case study of qualitative research

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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Home » Case Study – Methods, Examples and Guide

Case Study – Methods, Examples and Guide

Table of Contents

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

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

Types of Case Study

Types and Methods of Case Study are as follows:

Single-Case Study

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

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

Multiple-Case Study

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

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

Exploratory Case Study

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

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

Descriptive Case Study

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

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

Instrumental Case Study

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

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

Case Study Data Collection Methods

Here are some common data collection methods for case studies:

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

Observations

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

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

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

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

How to conduct Case Study Research

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

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

Examples of Case Study

Here are some examples of case study research:

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

Application of Case Study

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

Business and Management

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

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

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

Social Sciences

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

Law and Ethics

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

Purpose of Case Study

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

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

Case studies can also serve other purposes, including:

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

Advantages of Case Study Research

There are several advantages of case study research, including:

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

Limitations of Case Study Research

There are several limitations of case study research, including:

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

About the author

Muhammad Hassan

Researcher, Academic Writer, Web developer

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Qualitative study design: Case Studies

• Qualitative study design
• Phenomenology
• Grounded theory
• Ethnography
• Narrative inquiry
• Action research

Case Studies

• Field research
• Focus groups
• Observation
• Surveys & questionnaires
• Study Designs Home

In depth description of the experience of a single person, a family, a group, a community or an organisation.

An example of a qualitative case study is a life history which is the story of one specific person.  A case study may be done to highlight a specific issue by telling a story of one person or one group. 

• Oral recording

Ability to explore and describe, in depth, an issue or event. 

Develop an understanding of health, illness and health care in context. 

Single case can be used to develop or disprove a theory. 

Can be used as a model or prototype .  

Limitations

Labour intensive and generates large diverse data sets which can be hard to manage. 

Case studies are seen by many as a weak methodology because they only look at one person or one specific group and aren’t as broad in their participant selection as other methodologies. 

Example questions

This methodology can be used to ask questions about a specific drug or treatment and its effects on an individual.

• Does thalidomide cause birth defects?
• Does exposure to a pesticide lead to cancer?

Example studies

• Choi, T. S. T., Walker, K. Z., & Palermo, C. (2018). Diabetes management in a foreign land: A case study on Chinese Australians. Health & Social Care in the Community, 26(2), e225-e232. 
• Reade, I., Rodgers, W., & Spriggs, K. (2008). New Ideas for High Performance Coaches: A Case Study of Knowledge Transfer in Sport Science.  International Journal of Sports Science & Coaching , 3(3), 335-354. 
• Wingrove, K., Barbour, L., & Palermo, C. (2017). Exploring nutrition capacity in Australia's charitable food sector.  Nutrition & Dietetics , 74(5), 495-501. 
• Green, J., & Thorogood, N. (2018). Qualitative methods for health research (4th ed.). London: SAGE. 
• University of Missouri-St. Louis. Qualitative Research Designs. Retrieved from http://www.umsl.edu/~lindquists/qualdsgn.html   
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Research Writing and Analysis

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

Writing a Case Study

What is a case study?

A Case study is: 

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

What are the different types of case studies?

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

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

Who are your case study participants?

What is triangulation ? 

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

How to write a Case Study?

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

Was this resource helpful?

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23 Case Study Research: In-Depth Understanding in Context

Helen Simons, School of Education, University of Southampton

• Published: 02 September 2020
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This chapter explores case study as a major approach to research and evaluation. After first noting various contexts in which case studies are commonly used, the chapter focuses on case study research directly. Strengths and potential problematic issues are outlined, followed by key phases of the process. The chapter emphasizes how important it is to design the case, to collect and interpret data in ways that highlight the qualitative, to have an ethical practice that values multiple perspectives and political interests, and to report creatively to facilitate use in policymaking and practice. Finally, the chapter explores how to generalize from the single case. Concluding issues center on the need to think more imaginatively about design and the range of methods and forms of reporting required to persuade audiences to value qualitative ways of knowing in case study research.

Introduction

This chapter explores case study as a major approach to research and evaluation using primarily qualitative methods, as well as documentary sources, contemporaneous or historical. However, this is not the only way in which case study can be conceived. No one has a monopoly on the term. While sharing a focus on the singular in a particular context, case study has a wide variety of uses, not all associated with research. A case study, in common parlance, documents a particular situation or event in detail in a specific sociopolitical context. The particular can be a person, a classroom, an institution, a program, or a policy. In the sections that follow, I identify different ways in which case study is used before focusing directly on qualitative case study research. However, first I wish to indicate how I came to advocate and practice this form of research. Origins, context, and opportunity often shape the research processes we endorse. It is helpful for the reader, I think, to know how I came to the perspective I hold.

