a case study is conducted to assess

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

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

Research question

• Conceptual framework
• Conceptual vs. theoretical framework

Data collection

• Qualitative research methods
• Focus groups
• Observational research

What is a case study?

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

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

Case studies

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

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

Definition of a case study

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

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

Characteristics of case studies

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

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

The role of case studies in research

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

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

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

What is the purpose of a case study?

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

Why use case studies in qualitative research?

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

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

The explanatory, exploratory, and descriptive roles of case studies

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

The impact of case studies on knowledge development

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

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

Types of case studies

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

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

Exploratory case studies

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

Descriptive case studies

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

Explanatory case studies

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

Intrinsic, instrumental, and collective case studies

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

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

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

Critical information systems research

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

Health research

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

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

Asthma research studies

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

Other fields

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

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

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

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

Propositions

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

Units of analysis

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

Argumentation

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

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

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

Defining the research question

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

Selecting and defining the case

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

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

Developing a detailed case study protocol

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

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

Collecting data

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

Analyzing and interpreting data

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

Writing the case study report

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

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

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

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

Observations

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

Documents and artifacts

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

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

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

Ensuring the quality of data collection

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

Data analysis

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

Organizing the data

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

Categorizing and coding the data

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

Identifying patterns and themes

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

Interpreting the data

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

Verification of the data

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

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

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

Benefits include the following:

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

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

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

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

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Case Study – Methods, Examples and Guide

Table of Contents

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

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

Types of Case Study

Types and Methods of Case Study are as follows:

Single-Case Study

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

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

Multiple-Case Study

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

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

Exploratory Case Study

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

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

Descriptive Case Study

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

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

Instrumental Case Study

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

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

Case Study Data Collection Methods

Here are some common data collection methods for case studies:

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

Observations

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

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

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

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

How to conduct Case Study Research

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

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

Examples of Case Study

Here are some examples of case study research:

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

Application of Case Study

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

Business and Management

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

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

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

Social Sciences

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

Law and Ethics

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

Purpose of Case Study

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

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

Case studies can also serve other purposes, including:

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

Advantages of Case Study Research

There are several advantages of case study research, including:

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

Limitations of Case Study Research

There are several limitations of case study research, including:

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

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What Is a Case Study?

Weighing the pros and cons of this method of research

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

Cara Lustik is a fact-checker and copywriter.

Verywell / Colleen Tighe

• Pros and Cons

What Types of Case Studies Are Out There?

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

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

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

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

At a Glance

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

What Are the Benefits and Limitations of Case Studies?

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

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

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

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

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

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

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

Case Study Examples

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

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

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

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

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

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

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

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

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

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

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

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

Section 1: A Case History

This section will have the following structure and content:

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

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

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

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

Section 2: Treatment Plan

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

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

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

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

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

Need More Tips?

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

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

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

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

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

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

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

Organizing Your Social Sciences Research Assignments

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

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

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

How to Approach Writing a Case Study Research Paper

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

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

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

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

Structure and Writing Style

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

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

I.  Introduction

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

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

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

II.  Literature Review

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

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

III.  Method

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

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

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

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

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

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

IV.  Discussion

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

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

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

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

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

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

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

V.  Conclusion

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

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

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

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

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

Problems to Avoid

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

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

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

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

Writing Tip

At Least Five Misconceptions about Case Study Research

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

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

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

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

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Case Study Research Method in Psychology

Saul Mcleod, PhD

Editor-in-Chief for Simply Psychology

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

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

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On This Page:

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

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

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

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

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

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

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

 Famous Case Studies

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

Clinical Case Studies

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

Child Psychology Case Studies

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

Types of Case Studies

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

Where Do You Find Data for a Case Study?

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

1. Primary sources

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

2. Secondary sources

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

3. Archival records

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

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

4. Organizational records

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

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

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

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

How do I Write a Case Study in Psychology?

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

1. Introduction

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

2. Case Presentation

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

3. Management and Outcome

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

4. Discussion

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

5. Additional Items

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

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

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

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

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

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

Limitations

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Further Information

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

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• Roberta Heale 1 ,
• Alison Twycross 2
• 1 School of Nursing , Laurentian University , Sudbury , Ontario , Canada
• 2 School of Health and Social Care , London South Bank University , London , UK
• Correspondence to Dr Roberta Heale, School of Nursing, Laurentian University, Sudbury, ON P3E2C6, Canada; rheale{at}laurentian.ca

https://doi.org/10.1136/eb-2017-102845

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What is it?

Case study is a research methodology, typically seen in social and life sciences. There is no one definition of case study research. 1 However, very simply… ‘a case study can be defined as an intensive study about a person, a group of people or a unit, which is aimed to generalize over several units’. 1 A case study has also been described as an intensive, systematic investigation of a single individual, group, community or some other unit in which the researcher examines in-depth data relating to several variables. 2

Often there are several similar cases to consider such as educational or social service programmes that are delivered from a number of locations. Although similar, they are complex and have unique features. In these circumstances, the evaluation of several, similar cases will provide a better answer to a research question than if only one case is examined, hence the multiple-case study. Stake asserts that the cases are grouped and viewed as one entity, called the quintain . 6  ‘We study what is similar and different about the cases to understand the quintain better’. 6

The steps when using case study methodology are the same as for other types of research. 6 The first step is defining the single case or identifying a group of similar cases that can then be incorporated into a multiple-case study. A search to determine what is known about the case(s) is typically conducted. This may include a review of the literature, grey literature, media, reports and more, which serves to establish a basic understanding of the cases and informs the development of research questions. Data in case studies are often, but not exclusively, qualitative in nature. In multiple-case studies, analysis within cases and across cases is conducted. Themes arise from the analyses and assertions about the cases as a whole, or the quintain, emerge. 6

Benefits and limitations of case studies

If a researcher wants to study a specific phenomenon arising from a particular entity, then a single-case study is warranted and will allow for a in-depth understanding of the single phenomenon and, as discussed above, would involve collecting several different types of data. This is illustrated in example 1 below.

Using a multiple-case research study allows for a more in-depth understanding of the cases as a unit, through comparison of similarities and differences of the individual cases embedded within the quintain. Evidence arising from multiple-case studies is often stronger and more reliable than from single-case research. Multiple-case studies allow for more comprehensive exploration of research questions and theory development. 6

Despite the advantages of case studies, there are limitations. The sheer volume of data is difficult to organise and data analysis and integration strategies need to be carefully thought through. There is also sometimes a temptation to veer away from the research focus. 2 Reporting of findings from multiple-case research studies is also challenging at times, 1 particularly in relation to the word limits for some journal papers.

Examples of case studies

Example 1: nurses’ paediatric pain management practices.

One of the authors of this paper (AT) has used a case study approach to explore nurses’ paediatric pain management practices. This involved collecting several datasets:

Observational data to gain a picture about actual pain management practices.

Questionnaire data about nurses’ knowledge about paediatric pain management practices and how well they felt they managed pain in children.

Questionnaire data about how critical nurses perceived pain management tasks to be.

These datasets were analysed separately and then compared 7–9 and demonstrated that nurses’ level of theoretical did not impact on the quality of their pain management practices. 7 Nor did individual nurse’s perceptions of how critical a task was effect the likelihood of them carrying out this task in practice. 8 There was also a difference in self-reported and observed practices 9 ; actual (observed) practices did not confirm to best practice guidelines, whereas self-reported practices tended to.

Example 2: quality of care for complex patients at Nurse Practitioner-Led Clinics (NPLCs)

The other author of this paper (RH) has conducted a multiple-case study to determine the quality of care for patients with complex clinical presentations in NPLCs in Ontario, Canada. 10 Five NPLCs served as individual cases that, together, represented the quatrain. Three types of data were collected including:

Review of documentation related to the NPLC model (media, annual reports, research articles, grey literature and regulatory legislation).

Interviews with nurse practitioners (NPs) practising at the five NPLCs to determine their perceptions of the impact of the NPLC model on the quality of care provided to patients with multimorbidity.

Chart audits conducted at the five NPLCs to determine the extent to which evidence-based guidelines were followed for patients with diabetes and at least one other chronic condition.

The three sources of data collected from the five NPLCs were analysed and themes arose related to the quality of care for complex patients at NPLCs. The multiple-case study confirmed that nurse practitioners are the primary care providers at the NPLCs, and this positively impacts the quality of care for patients with multimorbidity. Healthcare policy, such as lack of an increase in salary for NPs for 10 years, has resulted in issues in recruitment and retention of NPs at NPLCs. This, along with insufficient resources in the communities where NPLCs are located and high patient vulnerability at NPLCs, have a negative impact on the quality of care. 10

These examples illustrate how collecting data about a single case or multiple cases helps us to better understand the phenomenon in question. Case study methodology serves to provide a framework for evaluation and analysis of complex issues. It shines a light on the holistic nature of nursing practice and offers a perspective that informs improved patient care.

• Gustafsson J
• Calanzaro M
• Sandelowski M

Competing interests None declared.

Provenance and peer review Commissioned; internally peer reviewed.

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• 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

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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.

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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.

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Acknowledgements

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

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Sarah Crowe & Anthony Avery

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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.

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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

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How to write a case study — examples, templates, and tools

It’s a marketer’s job to communicate the effectiveness of a product or service to potential and current customers to convince them to buy and keep business moving. One of the best methods for doing this is to share success stories that are relatable to prospects and customers based on their pain points, experiences, and overall needs.

That’s where case studies come in. Case studies are an essential part of a content marketing plan. These in-depth stories of customer experiences are some of the most effective at demonstrating the value of a product or service. Yet many marketers don’t use them, whether because of their regimented formats or the process of customer involvement and approval.

A case study is a powerful tool for showcasing your hard work and the success your customer achieved. But writing a great case study can be difficult if you’ve never done it before or if it’s been a while. This guide will show you how to write an effective case study and provide real-world examples and templates that will keep readers engaged and support your business.

In this article, you’ll learn:

What is a case study?

How to write a case study, case study templates, case study examples, case study tools.

A case study is the detailed story of a customer’s experience with a product or service that demonstrates their success and often includes measurable outcomes. Case studies are used in a range of fields and for various reasons, from business to academic research. They’re especially impactful in marketing as brands work to convince and convert consumers with relatable, real-world stories of actual customer experiences.

