. 'Where's Nancy?' he asked. After the brutal attack of Mr. Pelosi in October 2022, we knew the Speaker and her family were not safe in their own homes."

The Justice Department is seeking 40 years in prison for Depape, 44, who was convicted late last year on charges of attempted kidnapping of a federal official and assault on the immediate family member of a federal official.

DePape testified during his trial that he broke into the couple's San Francisco home intending to hold the then-speaker hostage and "break her kneecaps" if she lied to him, and he admitted to bludgeoning her husband with the hammer after police arrived.

Revealed: Data breach exposes staggering sums gambled by GOP legislator

Michigan state Rep. Matt Hall, an election denier and now House minority leader, placed more than $2,200 in bets a day on an online gambling website, according to a new report.

A Democratic source provided Rolling Stone with screenshots showing the Republican legislator's account on the Action Network sports gambling website, where he placed roughly $73,000 in bets for a net loss of $9,000, with most of that activity happening within his first month of opening the account in January 2018.

The amount Hall wagered in those 33 days is more than the entire yearly salary of a state legislator, which at that time was $71,685. The bets were made eight months before he was elected and nearly two years before Democratic Gov. Gretchen Whitmer signed legalized gambling into law in December 2019.

“This accusation, stemming from before Leader Hall was even in the Legislature, is blatantly untrue,” said Greg Manz, spokesman for the Michigan House Republican Campaign Committee.

“Sadly, Rolling Stone would rather employ tabloid tactics, act as liberal activists, and do the bidding of feckless House Democrats, than practice journalistic integrity," the spokesman added. "Michigan House Democrats, who fielded their weakest recruitment class in decades, reek of desperation because come January 2025 when Leader Hall is Speaker Hall, they will no longer be able to dole out corporate welfare, raise taxes on working families, and keep low-income students trapped in failing schools.”

Hall's gambling habits have been previously reported after his then-girlfriend called 911 in September 2019 to report that he was driving dangerously fast in a rush to place bets across the state line in Indiana.

“Maybe you shouldn’t gamble so much,” the girlfriend said in a recording she made of the incident, and Hall reportedly told her to "shut up."

Hall initially refused to take his girlfriend home, saying his gambling was more important, and after he eventually dropped her off police recommended charging him with domestic assault, malicious destruction of property, and interfering with a 911 call for damaging her phone, but he was never arrested.

The state legislator said that getting legalized sports gambling passed was one of the main reasons he had run for office, but shortly after he was elected he invited Donald Trump attorney Rudy Giuliani to testify about false election fraud conspiracy theories in a lengthy hearing lampooned on "Saturday Day Night Live."

Hall's gambling history was revealed after a data breach at the Action Network site he used to track his bets across five separate sports books.

When it comes to 'rage' of rural voters, liberals may not be asking the right question

Democratic congressman commits massive stock law violation, delay, delay: lauren boebert keeping personal finances secret until after gop primary.

Copyright © 2024 Raw Story Media, Inc. PO Box 21050, Washington, D.C. 20009 | Masthead | Privacy Policy | Manage Preferences | Debug Logs For corrections contact [email protected] , for support contact [email protected] .