The Beginnings

I first came to appreciate and enjoy the virtues of case study research when I entered the field of curriculum evaluation and research in the 1970s. The dominant research paradigm for educational research at that time was experimental or quasi-experimental, cost–benefit, or systems analysis, and the dominant curriculum model was aims and objectives (House, 1993 ). The field was dominated, in effect, by a psychometric view of research in which quantitative methods were preeminent. But the innovative projects we were asked to evaluate (predominantly, but not exclusively, in the humanities) were not amenable to such methodologies. The projects were challenging to the status quo of institutions, involved people interpreting the policy and programs, were implemented differently in different contexts and regions, and had many unexpected effects.

We had no choice but to seek other ways to evaluate these complex programs, and case study was the methodology we found ourselves exploring to understand how the projects were being implemented, why they had positive effects in some regions of the country and not others, and what the outcomes meant in different sociopolitical and cultural contexts. What better way to do this than to talk with people to see how they interpreted the “new” curriculum; to watch how teachers and students put it into practice; to document transactions, outcomes, and unexpected consequences; and to interpret all in the specific context of the case (Simons, 1971 , 1987 , ch. 3). From this point on and in further studies, case study in educational research and evaluation came to be a major methodology for understanding complex educational and social programs. It also extended to other practice professions, such as nursing, health, and social care (Greenhalgh & Worrall, 1997 ; Shaw & Gould, 2001 ; Zucker, 2001 ). (For further details of the evolution of the case study approach and qualitative methodologies in evaluation, see Greene, 2000 ; House, 1993 , pp. 2–3; Simons, 2009 , pp. 14–18).

This was not exactly the beginning of case study, of course. It has a long history in many disciplines (Gomm, Hammersley, & Foster, 2004 ; Platt, 2007 ; Ragin, 1992 ; Simons, 1980 ), many aspects of which form part of case study practice to this day. But its evolution in the context just described was a major move in the contemporary evolution of the logic of evaluative inquiry (House, 1980 ). It also coincided with movement toward the qualitative in other disciplines, such as sociology and psychology. This was all part of what Denzin & Lincoln ( 1994 ) termed “a quiet methodological revolution” (p. ix) in qualitative inquiry that had been evolving over the past two decades.

There is a further reason why I continue to advocate and practice case study research and evaluation to this day, and that is my personal predilection for trying to understand and represent complexity, for puzzling through the ambiguities that exist in many contexts and programs, and for presenting and negotiating different values and interests in fair and just ways.

Put more simply, I like interacting with people, listening to their stories, trials and tribulations—giving them a voice in understanding the contexts and projects with which they are involved and finding ways to share these with a range of audiences. In other words, the move toward case study methodology suited my preference for how I learn—through observation of people, events and social interaction in particular sociopolitical contexts.

Concepts and Purposes of Case Study

Before exploring case study as it has come to be established in educational research and evaluation since the mid-sixties I wish to acknowledge other uses of case study. More often than not, these relate to purpose, and appropriately so in their different contexts, but many do not have a research intention. For a study to count as research, it would need to be a systematic investigation generating evidence that leads to “new” knowledge that is made public and open to scrutiny. There are many ways to conduct research stemming from different traditions and disciplines, but they all, in different ways, involve these characteristics.

Everyday Usage: Stories We Tell

The most familiar of these uses of case study is the everyday reference to a person, an anecdote or story illustrative of a particular incident, event, or experience of that person. It is often a short, reported account seen commonly in journalism but also in books exploring a phenomenon, such as recovery from serious accidents or tragedies where the author chooses to illustrate the story or argument with a “lived” example. The story is sometimes written by the author and sometimes by the person whose tale it is. “Let me share with you a story” is a phrase frequently heard.

The spirit behind this everyday usage and its power to connect can be seen in a report by Tim Adams of the London Olympics opening ceremony’s dramatization by Danny Boyle.

It was the point when we suddenly collectively wised up to the idea that what we are about to receive over the next two weeks was not only about “legacy collateral” and “targeted deliverables,” not about G4S failings and traffic lanes and branding opportunities, but about the second-by-second possibilities of human endeavour and spirit and communality, enacted in multiple places and all at the same time. Stories in other words (Adams, 2012 ).

This was a collective story, of course, not an individual one, but it does convey some of the major characteristics of case study—that richness of detail, time, place, multiple happenings, and experiences—that are also manifest in case study research, although carefully evidenced in the latter instance. We can see from this common usage how people have come to associate case study with story. I return to this thread in the reporting section.

Individual Cases in the Professions

In professional settings, in health and social care, case studies, often called case histories , are used to accurately record a person’s health or social care history and his or her current symptoms, experience, and treatment. These case histories include facts, as well as judgments and observations about the person’s reaction to situations or medication. Usually they are confidential. Not dissimilar is the detailed documentation of a case in law, often termed a case precedent when referred to in a court case to support an argument being made. However, in law there is a difference in that such case precedents are publicly documented, whereas in health and social care, confidentiality of the client is the prime concern.