The best case studies tell the story of a customer’s success, including the steps they took, the results they achieved, and the support they received from a brand along the way. To write a great case study, you need to:

• Celebrate the customer and make them — not a product or service — the star of the story.
• Craft the story with specific audiences or target segments in mind so that the story of one customer will be viewed as relatable and actionable for another customer.
• Write copy that is easy to read and engaging so that readers will gain the insights and messages intended.
• Follow a standardized format that includes all of the essentials a potential customer would find interesting and useful.
• Support all of the claims for success made in the story with data in the forms of hard numbers and customer statements.

Case studies are a type of review but more in depth, aiming to show — rather than just tell — the positive experiences that customers have with a brand. Notably, 89% of consumers read reviews before deciding to buy, and 79% view case study content as part of their purchasing process. When it comes to B2B sales, 52% of buyers rank case studies as an important part of their evaluation process.

Telling a brand story through the experience of a tried-and-true customer matters. The story is relatable to potential new customers as they imagine themselves in the shoes of the company or individual featured in the case study. Showcasing previous customers can help new ones see themselves engaging with your brand in the ways that are most meaningful to them.

Besides sharing the perspective of another customer, case studies stand out from other content marketing forms because they are based on evidence. Whether pulling from client testimonials or data-driven results, case studies tend to have more impact on new business because the story contains information that is both objective (data) and subjective (customer experience) — and the brand doesn’t sound too self-promotional.

Case studies are unique in that there’s a fairly standardized format for telling a customer’s story. But that doesn’t mean there isn’t room for creativity. It’s all about making sure that teams are clear on the goals for the case study — along with strategies for supporting content and channels — and understanding how the story fits within the framework of the company’s overall marketing goals.

Here are the basic steps to writing a good case study.

1. Identify your goal

Start by defining exactly who your case study will be designed to help. Case studies are about specific instances where a company works with a customer to achieve a goal. Identify which customers are likely to have these goals, as well as other needs the story should cover to appeal to them.

The answer is often found in one of the buyer personas that have been constructed as part of your larger marketing strategy. This can include anything from new leads generated by the marketing team to long-term customers that are being pressed for cross-sell opportunities. In all of these cases, demonstrating value through a relatable customer success story can be part of the solution to conversion.

2. Choose your client or subject

Who you highlight matters. Case studies tie brands together that might otherwise not cross paths. A writer will want to ensure that the highlighted customer aligns with their own company’s brand identity and offerings. Look for a customer with positive name recognition who has had great success with a product or service and is willing to be an advocate.

The client should also match up with the identified target audience. Whichever company or individual is selected should be a reflection of other potential customers who can see themselves in similar circumstances, having the same problems and possible solutions.

Some of the most compelling case studies feature customers who:

• Switch from one product or service to another while naming competitors that missed the mark.
• Experience measurable results that are relatable to others in a specific industry.
• Represent well-known brands and recognizable names that are likely to compel action.
• Advocate for a product or service as a champion and are well-versed in its advantages.

Whoever or whatever customer is selected, marketers must ensure they have the permission of the company involved before getting started. Some brands have strict review and approval procedures for any official marketing or promotional materials that include their name. Acquiring those approvals in advance will prevent any miscommunication or wasted effort if there is an issue with their legal or compliance teams.

3. Conduct research and compile data

Substantiating the claims made in a case study — either by the marketing team or customers themselves — adds validity to the story. To do this, include data and feedback from the client that defines what success looks like. This can be anything from demonstrating return on investment (ROI) to a specific metric the customer was striving to improve. Case studies should prove how an outcome was achieved and show tangible results that indicate to the customer that your solution is the right one.

This step could also include customer interviews. Make sure that the people being interviewed are key stakeholders in the purchase decision or deployment and use of the product or service that is being highlighted. Content writers should work off a set list of questions prepared in advance. It can be helpful to share these with the interviewees beforehand so they have time to consider and craft their responses. One of the best interview tactics to keep in mind is to ask questions where yes and no are not natural answers. This way, your subject will provide more open-ended responses that produce more meaningful content.

4. Choose the right format

There are a number of different ways to format a case study. Depending on what you hope to achieve, one style will be better than another. However, there are some common elements to include, such as:

• An engaging headline
• A subject and customer introduction
• The unique challenge or challenges the customer faced
• The solution the customer used to solve the problem
• The results achieved
• Data and statistics to back up claims of success
• A strong call to action (CTA) to engage with the vendor

It’s also important to note that while case studies are traditionally written as stories, they don’t have to be in a written format. Some companies choose to get more creative with their case studies and produce multimedia content, depending on their audience and objectives. Case study formats can include traditional print stories, interactive web or social content, data-heavy infographics, professionally shot videos, podcasts, and more.

5. Write your case study

We’ll go into more detail later about how exactly to write a case study, including templates and examples. Generally speaking, though, there are a few things to keep in mind when writing your case study.

• Be clear and concise. Readers want to get to the point of the story quickly and easily, and they’ll be looking to see themselves reflected in the story right from the start.
• Provide a big picture. Always make sure to explain who the client is, their goals, and how they achieved success in a short introduction to engage the reader.
• Construct a clear narrative. Stick to the story from the perspective of the customer and what they needed to solve instead of just listing product features or benefits.
• Leverage graphics. Incorporating infographics, charts, and sidebars can be a more engaging and eye-catching way to share key statistics and data in readable ways.
• Offer the right amount of detail. Most case studies are one or two pages with clear sections that a reader can skim to find the information most important to them.
• Include data to support claims. Show real results — both facts and figures and customer quotes — to demonstrate credibility and prove the solution works.

6. Promote your story

Marketers have a number of options for distribution of a freshly minted case study. Many brands choose to publish case studies on their website and post them on social media. This can help support SEO and organic content strategies while also boosting company credibility and trust as visitors see that other businesses have used the product or service.

Marketers are always looking for quality content they can use for lead generation. Consider offering a case study as gated content behind a form on a landing page or as an offer in an email message. One great way to do this is to summarize the content and tease the full story available for download after the user takes an action.

Sales teams can also leverage case studies, so be sure they are aware that the assets exist once they’re published. Especially when it comes to larger B2B sales, companies often ask for examples of similar customer challenges that have been solved.

Now that you’ve learned a bit about case studies and what they should include, you may be wondering how to start creating great customer story content. Here are a couple of templates you can use to structure your case study.

Template 1 — Challenge-solution-result format

• Start with an engaging title. This should be fewer than 70 characters long for SEO best practices. One of the best ways to approach the title is to include the customer’s name and a hint at the challenge they overcame in the end.
• Create an introduction. Lead with an explanation as to who the customer is, the need they had, and the opportunity they found with a specific product or solution. Writers can also suggest the success the customer experienced with the solution they chose.
• Present the challenge. This should be several paragraphs long and explain the problem the customer faced and the issues they were trying to solve. Details should tie into the company’s products and services naturally. This section needs to be the most relatable to the reader so they can picture themselves in a similar situation.
• Share the solution. Explain which product or service offered was the ideal fit for the customer and why. Feel free to delve into their experience setting up, purchasing, and onboarding the solution.
• Explain the results. Demonstrate the impact of the solution they chose by backing up their positive experience with data. Fill in with customer quotes and tangible, measurable results that show the effect of their choice.
• Ask for action. Include a CTA at the end of the case study that invites readers to reach out for more information, try a demo, or learn more — to nurture them further in the marketing pipeline. What you ask of the reader should tie directly into the goals that were established for the case study in the first place.

Template 2 — Data-driven format

• Start with an engaging title. Be sure to include a statistic or data point in the first 70 characters. Again, it’s best to include the customer’s name as part of the title.
• Create an overview. Share the customer’s background and a short version of the challenge they faced. Present the reason a particular product or service was chosen, and feel free to include quotes from the customer about their selection process.
• Present data point 1. Isolate the first metric that the customer used to define success and explain how the product or solution helped to achieve this goal. Provide data points and quotes to substantiate the claim that success was achieved.
• Present data point 2. Isolate the second metric that the customer used to define success and explain what the product or solution did to achieve this goal. Provide data points and quotes to substantiate the claim that success was achieved.
• Present data point 3. Isolate the final metric that the customer used to define success and explain what the product or solution did to achieve this goal. Provide data points and quotes to substantiate the claim that success was achieved.
• Summarize the results. Reiterate the fact that the customer was able to achieve success thanks to a specific product or service. Include quotes and statements that reflect customer satisfaction and suggest they plan to continue using the solution.
• Ask for action. Include a CTA at the end of the case study that asks readers to reach out for more information, try a demo, or learn more — to further nurture them in the marketing pipeline. Again, remember that this is where marketers can look to convert their content into action with the customer.

While templates are helpful, seeing a case study in action can also be a great way to learn. Here are some examples of how Adobe customers have experienced success.

Juniper Networks

One example is the Adobe and Juniper Networks case study , which puts the reader in the customer’s shoes. The beginning of the story quickly orients the reader so that they know exactly who the article is about and what they were trying to achieve. Solutions are outlined in a way that shows Adobe Experience Manager is the best choice and a natural fit for the customer. Along the way, quotes from the client are incorporated to help add validity to the statements. The results in the case study are conveyed with clear evidence of scale and volume using tangible data.

The story of Lenovo’s journey with Adobe is one that spans years of planning, implementation, and rollout. The Lenovo case study does a great job of consolidating all of this into a relatable journey that other enterprise organizations can see themselves taking, despite the project size. This case study also features descriptive headers and compelling visual elements that engage the reader and strengthen the content.

Tata Consulting

When it comes to using data to show customer results, this case study does an excellent job of conveying details and numbers in an easy-to-digest manner. Bullet points at the start break up the content while also helping the reader understand exactly what the case study will be about. Tata Consulting used Adobe to deliver elevated, engaging content experiences for a large telecommunications client of its own — an objective that’s relatable for a lot of companies.

Case studies are a vital tool for any marketing team as they enable you to demonstrate the value of your company’s products and services to others. They help marketers do their job and add credibility to a brand trying to promote its solutions by using the experiences and stories of real customers.

When you’re ready to get started with a case study:

• Think about a few goals you’d like to accomplish with your content.
• Make a list of successful clients that would be strong candidates for a case study.
• Reach out to the client to get their approval and conduct an interview.
• Gather the data to present an engaging and effective customer story.

Adobe can help

There are several Adobe products that can help you craft compelling case studies. Adobe Experience Platform helps you collect data and deliver great customer experiences across every channel. Once you’ve created your case studies, Experience Platform will help you deliver the right information to the right customer at the right time for maximum impact.

To learn more, watch the Adobe Experience Platform story .

Keep in mind that the best case studies are backed by data. That’s where Adobe Real-Time Customer Data Platform and Adobe Analytics come into play. With Real-Time CDP, you can gather the data you need to build a great case study and target specific customers to deliver the content to the right audience at the perfect moment.

Watch the Real-Time CDP overview video to learn more.

Finally, Adobe Analytics turns real-time data into real-time insights. It helps your business collect and synthesize data from multiple platforms to make more informed decisions and create the best case study possible.

Request a demo to learn more about Adobe Analytics.

https://business.adobe.com/blog/perspectives/b2b-ecommerce-10-case-studies-inspire-you

https://business.adobe.com/blog/basics/business-case

https://business.adobe.com/blog/basics/what-is-real-time-analytics

• Our Mission

Making Learning Relevant With Case Studies

The open-ended problems presented in case studies give students work that feels connected to their lives.

To prepare students for jobs that haven’t been created yet, we need to teach them how to be great problem solvers so that they’ll be ready for anything. One way to do this is by teaching content and skills using real-world case studies, a learning model that’s focused on reflection during the problem-solving process. It’s similar to project-based learning, but PBL is more focused on students creating a product.

Case studies have been used for years by businesses, law and medical schools, physicians on rounds, and artists critiquing work. Like other forms of problem-based learning, case studies can be accessible for every age group, both in one subject and in interdisciplinary work.

You can get started with case studies by tackling relatable questions like these with your students:

• How can we limit food waste in the cafeteria?
• How can we get our school to recycle and compost waste? (Or, if you want to be more complex, how can our school reduce its carbon footprint?)
• How can we improve school attendance?
• How can we reduce the number of people who get sick at school during cold and flu season?

Addressing questions like these leads students to identify topics they need to learn more about. In researching the first question, for example, students may see that they need to research food chains and nutrition. Students often ask, reasonably, why they need to learn something, or when they’ll use their knowledge in the future. Learning is most successful for students when the content and skills they’re studying are relevant, and case studies offer one way to create that sense of relevance.

Teaching With Case Studies

Ultimately, a case study is simply an interesting problem with many correct answers. What does case study work look like in classrooms? Teachers generally start by having students read the case or watch a video that summarizes the case. Students then work in small groups or individually to solve the case study. Teachers set milestones defining what students should accomplish to help them manage their time.

During the case study learning process, student assessment of learning should be focused on reflection. Arthur L. Costa and Bena Kallick’s Learning and Leading With Habits of Mind gives several examples of what this reflection can look like in a classroom: 

Journaling: At the end of each work period, have students write an entry summarizing what they worked on, what worked well, what didn’t, and why. Sentence starters and clear rubrics or guidelines will help students be successful. At the end of a case study project, as Costa and Kallick write, it’s helpful to have students “select significant learnings, envision how they could apply these learnings to future situations, and commit to an action plan to consciously modify their behaviors.”

Interviews: While working on a case study, students can interview each other about their progress and learning. Teachers can interview students individually or in small groups to assess their learning process and their progress.

Student discussion: Discussions can be unstructured—students can talk about what they worked on that day in a think-pair-share or as a full class—or structured, using Socratic seminars or fishbowl discussions. If your class is tackling a case study in small groups, create a second set of small groups with a representative from each of the case study groups so that the groups can share their learning.

4 Tips for Setting Up a Case Study

1. Identify a problem to investigate: This should be something accessible and relevant to students’ lives. The problem should also be challenging and complex enough to yield multiple solutions with many layers.

2. Give context: Think of this step as a movie preview or book summary. Hook the learners to help them understand just enough about the problem to want to learn more.

3. Have a clear rubric: Giving structure to your definition of quality group work and products will lead to stronger end products. You may be able to have your learners help build these definitions.

4. Provide structures for presenting solutions: The amount of scaffolding you build in depends on your students’ skill level and development. A case study product can be something like several pieces of evidence of students collaborating to solve the case study, and ultimately presenting their solution with a detailed slide deck or an essay—you can scaffold this by providing specified headings for the sections of the essay.

Problem-Based Teaching Resources

There are many high-quality, peer-reviewed resources that are open source and easily accessible online.

• The National Center for Case Study Teaching in Science at the University at Buffalo built an online collection of more than 800 cases that cover topics ranging from biochemistry to economics. There are resources for middle and high school students.
• Models of Excellence , a project maintained by EL Education and the Harvard Graduate School of Education, has examples of great problem- and project-based tasks—and corresponding exemplary student work—for grades pre-K to 12.
• The Interdisciplinary Journal of Problem-Based Learning at Purdue University is an open-source journal that publishes examples of problem-based learning in K–12 and post-secondary classrooms.
• The Tech Edvocate has a list of websites and tools related to problem-based learning.

In their book Problems as Possibilities , Linda Torp and Sara Sage write that at the elementary school level, students particularly appreciate how they feel that they are taken seriously when solving case studies. At the middle school level, “researchers stress the importance of relating middle school curriculum to issues of student concern and interest.” And high schoolers, they write, find the case study method “beneficial in preparing them for their future.”

Evaluation of urban flood adaptability based on the InVEST model and GIS: A case study of New York City, USA

• Original Paper
• Published: 08 May 2024

Cite this article

• Song Yao   ORCID: orcid.org/0000-0002-7579-8585 1 , 2 ,
• Guoping Huang 3 &
• Zihan Chen 4  

Flood risk has become a serious challenge for many cities, including New York City (NYC). Evaluating urban flood adaptability evaluation is crucial for regulating storm and rain risks. In this study, we proposed an integrated framework based on the Integrated Valuation of Ecosystem Services (InVEST) model and Geographic Information System (GIS). First, the InVEST model was used to assess the water yield, soil conservation, and water quality purification in NYC. Second, the entropy weighting method was employed to determine the weights of indicators for computing the flood adaptability evaluation (FAE). Third, a spatial correlation of FAE was conducted and finally delineated the flood adaptability zones in GIS. The results show that: (1) The spatial distribution of FAE was uneven, high in the surrounding area and low in the center. (2) The Moran's I for FAE was 0.644, showing an overall positive spatial relationship of FAE. High-scoring clusters were located in the southeastern area while low-scoring clusters were in the northern, central, and southwestern areas. (3) The FAE in NYC can be divided into five categories: the lower-adapted zone (0.22–0.27), low-adapted zone (0.28–0.31), medium-adapted zone (0.32–0.36), high-adapted zone (0.37–0.43) and higher-adapted zone (0.44–0.50). These results of the study can provide evidence and recommendations for flood risk management in NYC and other cities worldwide.

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Acknowledgements

This research was supported by the National Natural Science Foundation of China (Grant No. 51878593).

This research was funded by the National Natural Science Foundation of China (Grant No. 51878593).

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Conceptualization, Song Yao and Zihan Chen; data curation, Song Yao; formal analysis, Song Yao and Zihan Chen; funding acquisition, Guoping Huang; methodology, Song Yao; resources, Guoping Huang; software, Song Yao; supervision, Guoping Huang; validation, Song Yao; visualization, Song Yao; writing—original draft preparation, Song Yao and Zihan Chen; writing—review and editing, Song Yao. All authors read and approved the final manuscript.

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Yao, S., Huang, G. & Chen, Z. Evaluation of urban flood adaptability based on the InVEST model and GIS: A case study of New York City, USA. Nat Hazards (2024). https://doi.org/10.1007/s11069-024-06632-y

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Strengthening event-based surveillance (EBS): a case study from Afghanistan

• Mohamed Mostafa Tahoun 1 , 2 ,
• Mohammad Nadir Sahak 3 ,
• Muzhgan Habibi 3 ,
• Mohamad Jamaluddin Ahadi 4 ,
• Bahara Rasoly 4 ,
• Sabrina Shivji 5 ,
• Ahmed Taha Aboushady 3 , 6 ,
• Pierre Nabeth 3 ,
• Mahmoud Sadek 3 &
• Alaa Abouzeid 1 , 7  

Conflict and Health volume  18 , Article number:  39 ( 2024 ) Cite this article

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The sustained instability in Afghanistan, along with ongoing disease outbreaks and the impact of the COVID-19 pandemic, has significantly affected the country.

During the COVID-19 pandemic, the country’s detection and response capacities faced challenges. Case identification was done in all health facilities from primary to tertiary levels but neglected cases at the community level, resulting in undetected and uncontrolled transmission from communities. This emphasizes a missed opportunity for early detection that Event-Based Surveillance (EBS) could have facilitated.

Therefore, Afghanistan planned to strengthen the EBS component of the national public health surveillance system to enhance the capacity for the rapid detection and response to infectious disease outbreaks, including COVID-19 and other emerging diseases. This effort was undertaken to promptly mitigate the impact of such outbreaks.

We conducted a landscape assessment of Afghanistan’s public health surveillance system to identify the best way to enhance EBS, and then we crafted an implementation work plan. The work plan included the following steps: establishing an EBS multisectoral coordination and working group, identifying EBS information sources, prioritizing public health events of importance, defining signals, establishing reporting mechanisms, and developing standard operating procedures and training guides.

EBS is currently being piloted in seven provinces in Afghanistan. The lessons learned from the pilot phase will support its overall expansion throughout the country.

Background information

Following years of war and recent political changes, Afghanistan is facing a severe humanitarian crisis, with 24.4 million people needing humanitarian assistance and 18.1 million requiring health assistance to survive as of 2022. These challenges have heightened the risk of infectious disease outbreaks due to interrupted access to health services, increased food insecurity, internal displacement, and higher-than-usual rates of cross-border return (1). The country has recently experienced multiple outbreaks, including measles, diarrheal disease (including cholera), dengue fever, Crimean Congo hemorrhagic fever, pertussis, and malaria [ 1 ].

From the first reported case of COVID-19 in February 2020 to 3 December 2022, a total of 206,675 confirmed cases of COVID-19 and 7,840 deaths were reported [ 2 ]. However, the national serosurvey of COVID-19 morbidity in Afghanistan, which was conducted during June and July 2021, revealed that around 10 million people (31.5% of the population) were seropositive for antibodies against SARS-CoV-2, reflecting either current or previous COVID-19 infection [ 3 ].

Amidst Afghanistan’s complex challenges, the “One Health” concept stands out as essential, emphasizing the interdependence of human, animal, and environmental health. This approach promotes collaborative surveillance, integrating public health, veterinary, and environmental sciences to improve infectious disease detection, response, and management. Given Afghanistan’s vulnerability to health crises, adopting One Health and enhancing collaborative efforts are crucial for addressing immediate issues and building long-term resilience against future emergencies, ensuring a unified and effective approach to safeguarding health across all fronts.