Case Studies in Teaching

Exemplars of practice.

In education, but also in health and social care training contexts, case studies have long been used as exemplars of practice. These are brief descriptions with some detail of a person or project’s experience in an area of practice. Though frequently reported accounts, they are based on a person’s experience and sometimes on previous research.

Case Scenarios

Management studies are a further context in which case studies are often used. Here the case is more like a scenario outlining a particular problem situation for the management student to resolve. These scenarios may be based on research, but frequently are hypothetical situations used to raise issues for discussion and resolution. What distinguishes these case scenarios and the case exemplars in education from case study research is the intention to use them for teaching purposes.

Country Case Studies

Then there are case studies of programs, projects, and even countries, as in international development, where a whole-country study might be termed a case study or, in the context of the Organization for Economic Co-operation and Development, which examines the state of the art of a subject, such as education or environmental science in one or several countries. This may be a contemporaneous study and/or what transpired in a program over a period of time. Such studies often do have a research base, but frequently are reported accounts that do not detail the design, methodology, and analysis of the case as a research case study would do. Nor do they report in ways that give readers a vicarious experience, through observations, incidents, and voices of participants, of what it is like to live in the particular context of the case. Such case studies tend to be more knowledge and information focused than experiential.

Case Study as History

Closer to a research context is case study as history—what transpired at a certain time in a certain place. This is likely to be supported by documentary evidence but not primary data, unless it is an oral history (see Leavy, 2011 , for the evolution and practice of oral history as a research method). In education, in the late 1970s, Stenhouse ( 1978 ) experimented with a case study archive. Using contemporaneous data gathering, primarily through interviewing, he envisaged this database, which he termed a case record , forming an archive from which different individuals, at some later date, could write a case study . This approach uses case study as a documentary source to begin to generate a history of education, as indicated in the subtitle of Stenhouse’s 1978 paper, “Towards a Contemporary History of Education.”

Case Study Research

From here on, my focus is on case study research per se, adopting for this purpose the following definition: “Case study is an in-depth exploration from multiple perspectives of the complexity and uniqueness of a particular project, policy, institution or system in a “real-life” context. It is research based, inclusive of different methods and is evidence-led” (Simons, 2009 , p. 21). For further related definitions of case study, see Stake ( 1995 ), Merriam ( 1988 ), and Chadderton and Torrance ( 2011 ). For definitions from a slightly different perspective, see Yin ( 2004 ) and Thomas ( 2016 , p. 23).

Not Defined by Method or Perspective

The inclusion of different methods in the definition quoted above signals that case study research is not defined by methodology or method. What defines case study is its singularity and the concept and boundary of the case. It is theoretically possible to conduct a case study using primarily quantitative data if this is the best way of providing evidence to inform the issues the case is exploring. This may not happen often, and only perhaps in some disciplines like medicine, although even in that context, there is increasing recognition, particularly in clinical settings, that client-centered and context studies are important for diagnosis and treatment (Greenhalgh & Worrall, 1997 ). It is equally possible to conduct case study that is mainly qualitative, to engage people with the experience of the case or to provide a rich portrayal of a person (MacDonald, 1977 ) or an event, project, or program. While the focus of the case is usually a project, program, or policy, within the case there can be portrayals of individuals who are key actors. These are what I term case profiles . In some instances, these profiles, or even shorter cameos of individuals, may be quite prominent. For it is through the perceptions, interpretations, and interactions of people that we learn how policies and programs are enacted (Kushner, 2000 , p. 12). The program is still the main focus of analysis in such cases, but, in exploring how individuals play out their different roles in the program, we get closer to the actual experience and meaning of the program in practice.

In the past three decades the literature and associated courses and conferences on mixed methods in educational and social research has proliferated (Greene, Caracelli, & Graham, 1989 ); (Greene & Caracelli, 1997 ; Tashakkori & Teddlie, 1998, 2003). This development, which first became evident in the eighties, evolved partly to overcome the partisan focus of either quantitative or qualitative research, but it also provides a perspective from different methodologies that may add to understanding of the case and increases the options for learning from different ways of knowing. Mixed methods methodology is sometimes preferred by stakeholders who believe it provides a firmer basis for informing policy. This is not necessarily the case, but is beyond the scope of this chapter to explore. Case study research has always been open to the inclusion of different methods because what is paramount in case research is understanding the complexity and uniqueness of the case, and a variety of methods offer different angles to comprehending this complexity and uniqueness. For further discussion of the complexities of mixing methods and the virtue of using qualitative methods and case study in a mixed methods design, see Greene ( 2007 ). The focus for the remainder of this chapter will be on the qualitative dimension of case study research.