The World Health Organization (WHO) recommends adopting an early warning and response (EWAR) function to enhance the capabilities of the surveillance system in detecting infectious diseases and outbreaks [ 4 ]. Event-based surveillance (EBS) is a crucial component of EWAR [ 5 ]. EBS helps rapidly detect unusual occurrences and outbreaks with pandemic potential, especially in areas with limited access to formal healthcare with a focus on all hazards approach, ensuring alignment with One Health concept. This rapid detection of potential events can trigger a quicker response than what might be expected from routine surveillance. For example, during a pandemic, EBS can detect new clusters and trigger response actions. EBS should work alongside case-based and laboratory surveillance systems such that individual cases identified in a cluster are referred to a health facility and have a sample collected, where appropriate. This link to case-based surveillance is essential to accurately count cases, track necessary epidemiologic and virologic information, and guide affected persons.

In Afghanistan, the National Disease Surveillance and Response (NDSR) system, operating under the General Directorate of Monitoring, Evaluation, and Health Information System, conducts infectious disease surveillance. This system includes indicator-based surveillance (IBS) and EBS components. The IBS component of NDSR gathers data on 17 notifiable diseases, prioritizing them based on preventability and public health importance from selected sentinel sites. However, EBS has been limited in scope and functionality, relying on few health facilities and communities through unstructured reporting.

During the onset of the COVID-19 pandemic, outbreak detection was primarily restricted to some health facilities later to all of them. The significance of EBS in Afghanistan became apparent following the escalation of the first COVID-19 wave in May 2020. During this period, numerous clusters of COVID-19 cases and deaths emerged within the community, yet they remained unreported and unmanaged. Consequently, the Ministry of Public Health (MoPH) surveillance department took action to enhance the EBS system.

The prioritization of EBS strengthening in Afghanistan, particularly in response to the COVID-19 pandemic, stems from its ability to capture a broader spectrum of signals related to disease activity, including outbreaks that might be missed or underreported in a weakened healthcare infrastructure. This approach compensates for the gaps left by traditional IBS, especially in scenarios where logistical, financial, or infrastructural constraints might hamper laboratory or case-based surveillance. By prioritizing EBS, Afghanistan aims to leverage its agility and broader scope to better navigate the complexities of disease surveillance in a context marked by significant disruptions to healthcare services and reporting mechanisms, thus offering a pragmatic path forward in bolstering the country’s disease outbreak response capabilities.

This paper highlights the EBS implementation process and shares lessons from an emergency country context. It presents the main steps and outputs of the first phase of EBS implementation in Afghanistan and discusses the subsequent steps in the implementation process.

The implementation of the EBS system in Afghanistan started through collaboration between the MoPH, the WHO Country Office Afghanistan (WCO), the WHO Regional Office for the Eastern Mediterranean (EMRO), the United States Centers for Disease Control and Prevention (CDC), and the Global Health Development/Eastern Mediterranean Public Health Network (GHD|EMPHNET). The MoPH led the EBS enhancement process and implementation in the country with the technical support of WHO, the CDC, and GHD|EMPHNET.

The initial phase involved conducting a landscape assessment to better understand the existing surveillance system in Afghanistan, facilitating the design of an EBS that would integrate seamlessly. The landscape assessment was conducted through guided interviews with key surveillance officials at the MoPH and WCO using a questionnaire developed by the CDC. The questionnaire focused on gathering information related to detection, reporting, verification, and risk assessment of potential public health threats.

The results of the assessment were utilised in the second phase, involving the crafting of the EBS work plan. This work plan was drafted at country level with technical support from EMRO and CDC. The work plan outelined the implementation steps and activities aimed to enhance EBS in Afghanistan. These activities included identifying and training EBS mentors at the MoPH, mapping EBS stakeholders, identifying EBS information sources, prioritizing EBS events and defining signals, developing EBS guidelines and Standard Operating Procedures (SoPs), contextualizing EBS training materials, deploying the Epidemic Intelligence from Open Sources (EIOS) tool to implement the media scanning component of EBS, identifying EBS pilot sites (provinces), evaluating the pilot sites and expanding EBS throughout the country.

The MoPH surveillance department designated three mentors to enhance the EBS system. These mentors identified all relevant stakeholders for EBS in Afghanistan, referring to the existing IHR stakeholders list, and made necessary additions or exclusions to ensure representation for all an hazards approach through a multi-sectoral collaboration.

They assigned the mapped stakeholders to a coordination committee (CC). In the first meeting, the EBS mentors introduced EBS, explained its importance, and presented the EBS workplan to the CC. In a second meeting, the CC, guided by the EBS mentors, identified priority information sources for EBS. Subsequently, the CC established a smaller Technical Working Group (TWG) to prioritize events, develop signals, and create Standard Operating Procedures (SoPs) and training materials.

The TWG convened regular biweekly meetings with an initial focus on identifying priority events under EBS. Events are considered to be manifestations of disease or occurrences which have potential to create disease of known or unknown origin. “Event” in the event-based surveillance context is a signal that is verified to be truly occurring [ 4 ].

To facilitate the practice of prioritizing events, EBS mentors developed a complete list of events ahead of the meetings based on a risk assessment process using locally developed tool by WHO country office and MOH. No sensitivity analyses was done for any unusual event. The EBS mentors discussed the list with the TWG, and based on several criteria, including the potential impact of the event on public health, epidemic-prone diseases, historically prevalent diseases with the potential to re-emerge, and diseases targeted for eradication or elimination, priority events were selected.

After prioritizing events, the TWG created corresponding signals. Signlas are bits of information or occurences that may represent an acute risk to human health [ 4 ]. The TWG finalized the drafted signals with technical input from the WHO EMRO and US CDC. Following the creation of signals, the flow of information for EBS, focal points at each level, and roles and responsibilities were discussed by the TWG. The embedding of the EBS flow of information into the existing surveillance structure took place. Subsequently, all pieces developed for EBS were merged into a technical guideline with technical support from WHO, CDC, and GHD|EMPHNET. The selection of pilot sites for EBS implementation was carried out by the EBS CC.

Key processes

Landscape assessment.

The landscape assessment of the surveillance system in Afghanistan highlighted the existence of an established National Disease Surveillance and Response (NDSR) system. NDSR includes different administrative levels (Fig.  1 ).

NDSR Structure and communication pathways in Afghanistan. NDSR Structure relies on IBS and EBS. IBS collects data from sentinel sites on priority disease. EBS (in blue) recentlcy been incorporated into NDSR structure. At the regional level and national level, NDSR offices disseminate information collected from EBS and IBS to relevant stakeholders, NGO’s, WHO and key department of Ministry of health

The NDSR functions at the national level and is responsible for the overall coordination of infectious diseases in the country. There are eight regional NDSR offices, each including several provinces, and their main responsibility is to coordinate the surveillance activities in their regions and report to the national surveillance office. Each province has its own surveillance office that is responsible for the implementation of surveillance activities in its province. In 2021, there were 519 sentinel sites (health facilities) (of 3750 health facilities countrywide) reporting to the NDSR system, including regional hospitals, provincial hospitals, district hospitals, and comprehensive and basic health facilities.

After the surge of the COVID-19 pandemic in May 2020, the country mandated both laboratory-confirmed and suspected clinical COVID-19 cases reporting from all health facilities daily using online reporting forms through a data capture tool developed using DHIS2.

The assessment found a well-established sentinel IBS within the NDSR. However, the EBS component was limited, relying on a small number of health facilities and communities as information sources without clear reporting mechanisms. Common signals such as hemorrhagic fever (1 and above), clusters of diarrhea (5+), and clusters of rash with fever (5+) in children were reported from these sources to provincial and national NDSR. The national NDSR then conducts outbreak investigations and laboratory confirmations.

Afghanistan’s challenging terrain, characterized by mountains, poses a unique challenge, with over 9 million individuals residing in under-served or hard-to-reach areas (defined as more than a one-hour walking distance to the nearest health facility). The IBS system gathers data solely from sentinel sites, not encompassing all health facilities, potentially leading to delays in case presentation at the nearest health facility due to both geographical barriers and the population’s health-seeking behavior.

Information in an EBS system can include informal sources such as media reports, reputable and well-connected community members, or other non-traditional sources for health information in addition to official or formal sources [ 4 ]. There was no specific and clear Community Event-Based Surveillance (CEBS), Health Facility Event-Based Surveillance (HEBS), Internet Event-Based Surveillance, laboratory, or veterinary EBS in place. Coordination with the animal health sector was limited to quarterly zoonotic committee meetings at the national and provincial levels and information sharing occured one way where only the MoPH surveillance department shared weekly surveillance information to animal health and other relevant sectors. There was no established reporting mechanism for disease and events from the private sector in the country. In addition, the lack of standardized guidelines and SoPs for EBS in Afghanistan posed a challenge for implementation and sustainability.

Assigning national EBS mentors

CDC and WHO EMRO trained the three assigned mentors for EBS from the surveillance department of the MoPH on the principles and methods of EBS. The EBS mentors played an important role in advocating for and leading the integration of EBS in-country, coordinating with all stakeholders, and developing EBS guidelines and SoPs. In the second phase of EBS implementation, the mentors trained provincial and regional surveillance officers on EBS. EBS mentors intends to ensure the sustainability of event-based surveillance as part of the national disease surveillance strategy.

Mapping the EBS stakeholders

Major stakeholders identified include the MoPH, Central Public Health Laboratory (CPHL), Ministry of Agriculture, Irrigation and Livestock (MAIL), Ministry of Borders and Tribal Affairs, Ministry of Hajj and Religious Affairs, Afghanistan Nuclear Energy Agency (ANEA), National Disaster Management Authority, National Environment Protection Agency, Civil Aviation Authority Afghanistan, International Organization for Migration (IOM), and the WHO Country Office in Afghanistan. Maintaining constant communications among these stakeholders involved establishing an EBS coordination committee (CC), led by the MoPH.

The CC, under the leadership of the MoPH, played a central role in mobilizing all necessary resources for EBS, identifying EBS information sources, and validating signals, guidelines, SoPs, training materials, data collection tools, and the work plan for EBS implementation. Additionally, the CC led the monitoring and evaluation of EBS implementation in the country.

To streamline focus on EBS activities, the TWG was established, comprising key focal points from the MoPH, MAIL, CPHL, and WCO. The TWG, through its collaboration, prioritized events, defined signals, developed EBS SoPs, contextualized training materials, and identified sites for EBS implementation.

The information sources for EBS

EBS requires multi-sectoral collaboration and coordination between different stakeholders and relies on information sources beyond the traditional health system. While these may be directly linked to human health, data can also be provided by the non-human health sector, local communities, media, and international sources. Some information sources have key informants, who generally are community members with strong ties within their communities, such as religious leaders, schoolteachers, or even shop owners. The EBS CC identified and prioritized the EBS information sources in Afghanistan as described in Table  1 below.

Identify priority events and define signals

The prioritized events for EBS in Afghanistan include clusters of COVID-19 cases, avian influenza, acute hemorrhagic fever, vaccine-preventable diseases such as measles and poliomyelitis, cholera, norovirus (food poisoning), zoonotic priority diseases causing outbreaks, and emerging new diseases. The EBS TWG defined signals for each of these prioritized events and identified information sources, with key members from the Ministry of Education, municipality, Haj and Awkaf, Community Based Health Care department of the MoPH, MAIL, and other relevant stakeholders. These signals are standardized across the country.

Table  2 displays the list of signals defined for communities, health facilities, laboratories, and veterinary services.

EBS flow of information

The flow of information for the EBS (Fig.  2 ) was defined based on the steps of EBS and the current structure of the surveillance system. The flow of information relies mainly on key surveillance officers functioning at the local, provincial, regional and national levels as well as focal points from other relevant sources (laboratories, health facilities, veterinary services and PoEs).

EBS flow of information in Afghanistan

In Afghanistan, the community signals should be notified immediately by CHWs and other key informants to the community health supervisors (CHSs). Meanwhile, signals from health facilities, veterinary services, laboratories, and PoEs should be reported immediately to the surveillance focal points at the provincial level. Each community signal will be triaged and verified within 24 h of detection by CHSs and by surveillance officers at the provincial level for health facility, laboratory, PoE and veterinary-related signals.

Triage involves evaluating two questions: (1) Is the reported information pertinent to early warning (i.e., could this signal indicate a genuine public health event)? and (2) Has the signal been previously reported (i.e., is it a duplicate)? Verification is conducted by addressing three questions: (1) Is the report accurate (i.e., is it truel)? (2) Has the information been provided by a trustworthy source or sources? and (3) Does the report fulfill the criteria for one or more of the already developed list of signals?. Once a signal is verified as true, reported by credible source and meet criterial for the list of signals, it is called event (alert).

The community-verified events must be immediately reported to the provincial surveillance officers to undergo a risk assessment and response process jointly with its RRTs. Meanwhile, provincial surveillance officers must triage and verify signals from the health facility, veterinary services, laboratories, and PoEs and if verified, should initiate the risk assessment and provide a response immediately in coordination with the provincial RRTs. High-risk events as indicated by the risk assessment process must be assessed or responded to within 48 h of notification.

To conduct risk assessment, the team need to formulate risk assessment questions. These questions will differ from one event to another. Examples of these questions are:

Does the suspected disease have a high potential for spread?

Is there higher than expected mortality and morbidity from the diseases?

Is there a cluster of cases or deaths?

Does the disease have possible consequences on trade or travel?

Does the event affect livestock/wildlife?

Are there any environmental consequences?

Once sufficient information has been collected, the risk assessment team must determine the the leve of risk and type of action. The WHO risk matrix should should be used for this purpose (Table 3 ).

Based on the level of risk the team should determine the outcome of risk assessment and actions needed. Table  4 describes the potential outcomes of the risk assessment based on information collected during the risk assessment process and assigned level of risk.

Feedback mechanism should be maintained through all levels, ensuring that all levels are aware of the actions has been take on the reported signal and events. This will not only essure that the system runs smoothly but also to enable trust and motivation at each levels.

The provincial surveillance officers should report EBS activities to the national team. The regional surveillance office is responsible for coordinating the EBS implementation in their provinces, providing training, conducting supervisory visits, and providing other operational support.

The central team of NDSR will lead the EBS implementation by coordinating the training of regional and provincial EBS personnel, supporting cascade training, providing training materials and SoPs, monitoring and evaluating EBS implementation, and conducting regular meetings to review data collected and provide feedback. The national surveillance office and the regional surveillance office are also responsible for giving support to the provincial-level surveillance officers in providing an appropriate response to the verified events in coordination with all other sectors.

Furthermore, the National Surveillance Officer is responsible for conducting regular monitoring of the media using the Epidemic Intelligence from Open Sources (EIOS) system, focusing on the prioritized list of events and diseases. During the verification process of signals detected through EIOS, the regional and provincial surveillance officers will serve as contacts. Once a signal is verified, the national surveillance officer will perform a rapid risk assessment and initiate a response.

Developing operational EBS guidelines

After defining EBS information sources, prioritizing events, defining signals, and outlining the EBS information flow, EBS TWG developed a comprehensive operational guideline. This guideline integrates these steps and provides direction to EBS focal points at each level for effective implementation.

EBS TWG tailored Afghanistan’s EBS guidelines uniquely to its specific context, seamlessly integrating EBS into the existing NDSR structure and optimizing available human resources. They prioritized events based on the Afghan context, and carefully developed signals. These guidelines received technical support from the US CDC and WHO. Various guidelines, including WHO’s guidelines on EWAR with a specific focus on EBS and the US CDC’s EBS framework, served as references [ 4 , 6 ].

The guideline itself is structured into three main sections, further subdivided into subsections, as elaborated in Table 5 .

Contextualizing the EBS training materials

In order to facilitate the training of EBS focal points at different levels (Fig.  2 ), training manuals were developed using the CDC-developed EBS training manual as a reference [ 6 ]. A total of five facilitator and corresponding participant training manuals exist to train focal points for EBS in communities, health facilities, laboratories, veterinary services, and at the provincial surveillance office.

EIOS deployment

Media is an important source of information for EBS [ 7 ]. Afghanistan integrated media scanning as one of the surveillance functions under EBS. The EIOS tool has been deployed to facilitate the media scanning function in the country.

WHO proposes the EIOS tool to its member states to strengthen and solidify the surveillance system’s early detection, verification, assessment, and communication functions by utilizing publicly available, open-access information.

After ministerial approval for the initiation of the EIOS, a rigorous configuration process was conducted to capture the local context and language. First, the priority diseases were identified, and for Afghanistan, the list was previously identified through the NDSR. Afterwards, the keywords were translated to the local languages, Pashto and Dari. The local news sources, social media (SM) accounts, and relevant websites were identified to be added to the sources list on the portal. Finally, a physical workshop was conducted to build the MoPH capacities to use EIOS. The steps of EIOS deployment are mentioned in Fig.  3 .

Steps of EIOS deployment in Afghanistan

Following the training, a close follow-up was conducted. The SoP for EIOS was developed and incorporated into the EBS guidelines.

Pilot implementation

Following the development of country-specific guidelines, implementation commenced with a pilot phase in 7 provinces of the country by the end of 2022. The pilot focused on communities and health facilities. Implementation included training trainers for the 45 NDSR officers and coordinators at the national level, regional and provincial levels, with technical support from the WHO.

Subsequently, these trainers conducted training sessions for 883 medical doctors and CHSs in the piloted provinces. Following this, through third-party contractors, these medical doctors and CHSs further trained approximately 11,000 key informants at the community and health facility levels.

The pilot phase in the seven provinces yielded a total of 2,335 signals, of which 1,197 were verified as events. Risk assessments were conducted on 1,153 of these events.

The EBS in Afghanistan has advanced through several steps aimed at enhancing the country’s surveillance capabilities. This thorough process from assessment to selection of pilot sites, lasting about seven months, included extensive consultations at different levels. Key stakeholders under EBS CC and TWG, the US CDC, and the WHO provided valuable insights and expertise during the assessment and guideline development phases.

The approach to enhancing EBS in Afghanistan included several components that led to increased system efficiency and a more inclusive, structured system, despite the challenges posed by the country’s ongoing emergency situation. Afghanistan’s approach to EBS implementation can serve as a model for other countries facing similar contexts and aiming to establish EBS. One of the key strategies involved creating a roadmap for EBS and implementing it based on the results of a surveillance system landscape assessment. This approach ensured the integration of EBS into the existing structure of the surveillance system, which is the key for this work. The second strategy involved selecting key mentors from the national surveillance team and training them on EBS concepts from the very begining. This approach was crucial to ensure that MoPH took ownership of the system and led EBS efforts in the country.

Additionally establishing an EBS CC and a TWG fostered collaboration among diverse stakeholder groups and sectors. This collaboration aimed to collectively enhance the EBS system and broaden the sources of information for EBS in the country. The success of this approach can be seen in Vietnam [ 8 ], where the establishment of an EBS TWG resulted in improved alignment and reduced redundancies, as recommended in other published guidelines. The collaboration with other sectors for EBS also created political willness to implement the system which is key to highlight.

Finally, the development of SoP’s and signals for each identified information source under EBS establishes formalized reporting linkages among various important entities. One crucial linkage is between the human and animal health sectors, enhancing the detection of zoonotic events and advancing One Health efforts in the country [ 9 , 10 , 11 ]. Another significant linkage is the connection between communities and the health sector. Involving communities improves the detection of outbreaks, COVID-19 clusters and similar risks at the local level, leading to controlled transmission and reduced burden. Numerous countries have demonstrated improved risk detection by implementing community-based EBS [ 8 , 12 , 13 , 14 ]. However, ensuring sustainability is essential when implementing EBS through communities. In Afghanistan, CHWs are integral to the community-based healthcare component of the Basic Package of Health Services (BPHS), which has been implemented for 20 years. NGOs train and supervise CHWs under government or United Nations Children’s Fund (UNICEF) contracts. The MoPH NDSR department coordinates with NGOs through the Community-Based Health Care (CBHC) department to support the surveillance system. CHWs, who are volunteers without incentives, work in pairs at health posts, offering services ranging from health promotion to referrals. They receive training from contracted NGOs for their surveillance roles. They received trainings for EBS through similar NGO’s.

In addition to communities, created linkages with health facilities and laboratories for EBS enables the detection of new emerging diseases and pathogens. EBS through these sources also enable detection of clusters of cases among health workers, which was challenging during the COVID-19 pandemic and resulted in increased transmission among health care workers. A systematic review targeted low and middle income countries similary highlights impotance of health facilities to strengthen the early warning function of national surveillance systems [ 15 ].

Importantly, this is the first time the country used the media as a source for EBS by deploying the EIOS platform. EIOS plays an important role in the detection of risks signaled through media [ 16 ]. EIOS also allows monitoring the health risks in bordering countries through published sources and having the control measures in place in response to the increased cross-border activities.