Case study research may also be conducted from different standpoints—realist, interpretivist, or constructivist, for example. My perspective falls within a constructivist, interpretivist framework. What interests me is how I and those in the case perceive and interpret what we find and how we construct or co-construct understandings of the case. This suits not only my predilection for how I see the world, but also my preferred phenomenological approach to interviewing and curiosity about people and how they act in social and professional life.

Qualitative Case Study Research

Qualitative case study research shares many characteristics with other forms of qualitative research, such as narrative, oral history, life history, ethnography, in-depth interview and observational studies that utilize qualitative methods. However, its focus, purpose, and origins, in educational research and evaluation at least, are a little different. The focus is clearly the study of the singular. The purpose is to portray an in-depth view of the quality and complexity of social/educational programs or policies as they are implemented in specific sociopolitical contexts. What makes it qualitative is its emphasis on subjective ways of knowing, particularly the experiential, practical, and presentational rather than the propositional (Heron, 1992 , 1999 ) to comprehend and communicate what transpired in the case.

Characteristic Features and Advantages

Case study research is not method dependent, as noted earlier, nor is it constrained by resources or time. Although it can be conducted over several years, which provides an opportunity to explore the process of change and explain how and why things happened, it can equally be carried out contemporaneously in a few days, weeks, or months. This flexibility is extremely useful in many contexts, particularly when a change in policy or unforeseen issues in the field require modifying the design.

Flexibility extends to reporting. The case can be written up in different lengths and forms to meet different audience needs and to maximize use (see the section on reporting). Using the natural language of participants and familiar methods (like interview, observation and oral history) also enables participants to engage in the research process, thereby contributing significantly to the generation of knowledge of the case. As I have indicated elsewhere (Simons, 2009 ), “This is both a political and epistemological point. It signals a potential shift in the power base of who controls knowledge and recognizes the importance of co-constructing perceived reality through the relationships and joint understandings we create in the field” (p. 23).

Possible Disadvantages

If one is an advocate, identifying advantages of a research approach is easier than pointing out its disadvantages, something detractors are quite keen to do anyway! But no approach is perfect, and here are some of the issues that often trouble people about case study research. The sample of one is an obvious issue that worries those convinced that only large samples can constitute valid research, especially if it is to inform policy. Understanding complexity in depth may not be a sufficient counterargument, and I suspect there is little point in trying to persuade otherwise. For frequently this perception is one of epistemological and methodological, if not ideological, preference.

However, there are some genuine concerns that many case researchers face: the difficulty of processing a mass of data; of “telling the truth” in contexts where people may be identifiable; personal involvement, when the researcher is the main instrument of data gathering; and writing reports that are data based, yet readable in style and length. But one issue that concerns advocates and nonadvocates alike is how inferences are drawn from the single case.

Answers to some of these issues are covered in the sections that follow. Whether they convince may again be a question of preference. However, it is worth noting here that I do not think we should seek to justify these concerns in terms identified by other methodologies. Many are intrinsic to the nature and strength of qualitative case study research.

Subjectivity, for instance, both of participants and of the researcher, is inevitable, as it is in many other qualitative methodologies. This is often the basis on which we act. Rather than seeing this as bias or something to counter, it is an intelligence that is essential to understanding and interpreting the experience of participants and stakeholders. Such subjectivity needs to be disciplined, of course, through procedures that examine the validity of individuals’ representations of “their truth” and demonstrate how the researcher took a reflexive approach to monitoring how his or her own values and predilections may have unduly influenced the data.

Types of Case Study

There are numerous types of case study, too many to categorize, I think, as there are overlaps between them. However, attempts have been made to do so and, for those who value typologies, I refer them to Bassey ( 1999 ) and, for a more extended typology, to Thomas ( 2011 ). A slightly different approach is taken by Gomm et al. ( 2004 ): noting, in an annotated bibliography, the different emphases in major texts on case study. What I prefer to do here is to highlight a few familiar types to focus the discussion that follows on the practice of case study research.

Stake ( 1995 ) offered a threefold distinction that is helpful when it comes to practice, he says, because it influences the methods we choose to gather data (p. 4). He distinguishes between an intrinsic case study , one that is studied to learn about the particular case itself, and an instrumental case study , in which we choose a case to gain insight into a particular issue (i.e., the case is instrumental to understanding something else; p. 3). The collective case study is what its name suggests: an extension of the instrumental to several cases.

Theory-led or theory-generated case study is similarly self-explanatory, the first starting from a specific theory that is tested through the case and the second constructing a theory through interpretation of data generated in the case. In other words, one ends rather than begins with a theory. In qualitative case study research, this is the more familiar route. The theory of the case becomes the argument or story you will tell.

Evaluation case study has three essential elements. Its purpose is to determine the value of a particular project, program or policy, to include and balance different interests and perspectives and to report findings to a range of stakeholders in ways that they can use. It is a social, political and ethical practice. It needs to be responsive to issues or questions identified by stakeholders, including those who commission evaluations, who often have different perspectives of the program and different interests in the expected outcomes. The task of the evaluator in such situations becomes one of negotiating and representing all interests and values in the program fairly and justly. This is an inherently political process and requires an ethical practice that offers participants some protection over the personal data they give as part of the research and agreed audiences access to the findings presented in ways they can understand. The ethical protocols that have evolved to support this process are outlined in the section on ethics.

Designing Case Study Research

Design issues in case study sometimes take second place to those of data gathering, the more exciting task, perhaps, in beginning research. However, it is critical to consider the design at the outset, even if changes are required in practice due to the reality of what is encountered in the field. In this sense, the design of case study is emergent, rather than preordinate (predetermined in advance), shaped and reshaped as understanding of the significance of foreshadowed issues emerges and other, perhaps more pertinent issues are discovered.

Before entering the field, there are a myriad of planning issues to think about related to stakeholders, participants, and audiences. These include whose values matter, whether to engage these groups in data gathering and interpretation, the style of reporting appropriate for each, and the ethical guidelines that will underpin data collection and reporting. However, here I emphasize only three: the broad focus of the study, what the case is a case of, and framing questions/issues. These steps are often ignored in an enthusiasm to gather data, resulting in a case study that claims to be research but lacks the basic principles required for generation of valid, public knowledge.

Conceptualize the Topic

First, it is important that the topic of the research is conceptualized in a way that it can be researched (i.e., it is not too wide). This seems an obvious point to make, but failure to think through precisely what it is about your research topic you wish to investigate will have a knock-on effect on the framing of the case, data gathering and interpretation and may lead, in some instances, to not gathering or analyzing data that actually inform the topic. Further conceptualization or reconceptualization may be necessary as the study proceeds, but it is critical to have a clear focus at the outset.

What Constitutes the Case

Second, it is important to decide what would constitute the case (i.e., what it is a case of) and where the boundaries lie. This often proves more difficult than first appears. And sometimes, partly because of the semifluid nature of the way the case evolves, it is only possible to finally establish what the case is a case of at the end. Nevertheless, it is useful to identify what the case and its boundaries are at the outset to help focus data collection while maintaining an awareness that they may shift. This is emergent design in action.

In deciding the boundary of the case, there are several factors to bear in mind. Is it bounded by an institution or a unit within an institution, by people within an institution, by region, or by project, program, or policy? If we take a school as an example, the case could be composed of the principal, teachers and students, or the boundary could be extended to the cleaners, the caretaker, or the receptionist, people who often know a great deal about the subnorms and culture of the institution.

If the case is a policy or particular parameter of a policy, the considerations may be slightly different. People will still be paramount—those who generated the policy and those who implemented it—but there is likely also to be a political culture surrounding the policy that had an influence on the way the policy evolved. Would this be part of the case? In evaluation case study it invariably would, because it is difficult to fully comprehend how a policy is interpreted and implemented without an understanding of the values and intentions behind the setting up of the policy in the first place.

Whatever boundary is chosen, it may change in the course of conducting the study when issues arise that can only be understood by going to another level. What transpires in a classroom, for example, if a classroom is the case, is often partly dependent on the support of the school leadership and culture of the institution and this, in turn, to some extent is dependent on what resources are allocated from the local education administration. Much like a series of Russian dolls, one context inside the other.

Unit of analysis

Thinking about what would constitute the unit of analysis—a classroom, an institution, a program, a region—may help in setting the boundaries of the case, and it will certainly facilitate analysis. But this is a slightly different issue from deciding what the case is a case of. Taking a health example, the case may be palliative care support, but the unit of analysis the palliative care ward. The focus would be directly on how palliative care was managed in the context of a particular ward or wards and the understanding this generated for palliative care support in general. Here, as in the school example, you would need to consider which of the many people who populate the ward form part of the case—is it the nurses, interns, or doctors only, or does it extend to patients, cleaners, nurse aides, and medical students? If you took palliative care support as the unit of analysis, you would be less concerned about the specific details of the ward. Your focus would be more on the broader policy, key strategies, and units supporting palliative care, as well as the perspective of key actors in the process and how they delivered such care.

Framing Questions and Issues

The third most important consideration is how to frame the study, and you are likely to do this once you have selected the site or sites for study. There are at least four approaches: specific research or evaluative questions, foreshadowed issues (Smith & Pohland, 1974 ), theoretical framework, or a program logic. To some extent, your choice will be dictated by the type of case you have chosen, as well as by your personal preference for how to conduct it—in either a structured or an open way.