Afghanistan launched the pilot phase of EBS in seven provinces: Kabul (one zone), Herat, Kandahar, Nangarhar, Badakhshan, Balkh, and Bamiyan. This initial phase is focusing on communities and health facilities. Countries can choose to start implementing EBS from a single source and then expand to other sources by time based on workforce, resources, and infrastructure availability to ensure effectiveness and sustainability [ 6 ]. Afghanistan plans to introduce other sources after evaluating the current pilot phase.

The pilot phase provides insight into operationalizing elements of the guideline and SoP, identifying what does not work well, and offering guidance to adjust the EBS strategy for full-scale implementation in the country. The national surveillance office ensures the efficient implementation of EBS in Afghanistan through regular monitoring and evaluation activities. The monitoring and evaluation framework used in Vietnam for the pilot phase is utilized and developed a supervision visit checklist used at different levels responsible for EBS in Afghanistan [ 17 ]. For the final evaluation of the pilot phase, Afghanistan will adopt and use the Africa CDC Monitoring and Evaluation framework [ 18 ].

EBS implementation in Afghanistan encountered limitations such as delays in launching the pilot phase after selection of pilot sites due to political changes and the assignment of new EBS focal points. The Ministry collaborated closely with WHO to revitalize the EBS through training and consultations with the new mentors. With the changes since 2021, the use of EIOS has been limited, requiring training and onboarding of new focal points to replace those previously responsible. The TWG supporting the EBS had been inactive for an extended period and needs restructuring to support ongoing implementation and evaluation of the system for full countrywide implementation.

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Acknowledgements

We are grateful to the following staff of MoPH Afghanistan for their ongoing support of the EBS project: Dr Fazal Elahi Alizai, Director General of Monitoring and Evaluation and Health Information System (M&E HIS)Dr. Sayed Ataullah Saeedzai, former director general of Monitoring & Evaluation and Health Information SystemEBS CC and TWG members Also, we would like to acknowledge the technical support provided by WCO, WHO EMRO, CDC, and GHD|EMPHNET.

Funding for this EBS project was provided by WHO, the United States CDC Global Health Security Agenda, and COVID-19 support under grant number GH0002225, a cooperative agreement for this surveillance activity.

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Contributions

MH and MNS conducted the surveillance assessment. SS, MMT, MS, MH, MNS and PN analyzed the result of the surveillance assessment and identified EBS gaps. SS, MS, MH and MT trained EBS mentors on EBS. MH, MNS, MS, MMT, SS, MJA, and PN participated in development of EBS workplan, implementation of workplan, development of EBS guidelines and training materials. MS and AA provided the training and deployed EIOS. MJA, MH, MNS, and BR created and coordinated EBS CC and TWG meetings. MMT, MJA, BR, AA, MS, and MH developed an EBS pilot implementation plan. MH, MMT, MS, MNS, SS drafted the manuscript. MMT, MNS, MTS, SS, MJA, AB, PN and AA reviewed and revised the manuscript. All authors read and approved the final manuscript.

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Correspondence to Muzhgan Habibi .

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Tahoun, M.M., Sahak, M.N., Habibi, M. et al. Strengthening event-based surveillance (EBS): a case study from Afghanistan. Confl Health 18 , 39 (2024). https://doi.org/10.1186/s13031-024-00598-1

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Access to anaesthesia and surgical care is a major problem for people living in Sub-Saharan Africa. In this region, ketamine is critical for the provision of anaesthesia care. However, efforts to control ketamine internationally as a controlled substance may significantly impact its accessibility. This research therefore aims to estimate the importance of ketamine for anaesthesia and surgical care in Sub-Saharan Africa and assess the potential impact on access to ketamine if it were to be scheduled.

This research is a mixed-methods study, comprising of a cross-sectional survey at the hospital level in Rwanda, and key informant interviews with experts on anaesthesia care in Sub-Saharan Africa. Data on availability of four anaesthetic agents were collected from hospitals ( n  = 54) in Rwanda. Semi-structured interviews with 10 key informants were conducted, collecting information on the importance of ketamine, the potential impact of scheduling ketamine internationally, and opinions on misuse of ketamine. Interviews were transcribed verbatim and analysed using a thematic analysis approach.

The survey conducted in Rwanda found that availability of ketamine and propofol was comparable at around 80%, while thiopental and inhalational agents were available at only about half of the hospitals. Significant barriers impeding access to anaesthesia care were identified, including a general lack of attention given to the specialty by governments, a shortage of anaesthesiologists and migration of trained anaesthesiologists, and a scarcity of medicines and equipment. Ketamine was described as critical for the provision of anaesthesia care as a consequence of these barriers. Misuse of ketamine was not believed to be an issue by the informants.

Ketamine is critical for the provision of anaesthesia care in Sub-Saharan Africa, and its scheduling would have a significantly negative impact on its availability for anaesthesia care.

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Introduction

Surgical care is defined by the Lancet Commission on Global Surgery as “the provision of operative, perioperative, and non-operative management; anaesthesia; and obstetric care for all surgical conditions” [ 1 ]. Surgical care is a cross-cutting field of care, and surgical procedures are essential in the treatment of communicable and non-communicable diseases, maternal, neonatal and nutritional disorders, and injuries [ 1 ]. It is estimated that conditions requiring surgery are responsible for around 30% of the global burden of disease, while access to safe, affordable and timely surgical and anaesthesia care is a major issue for more than 4.8 billion people worldwide [ 2 , 3 ]. This treatment gap is felt the most by people living in low- and middle-income countries (LMICs): an additional 143 million surgical procedures are needed in LMICs annually to avert preventable disability and deaths, and more than 77 million disability-adjusted life-years (DALYs) could be averted with adequate provision of basic surgical care [ 1 ]. Anaesthesia is a key component of surgical care.

Access to to timely, safe and affordable surgical and anaesthesia care is a major problem for people living in Sub-Saharan Africa (SSA), where it is beyond the reach of more than 95% of the population [ 3 ]. Lack of access to surgical and anaesthesia care in SSA is caused by a paucity of specialised healthcare workers, poor basic infrastructure, absence of surgical and anaesthesia equipment, and scarcity of essential medicines, including anaesthetic agents [ 4 ]. It is estimated that in the World Health Organization (WHO) Africa Region, there are on average 0.41 physician anaesthesia providers (PAPs) per 100,000 population. This number is far below the 10 PAPs per 100,000 population as recommended by the World Federation of Societies for Anaesthesiologists (WFSA) [ 5 ]. Research has shown that consistent access to electricity and running water remains problematic across SSA, and that availability of oxygen and functional anaesthetic machines is generally low [ 6 , 7 , 8 , 9 , 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 ]. Essential medicines, such as local or general anaesthetic agents, remain in low supply [ 6 , 9 , 17 , 19 , 20 , 21 ].

Due to the lack of PAPs, infrastructure, equipment, and essential medicines in much of SSA, surgical procedures often take place without adequate anaesthesia or pain management [ 22 ]. To alleviate the suffering of patients in these settings, hospitals have become reliant on ketamine. The WHO Model List of Essential Medicines lists ketamine for use as an anaesthetic [ 23 , 24 ]. Its use in low-resource settings is popular as ketamine does not depress respiratory function in patients while it increases blood pressure, and can therefore be used when access to airway equipment is lacking and monitoring of vital signs is challenging [ 22 , 23 ]. Because of these properties, ketamine can also be used by non-physician providers, if they have been appropriately trained [ 22 ].

Ketamine is misused as a recreational drug in high-income countries, especially in China, Hong Kong, Taiwan, and Japan, and more generally in East and Southeast Asia [ 4 , 23 , 25 ]. Because of this misuse, China has repeatedly submitted a request to schedule ketamine as a Schedule I drug under the Single Convention on Narcotic Drugs in 2006, 2012 and 2014, and submitted a request to have it scheduled as a schedule IV drug under the Convention on Psychotropic Substances in 2015 [ 23 , 26 , 27 , 28 , 29 ], see Box 1 for detailed information.

All four instances that scheduling was requested, the WHO Expert Committee on Drug Dependence (ECDD) declined, stating that ketamine poses no great global public health risk, while scheduling it would have a significant impact on medical care in LMICs and in emergency situations [ 25 , 26 , 27 ]. Subsequently, the United Nations Commission on Narcotic Drugs (CND) has not scheduled ketamine as a Schedule I drug in the Single Convention, or as a Schedule IV drug in the Convention on Psychotropic Substances [ 25 , 26 , 27 ]. However, it is likely that similar requests will be made in the future.

While the importance of ketamine for anaesthesia care has been discussed in an article in the Guardian and in editorials, no research has been undertaken in which anaesthesiologists from the field provide their insights into the issue [ 26 , 27 , 30 , 31 ]. This research therefore aims to estimate the importance of ketamine for anaesthesia and surgical care in SSA, and assess the potential impact on access to ketamine if it were to be scheduled, through a case study of essential anaesthesia commodities availability in Rwanda, and key informant interviews with experts from SSA.

Study design

This research is a mixed-methods study, comprising of a cross-sectional survey at the hospital level in Rwanda, and key informant interviews with experts on anaesthesia care in SSA. The survey on the availability of anaesthesia commodities was part of a larger project in Rwanda on access to essential medicines for the management and treatment of snakebites [ 32 ]. In this study, 34 commodities were surveyed, including four commodities that are used in anaesthesia care (ketamine, thiopental, inhalational agents, and propofol). The survey functioned as a case-study to gain insight into the availability of a range of anaesthesia commodities in a specific SSA country. Semi-structured interviews were conducted with key informants from the whole of SSA to gather a more generalised insight into the importance of ketamine for anaesthesia and surgical care in the entire region, given the situation in Rwanda may not be representative of the region.

Study participants and recruitment

In Rwanda, all general, non-specialised hospitals from the public and private sectors were selected for the survey. This included four private hospitals, and 51 public district-, provincial- and referral hospitals. The hospitals were contacted beforehand by email or telephone to schedule a study visit. One specialised hospital solely focussing on psychiatric care was excluded as were lower level health facilities, including health centres and health posts. These facilities were not included since they were not expected to have (most) anaesthetic agents.

Key stakeholders identified for participation in the interview component of this study were anaesthesiologists with expertise in anaesthesia care in SSA. They were identified and recruited through document desk review, the network of the WFSA and its national chapters, and the professional network of the researchers. Inclusion criteria for participation were: participants are 18 years or older, knowledgeable on anaesthesia care and ketamine use in SSA, and able to communicate in English. Participants were invited over email and provided with background information on the study. Multiple follow-up emails were sent in case of non-response.