Initial questions give structure; foreshadowed issues give more freedom to explore. In qualitative case study, foreshadowed issues are more common, allowing scope for issues to change as the study evolves, guided by participants’ perspectives and events in the field. With this perspective, it is more likely that you will generate a theory of the case toward the end, through your interpretation and analysis, rather than start with a preexisting theoretical framework. See Thomas ( 2016 , ch. 11) for an exploration of different ways to generate theory in and of your case.

If you are conducting an instrumental case study , staying close to the questions or foreshadowed issues is necessary to be sure you gain data that will illuminate the central focus of the study. This is critical if you are exploring issues across several cases, although it is possible also to do a cross-case analysis from cases that have each followed a different route to discovering significant issues.

Opting to start with a theoretical framework provides a basis for formulating questions or identifying issues, but it can also constrain the study to only those questions/issues that fit the framework. The same is true with using program logic to frame the case. This approach is frequently adopted in evaluation case study, where the evaluator, individually or with stakeholders, examines how the aims and objectives of the program relate to the activities designed to promote it and the outcomes and impacts expected. It provides direction and is useful for engaging stakeholders in thinking through the assumptions underlying any theory of change they propose. However, it can lead to simply confirming what was anticipated, rather than documenting what transpired in the case (see Rogers, 2017 ; and Funnell & Rogers, 2011 , for helpful accounts of the potential and pitfalls of adopting a logic model as a framework).

Whichever approach you choose to frame the case, it is useful to think about the rationale or theory for each question or aspect of the framing and what methods would best enable you to gain an understanding of them. This will not only start a reflexive process of examining your choices—an important aspect of the process of data gathering and interpretation—but also aid analysis and interpretation further down the track.

Methodology and Methods

Qualitative case study research, as already noted, appeals to subjective ways of knowing and to a primarily qualitative methodology that captures experiential understanding (Stake, 2010 , pp. 56–70). It follows that the main methods of data gathering to access this way of knowing will be qualitative. Interviewing, observation, and document analysis are the primary three, often supported by critical incidents, focus groups, cameos, vignettes, diaries/journals, and photographs. Before gathering any primary data, however, it is useful to search relevant existing sources (written or visual) to learn about the antecedents and context of a project, program, or policy as a backdrop to the case. This can sharpen framing questions, avoid unnecessary data gathering, and shorten the time needed in the field.

Given that there are excellent texts on qualitative methods (see, for example, Denzin & Lincoln, 1994 ; Seale, 1999 ; Silverman, 2000 , 2004 ; Stake, 2010 ), I will not discuss all potential relevant methods here, but simply focus on the qualities of the primary methods that are particularly appropriate for case study research.

Primary Qualitative Data Gathering Methods

Interviewing.

The most effective style of interviewing in qualitative case study research is the unstructured interview, in which active listening and open questioning are paramount, whatever prequestions or foreshadowed issues have been identified. Specific advantages of this approach to gaining in-depth data are the opportunity to document multiple perspectives and experiences and establish which issues are most significant in the case—an important step in refining the emergent design. This form of interviewing can include photographs—a useful starting point with certain cultural groups and the less articulate, to encourage them to tell their story through connecting or identifying with something in the image. The flexibility of unstructured interviewing has three further advantages for understanding participants’ experiences. First, through questioning, probing, listening, and, above all, paying attention to the silences and what they mean, you can get closer to the meaning of participants’ experiences. It is not always what they say. For thoughtful observations of the meaning of silences in qualitative research, see Mazzei ( 2003 , 2007 ).Second, unstructured interviewing is useful for engaging participants in the process of research. Instead of starting with questions and issues, invite participants to tell their stories or reflect on specific issues, to conduct their own self-evaluative interview, in fact. Not only will they contribute their particular perspective to the case, they will also learn about themselves, thereby making the process of research educative for them as well as for audiences of the research. Third, the open-endedness of this style of interviewing has the potential for creating a dialogue between participants and the researcher and between the researcher and the public, if enough of the dialogue is retained in the publication (Bellah, Madsen, Sullivan, Swidler, & Tipton, 1985 ).

Observations

Observations in case study research are likely to be close-up descriptions of events, activities, and incidents that detail what happens in a particular context. These will record time, place, specific incidents, transactions, dialogue, and note characteristics of the setting and of people within it without preconceived categories or judgment. No description is devoid of some judgment in selection, but, on the whole, the intent is to describe the scene or event as it is, providing a rich, textured description to give readers a sense of what it was like to be there or provide a basis for later interpretation.

Take the following excerpt from a study of the West Bromwich Operatic Society. It is the first night of a new production, The Producers , by this amateur operatic society. This brief excerpt is from a much longer observation of the overture to the first evening’s performance, detailing exactly what the production is, where it is, and why there is such a tremendous sense of atmosphere and expectation surrounding the event. Space prevents including the whole observation, but I hope you can get a glimmer of the passion and excitement that precedes the performance:

Birmingham, late November, 2011, early evening.… Bars and restaurants spruce up for the evening’s trade. There is a chill in the air but the party season is just starting … A few hundred yards away, past streaming traffic on Suffolk Street, Queensway, an audience is gathering at the New Alexandra Theatre. The foyer windows shine in the orange sodium night. Above each one is the rubric: WORLD CLASS THEATRE. Inside the preparatory rituals are being observed; sweets chosen, interval drinks ordered and programmes bought. People swap news and titbits about the production … The bubble of anticipation grows as the 5-minute warning sounds. People make their way to the auditorium. There have been so many nights like this in the past 110 years since a man named William Coutts invested £10,000 to build this palace of dreams.… So many fantasies have been played under this arch: melodramas and pantomimes, musicals and variety.… So many audiences, settling down in their tip-up seats, wanting to be transported away from work, from ordinariness and private troubles … The dimming lights act like a mother’s hush. You could touch the silence. Boinnng! A spongy thump on a bass drum, and the horns pipe up that catchy, irrepressible, tasteless tune and already you’re singing under your breath, “Springtime for Hitler and Germany …” The orchestra is out of sight in the pit. There’s just the velvet curtain to watch as your fingers tap along. What’s waiting behind? Then it starts it to move. Opening night … It’s opening night! (Matarasso, 2012 , pp. 1–2)

For another and different example—a narrative observation of an everyday but unique incident that details date, time, place, and experience—see Simons ( 2009 , p. 60).

Such naturalistic observations are also useful in contexts where we cannot understand what is going on through interviewing alone or in cultures with which we are less familiar and where key actors may not share our language or have difficulty expressing what they mean. Careful description in these situations can help identify key issues, discover the norms and values that exist in the culture, and, if sufficiently detailed, allow others to cross-corroborate what significance we draw from these observations. This last point is very important to avoid the danger in observation of ascribing motivations to people and meanings to transactions.

Finally, naturalistic observations are very important in highly politicized environments, often the case in commissioned evaluation case study, where individuals in interview may try to elude the “truth” or press upon you that their view is the right view of the situation. In these contexts, naturalistic observations not only enable you to document interactions as you perceive them, but also provide a cross-check on the veracity of information obtained in interviews.

Document Analysis

Analysis of documents, as already intimated, is useful for establishing what historical antecedents might exist to provide a springboard for contemporaneous data gathering. In most cases, existing documents are also extremely pertinent for understanding the policy context.

In a national policy case study I conducted on a major curriculum change, the importance of preexisting documentation was brought home to me sharply when certain documentation initially proved elusive to obtain. It was difficult to believe that it did not exist, because the evolution of the innovation involved several parties who had not worked together before and they needed to develop a shared understanding of the ‘new’ curriculum. There was bound, I thought, to be minuted meetings sharing progress and documentation of the “new” curriculum. In the absence of some crucial documents, I began to piece together the story through interviewing different individuals who had a role to play in the evolution of the new curriculum. But there were gaps, and certain issues did not make sense.

It was only when I presented two versions of what I discerned had transpired in the development of this initiative in an interim report 18 months into the study that things started to change. Subsequent to the meeting at which the report was presented, the “missing” documents started to appear. Suddenly found! What lay behind the “missing” documents, something I suspected from what certain individuals did and did not say in interview, was a major difference of view about how the innovation evolved, who was key in the process, and whose voice was more important in the context: political differences, in other words, that some stakeholders were trying to keep from me. The emergence of the documents enabled me to finally produce an accurate and fair account.

This is an example of the importance of having access to all relevant documents relating to a program or policy to study it fairly. The other major way in which document analysis is useful in case study is for understanding the values, explicit and hidden, in policy and program documents and in the organization where the program or policy is implemented. Not to be ignored as documents are photographs; these, too, can form the basis of a cultural and value analysis of an organization (Prosser, 2000 ).

Creative Artistic Approaches

Increasingly, some case study researchers are employing creative approaches associated with the arts as a means of data gathering and analysis. Artistic approaches have often been used in representing findings, but less frequently in data gathering and interpretation (Simons & McCormack, 2007 ). A major exception is the work of Richardson ( 1994 ), who views the very process of writing as an interpretative act, and that of Cancienne and Snowber ( 2003 ), who argue for movement as method.

The most familiar of these creative and artistic forms are written—narratives and short stories (Clandinin & Connelly, 2000 ; Richardson, 1994 ; Sparkes, 2002 ), poems or poetic form (Butler-Kisber, 2010 ; Duke, 2007 ; Richardson, 1997; Sparkes & Douglas, 2007 ), and cameos of people, or vignettes of situations. These can be written by participants or by the researcher or developed in partnership. They can also be shared with participants to further the interpretation of the data.