Data collection

The WHO-WFSA International Standards for a Safe Practice of Anesthesia guided the selection of the general anaesthesia commodities [ 33 ]. Information on electricity, running water, and functional anaesthesia machines was also recorded. Data within the Rwandan hospitals was collected in February 2023. A mobile application, KoboCollect, was used for data collection. Data collectors received a two-day training from one of the authors (GIO), which included a field-test. Data collectors collected data in pairs and were supervised by an in-country lead investigator. Data on availability of the commodities was recorded only when they could be physically seen. A commodity was considered available if it was present at the hospital at the time of data collection. A photo was taken of each available, surveyed commodity as an additional validity measure.

A semi-structured key-informant interview guide was developed based on literature to guide the interviews (see Additional File 1 ). Questions focused on the contextual situation of anaesthesia care, including barriers to access, in the countries in which participants have work experience, their beliefs about ketamine and its relevance for anaesthesia care in these respective countries, and their perceived potential impact of ketamine scheduling on anaesthesia and surgical care in these contexts. We also sought the participants’ opinions on the level of misuse of ketamine in their countries, and about recommendations to safeguard access to anaesthesia care while at the same time preventing misuse of ketamine. Interviews were conducted by GIO from May to July 2023 with 10 participants. Nine interviews took place online through virtual meeting platform Zoom, and one interview was conducted via email, where the key informant responded to the questions in written form due to language barriers. Interviews lasted between 27 and 53 min. Interviews were recorded, and Zoom’s build-in automatic transcription setting was used.

Data management and analysis

Survey data were uploaded to the KoboToolbox server by the data collectors after completion, after which the data was downloaded into Microsoft Excel. The data was double-checked and cleaned by the researchers, and was analysed in Microsoft Excel using descriptive statistics. Availability across all hospitals was calculated as the proportion of hospitals where the commodity was present at the time of the survey.

The automatic, verbatim interview transcripts were checked by the researchers for errors and corrected when necessary after a consensus was reached. The interviews were analysed using a thematic analysis approach by one researcher (GIO), and consisted of coding text into predetermined themes, which were based on the interview topics.

Quality assurance

The qualitative component of this research was guided by the Consolidated Criteria for Reporting Qualitative Research (COREQ) framework (see Additional File 2 ) [ 34 ]. Triangulation occurred in two ways: informant triangulation through the inclusion of stakeholders from multiple countries, and data triangulation through the use of both quantitative and qualitative research methods. Transferability of the research is increased through a detailed description of the context of the research, the data collection, and data analysis.

Ethical considerations

In accordance with the Declaration of Helsinki, ethical approval for the hospital survey was granted by the University of Global Health Equity Institutional Review Board, approval number UGHE-IRB/2022/056, and by the Rwanda National Health Research Committee, approval number NHRC/2022/PROT/050. Ethical approval for the interviews was granted by the Ethics Review Board of the faculties of Science and Geosciences, Utrecht University, approval number S-23,008. Informed consent was given by all participants (see Additional File 3 ).

Availability of anaesthetic commodities in Rwandan hospitals

In total, 54 hospitals participated in this study. One hospital declined participation. The general anaesthetic with highest availability was propofol (81.5%), followed by ketamine (77.8%). Inhalational agents, such as halothane, isoflurane or sevoflurane were available at 53.7% of the hospitals, and thiopental at 44.4%. All hospitals had running water and electricity, and 90.7% had a functional anaesthetic machine.

Ketamine was indicated as the general anaesthetic agent most used by 23 hospitals (42.6%). Twenty hospitals (37.0%) indicated it was propofol, while the remaining ten medical professionals (18.5%) indicated it was halothane. Data was missing for one hospital. In the hospitals where ketamine was the most used anaesthetic agent, it was also the anaesthetic agent with the highest availability at 82.6% (see Fig.  1 ). In the 30 hospitals where other general anaesthetic agents were indicated to be most used, highest availability was found for propofol (90.0%, see Fig.  1 ).

Anaesthetic agents’ availability in hospitals, stratified by self-reported most used anaesthetic agent

Key informant interviews

Sixty-nine individuals or national anaesthesia societies were contacted for participation in the study, of which ten agreed to participate. Key informant characteristics are provided in Table  1 . Nine informants were knowledgeable about a country-specific context, while one informant (a WFSA member from Europe) had knowledge about the Sub-Saharan region in general.

Barriers to anaesthesia care

Multiple barriers to anaesthesia care were highlighted by the key informants. One of the main issues raised by all participants, was the lack of anaesthesiologists (Table  2 , Quote 1). The number of anaesthesiologists was said to be critically low, with all anaesthesiologists primarily located in urban locations, in the more specialised hospitals. The key informant from the Democratic Republic of Congo (DRC) sketched this situation (Table  2 , Quote 2). As a consequence, anaesthesia care is provided by non-physician providers, such as nurses and medical officers. However, eight of the key informants reported that these non-physician providers often had limited training in anaesthesia care, and do not have the skills or knowledge to provide more complex anaesthesia. This issue was highlighted by the key informant from Zambia (Table  2 , Quote 3). One key informant also reported that protocols are not followed in some locations when providing anaesthesia care.

Another issue raised by the two informants from South Africa and Zimbabwe, was migration of trained anaesthesiologists, both within the country and abroad. For example, anaesthesiologists moved towards the private sectors, as they are offered better wages and working conditions there (Table  2 , Quote 4). Crucially, the lack of medicines and equipment was also a significant barrier to anaesthesia care. Nine of the informants reported that the lack of medicines and equipment experienced in health facilities impedes the provision of anaesthesia care (Table  2 , Quote 5). The respondent from Zimbabwe mentioned that the government, as part of the National Surgical, Obstetrician and Anaesthesia Strategy is purchasing equipment to tackle this problem. In South Africa, the respondent shared that availability of medicines has improved and is not a major issue there.

Lastly, four informants specifically mentioned the lack of training opportunities and attention, and subsequently the lack of budget, given to anaesthesia care. The informant from Ethiopia referred to the government’s primary policy focus on prevention of infectious diseases, not on chronic diseases. The respondent from Namibia shared that only since 2018, doctors can train to become anaesthesiologists as part of the Namibian medical curriculum; before they needed to travel to other countries, such as South Africa, to study. In the Gambia there is no training available yet for anaesthesiologists. The informant from Zambia referred to the lack of attention among medical professionals and the public, as well as policy makers, as the main barrier to anaesthesia care (Table  2 , Quote 6).

Ketamine for anaesthesia care

Ketamine was described as critical for the provision of anaesthesia care in their respective countries by all of the key informants. Five of the informants reported that in more specialised hospitals, where anaesthesiologists provide anaesthesia care, propofol, also a non-controlled substance, was the preferred anaesthetic. However, ketamine is also commonly used in these hospitals, specifically for haemodynamically unstable patients, hypotensive patients, patients who are in shock, and as a sedative in paediatric patients, patients with asthma or patients on the intensive care unit (ICU). Ketamine is also used for pain management. Four of the informants also referred to shortages of anaesthetic agents, such as propofol, that occurred in the specialised hospitals, which made them reliant on ketamine (Table  3 , Quote 1).

One of the primary reasons given for the importance of ketamine by all of the informants, is that it can easily be used by non-physician providers, who provide the bulk of anaesthesia services, especially in rural areas (Table  3 , Quote 2). Informants shared that non-physician providers prefer to use ketamine as they are uncomfortable providing anaesthesia with alternatives because of potential side effects. Further, these providers often have only received a basic training in anaesthesia care and are not conversant with providing other anaesthetic agents (Table  3 , Quote 3). Related, in lower-level hospitals and in rural areas, a lack of equipment, such as anaesthetic machines, exacerbated the difficulties of providing anaesthesia, and increased the reliance on ketamine, as they were fearful of the adverse consequences, and the possibility of death, when using other anaesthetic agents (Table  3 , Quote 4). The informants from Somaliland and Nigeria raised the issue of affordability of medicines, and that next to ketamine being the most available anaesthetic agent, it was also the most affordable (Table  3 , Quote 5).

When the key informants were asked about the availability of anaesthetic agents in their respective countries as compared to the findings of the survey conducted in Rwanda, variations were reported. First, the informants emphasised it is difficult to report exact availabilities of the anaesthetic agents without conducting a similar survey. However, the informants shared that ketamine availability would be similar, or even higher, in their countries. Zambia was an exception, as the informant reported that for months preceding the interview, there had been critical shortages of ketamine (Table  3 , Quote 6). The informant did not know the reason for the shortages. Informants from the DRC, Ethiopia, Nigeria, Somaliland and Zambia shared that the availability of propofol would be (slightly) lower than in Rwanda, especially in rural hospitals, while the informants from the Gambia, Namibia and South Africa shared that it would be more or less similar.

Misuse of ketamine

None of the key informants reported that misuse of ketamine was a significant issue in their respective countries, as far as they were aware. Three informants offered anecdotal evidence of specific instances of misuse that they knew or had heard about, although the case reported by the informant from the DRC about a sickle cell patient misusing it for the treatment of vaso-occlusive crisis is strictly speaking not about misuse but unlicensed use. Two informants shared that there was some misuse of ketamine among medical professionals in their countries. The Zambian informant shared that a medical professional had died as a consequence of the misuse. The South African informant reported that while she was aware of medical professionals that had misused ketamine and this issue should not be overlooked, the balance between control and access should be kept in mind (Table  4 , Quote 1).

In all the other countries, the informants were unaware of misuse cases among medical professionals. Additionally, all of the informants shared that ketamine misuse among the general public was not an issue. The informant from Nigeria shared their opinion that ketamine may be misused among the internally displaced. Some of the informants also shared that if misuse is occurring in high-income countries, it might eventually also happen in their countries (Table  4 , Quote 2).

International scheduling of ketamine as a controlled substance

In three of the nine countries in which the informants work, ketamine is scheduled or regulated to some extent at the national level. In the Gambia, Namibia and South Africa, ketamine is stored in a locked cabinet, and medical professionals are required to request ketamine, and the release is signed off in a logbook by both the requesting medical professional as well as an in-charge nurse. However, in Namibia and South Africa informants shared that this procedure is not always followed as tightly as it might need to be (Table  4 , Quote 3). In the other countries, ketamine was not subject to additional, national control. Some of the informants from these countries could see the added value of having such controls at the national level for better stewardship (Table  4 , Quote 4).

If ketamine were to be scheduled as a controlled substance at the international level, it was believed it would negatively impact access in the informants’ respective countries, especially in the more rural locations. They all emphasised the critical importance of ketamine (Table  4 , Quote 5). Informants from Namibia, the Gambia and Somaliland also made the comparison to already controlled substances, fearing the availability of ketamine would decrease to similar levels (Table  4 , Quote 6). Next to the availability, some informants also raised concerns about increased costs of ketamine as a consequence of its scheduling, which would hamper access. In Zambia, where there is currently a shortage of ketamine, the informant shared their fears of this being the new reality. Lastly, one of the informants argued that LMICs and high-income countries should not be subjected to the same measures as they have very different resources available to them (Table  4 , Quote 7).

Recommendations to improve access to anaesthesia care

Recommendations made by the key informants to improve access to anaesthesia care were related to increasing attention and budgets for anaesthesia care, training and retention of anaesthesiologists and non-physician providers, improving availability of medicines and equipment, and decentralisation of care. For example, the key informant from Europe representing the global view argued that countries need to take responsibility and put resources into anaesthesia care (Table  5 , Quote 1). Similarly, the key informant from the Gambia argued for increasing the incentives to work in anaesthesia (Table  5 , Quote 2). In line with this, the informant from Ethiopia argued for better collaboration between medical professionals and the Ministry of Health to ensure the medicines provided are the ones needed. The informant from Zimbabwe highlighted that, while much can still be improved, in the last few years, more and more attention has been paid to anaesthesia care. The informant from Nigeria pointed to COVID-19 for the increased availability of equipment, but also stressed the need for better policies without waiting for another pandemic to occur (Table  5 , Quote 3). The importance of training of medical professionals was highlighted by the informant from Namibia (Table  5 , Quote 4), while the informant from South Africa added the need to find a way to retain their trained specialists, as many are leaving to work in high-income countries. Last, the same informant also emphasised the importance of decentralisation of care, in which anaesthesiologists should go to rural areas to treat patients, instead of patients travelling far to come to the specialised hospitals in the big cities (Table  5 , Quote 5).

This is a first-of-its kind research on the importance of ketamine as detailed by anaesthesiologists working in SSA. It also studied the availability of ketamine compared to other anaesthetic agents specifically in Rwandan hospitals. The interviews with the key informants from across SSA found that there were significant barriers impeding access to anaesthesia care, including a general lack of attention given to the speciality by governments, a shortage of anaesthesiologists and migration of trained anaesthesiologists, and a scarcity of medicines and equipment. Ketamine was described as critical for the provision of anaesthesia care as a consequence of these barriers, and its scheduling would have a significantly negative impact on the quality of anaesthesia care that can be provided. The survey conducted in Rwanda found that availability of ketamine and propofol was comparable at around 80%, while thiopental and inhalational agents such as halothane, isoflurane or sevoflurane were available at only about half of the hospitals.

These barriers to anaesthesia care identified in this study have been identified previously in different contexts, and this research supports those findings [ 4 , 6 , 7 , 8 , 9 , 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 ]. When the key informants were asked whether the availability in their respective countries was comparable to the availability found in Rwanda, the responses were variable. This is in line with previous research studying the availability of anaesthetic agents [ 6 , 17 , 21 ]. For instance, a study from Liberia found that ketamine was available 76-100% of the time in 88% of surveyed facilities, and this was the case for propofol in only 46% of facilities [ 6 ]. Similarly, while anaesthesia using ketamine was available in 13 of 14 health facilities surveyed in Somalia, anaesthesia using inhalational agents was available at five of the facilities [ 17 ]. Further, all surveyed hospitals in Rwanda had running water and electricity. Previous studies in Nigeria and Somalia found that access to running water and electricity was not guaranteed; the study in Nigeria found that hospitals suffered daily power outages ranging from 10 to 22 h, and only 15% had running water [ 18 ]. In Somalia, 28% of surveyed health facilities never or only sometimes had access to running water, and only 50% had consistent access to electricity [ 17 ]. Last, in this study it was found that 90.7% of hospitals had a functional anaesthesia machine. In Tanzania, Nigeria and Somalia, 67%, 23% and 15% of hospitals, respectively, had a functional anaesthesia machine available [ 15 , 17 , 18 ].

The case study of Rwanda thus may not be representative of the availability in other countries in the region. However, this research has shown that even when other anaesthetic agents, such as propofol, are available, much of anaesthesia care is still provided using ketamine. This is due to the lack of trained anaesthesiologists, and the subsequent reliance on non-specialist anaesthesia providers, such as nurses and medical officers. These non-physician providers feel better prepared to provide anaesthesia using ketamine, as there are much fewer potential side-effects than the other agents. This has also been described elsewhere [ 27 , 35 ]. Further, also in more specialised hospitals where anaesthesiologists are present to provide anaesthesia care, key informants shared ketamine is still one of the main anaesthetic agents used due to shortages of propofol that occur. A study conducted in district hospitals in Malawi, Zambia and Tanzania reported similar findings, showing that anaesthesia care at the district level is provided only by non-physician anaesthesia providers, and that ketamine was widely used to mitigate shortages of other anaesthetic agents [ 8 ].

In this study, the key informants reported that, as far as they were aware, misuse of ketamine is not a significant issue in their respective countries. A few did provide anecdotal evidence of specific instances of misuse among medical professionals. However, all informants believed scheduling ketamine internationally as a controlled substance would have a negative impact on access to anaesthesia care, as its availability would likely decrease. This fear is not unsubstantiated, as multiple informants referred to the difficulties with accessing opioids in their countries. In line with this, while in Liberia and Ethiopia ketamine was (almost) always available in 88% and 100% of facilities, respectively, morphine was (almost) always available at only 35% and 27% of facilities, respectively [ 6 ]. Consequences of international scheduling are restrictions on production, manufacturing, importation, distribution and use of medicines, resulting in severely limited access to controlled medicines [ 36 ]. It is thus paramount that ketamine does not become a scheduled substance. Instead, to safeguard against potential ketamine misuse in their respective countries, key informants believed in strengthening prescribing and dispensing practices in the healthcare setting. In many countries, ketamine is still freely available for all healthcare workers. Limiting ketamine so it is only obtainable for those allowed to use it may prevent future misuse. In Namibia, for example, ketamine is a Schedule 3 substance, and subsequently needs to be locked away and can only be sold or provided by designated personnel, on the basis of a prescription. The amount sold or provided has to be recorded in a logbook or prescription book [ 37 ].

Limitations

While this is the first study collecting experts’ insights into the importance of ketamine for anaesthesia care in SSA, some limitations should be noted. In the survey conducted in Rwandan hospitals, no price or stock data was collected for the anaesthetic agents. This might have provided insights into the differences in costs between the different agents, and the availability over time. While the hospitals in Rwanda were contacted beforehand to schedule a visit for the survey, because the data collected for this study was part of a larger study on snakebites it is believed that hospitals could not have taken measures that might have changed the availability numbers. Further, while more than 60 individuals and national anaesthesia societies were contacted, only ten individuals agreed to participate. Of these, none were unfortunately from Rwanda and only two were from West Africa. Due to this low number of respondents, it is difficult to assess whether topical saturation was fully reached. However, after initial analysis of eight interviews, the subsequent analysis of the last two interviews did not yield new insights, indicating potential data saturation. This study thus gives a first, detailed insight into the importance of ketamine for anaesthesia care in SSA. Further research may be undertaken to tease out more detailed, contextual factors that may not have been caught in this study.

This study has shown that ketamine is a critical medicine for the provision of anaesthesia care in SSA, as this field faces barriers related to its workforce and availability of medicines and equipment. If accessibility of ketamine changes as a result of its international scheduling, millions of people’s access to safe anaesthesia and surgical care will be in danger. Countries should strengthen prescribing and dispensing practices in the healthcare setting. Further, concerted efforts should focus on improving anaesthesia care in SSA in general, so in the future there can be less of a reliance on ketamine. Governments should focus more of their attention on the speciality, allocating more budget, facilitating training of more anaesthesiologists and non-physician providers, improving availability of medicines and equipment, as well as focusing efforts on retaining their anaesthesia workforce.

Data availability

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

Abbreviations

Commission on Narcotic Drugs

Disability-adjusted life-years

Democratic Republic of Congo

Expert Committee on Drug Dependence

Intensive care unit

Low- and middle-income countries

Physician anaesthesia providers

Consolidated Criteria for Reporting Qualitative Research

Sub-Saharan Africa

World Federation of Societies for Anaesthesiologists

World Health Organization

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Acknowledgements

We would like to thank the key informants and hospitals for participating in this research.

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

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Health Action International, Overtoom 60-2, 1054HK, Amsterdam, The Netherlands

Gaby I. Ooms & Tim Reed

Utrecht WHO Collaborating Centre for Pharmaceutical Policy and Regulation, Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences (UIPS), Utrecht University, Utrecht, The Netherlands

Gaby I. Ooms, Hendrika A. van den Ham & Aukje K. Mantel-Teeuwisse

Federal University of Dutse, Dutse, Jigawa State, Nigeria

Mohammed A. Usman

Rasheed Shekoni Teaching Hospital, Dutse, Jigawa State, Nigeria

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Contributions

GIO: conceptualisation, methodology, investigation, data curation, formal analysis, writing – original draft, visualisation; UAM: methodology, validation, writing – review and editing; HAvdH: conceptualisation, methodology, validation, writing – review and editing; AKM: conceptualisation, methodology, validation, writing – review and editing; TR: conceptualisation, methodology, validation, writing – review and editing.

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Correspondence to Gaby I. Ooms .

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In accordance with the Declaration of Helsinki, ethical approval for the hospital survey was granted by the University of Global Health Equity Institutional Review Board, approval number UGHE-IRB/2022/056, and by the Rwanda National Health Research Committee, approval number NHRC/2022/PROT/050. Ethical approval for the interviews was granted by the Ethics Review Board of the faculties of Science and Geosciences, Utrecht University, approval number S-23008. Informed consent was given by all participants.

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Ooms, G.I., Usman, M.A., Reed, T. et al. The impact of scheduling ketamine as an internationally controlled substance on anaesthesia care in Sub-Saharan Africa: a case study and key informant interviews. BMC Health Serv Res 24 , 598 (2024). https://doi.org/10.1186/s12913-024-11040-w

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Received : 16 November 2023

Accepted : 24 April 2024

Published : 07 May 2024

DOI : https://doi.org/10.1186/s12913-024-11040-w

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