Photographs also have a long history in qualitative research for presenting and constructing understanding (Butler-Kisber, 2010 ; Collier, 1967 ; Prosser, 2000 ; Rugang, 2006 ; Walker, 1993 ). The photo story in particular—a selection of photographs placed in sequence to show the interpretation of an event or circumstance—is a powerful way of telling. Less common are other visual forms of gathering data, such as “draw and write” (Sewell, 2011 ), artifacts, drawings, sketches, paintings, and collages, although these, too, are increasingly being adopted. For examples of the use of collage in data gathering, see Duke ( 2007 ) and Butler-Kisber ( 2010 ), and for charcoal drawing, see Elliott ( 2008 ). Collages have the potential not only for revealing inner states and feelings, but also for documenting conflicts and tensions in a case. Duke ( 2007 ) made effective use of collage in this respect to portray differences and tensions with doctors in a medical setting where she, in her role as a nurse consultant, was conducting research as well as performing her normal nurse duties. The collage served to channel the emotions she was experiencing in this hierarchical context without influencing the research or her professional role. More recently, Plakoyiannaki & Stavraki ( 2018 ) explored the various ways in which collages can be interpreted to reveal the meaning embedded in the juxtaposition of images and visual metaphors in a collage. They also offer a heuristic analytic approach to counter what they see as limitations in some of the other forms of analyzing collages. Though written primarily for an audience in management research, many aspects of their paper are pertinent for case study research.

Videos can be a useful means of documenting events and interactions between people, especially when individuals cannot be interviewed. See, for example, Flewitt ( 2005 ) for a discussion of the value of video for exploring communications between young children in the home and preschool contexts. In other contexts—videos of classroom events, for example—they can be extremely useful for engaging participants and stakeholders in the interpretation of such events. It is often suggested, furthermore, that videos are a useful means of reporting case study data. Not, I suggest, in raw form. Beyond the ethical issue of the potential identification of individuals is the difficulty of understanding what is going on if you were not present at the time and had a grasp of other data relevant to that understanding. In other words, videos have a temporary life. Without additional data, the distant viewer may not comprehend. This is a separate issue from preparing a video report, composed of different kinds of data to tell the story of the case in a visual, succinct way. Such videos have the power to engage different audiences and can facilitate immediate understanding of the critical issues in the case. An excellent example of this is the CD that Jenny Elliot ( 2008 ) prepared as part of her Ph.D. thesis, showing how it was possible through the research she conducted to get a unit of brain-damaged men to dance. The video was widely shown subsequently in many healthcare contexts.

In qualitative inquiry broadly, these creative approaches are now quite common. And in the context of arts and health (see, for example, Frank, 1997 ; Liamputtong & Rumbold, 2008 ; Spouse, 2000 ), they are frequently used to illuminate perspectives of individuals in therapeutic settings or enhance understanding of how spaces and environments in health and social care affect those who inhabit them (Fenner, 2011 , 2017 ). However, in case study research to date, narrative forms have tended to dominate, possibly because the contexts in which much case study research is conducted are policy or program focused where narrative forms of understanding are more the norm. This is not to say creative approaches may not be useful in these contexts. It may be a question of lack of familiarity with such approaches and acceptance of their usefulness in those environments.

Finally, for capturing the quality and essence of peoples’ experience, nothing could be more revealing than a recording of their voices. Video diaries—self-evaluative portrayals by individuals of their perspectives, feelings, or experience of an event or situation—are a most potent way both of gaining understanding and of communicating that to others. It is rather more difficult to gain access for observational videos because it is hard to effectively disguise individuals. Even if consent is granted, where individuals are visible it is not possible to foresee how portrayals of their life and experience will be viewed years after the research is completed. Research is context and time bound. So, video diaries may be most useful in a temporal sense to facilitate understanding of the case. See Simons ( 2007 ) for an exploration of the ethical dimension of the use of visual data.

It will be evident from the foregoing discussion of qualitative methods that close-up portrayals of individuals and contexts requires sensitive ethical protocols. Negotiating what information becomes public can be quite difficult in singular settings where people are identifiable and intricate or problematic transactions have been documented. The consequences that ensue from making knowledge public that hitherto was private may be considerable for those in the case. It may also be difficult to portray some of the contextual detail that would enhance understanding for readers because it would raise the risk of identifiability of individuals, as would visual data, as already noted.

The ethical stance that underpins the case study research and evaluation I conduct stems from a theory of ethics that emphasizes the centrality of relationships in the specific context (see Kirkhart, 2013 , for the concept of relational validity that supports this focus) and the consequences for individuals, while remaining aware of the research imperative to publicly report. It is essentially an independent democratic process based on the concepts of fairness and justice, in which confidentiality, negotiation, and accessibility are key principles (MacDonald, 1976 ; Simons, 2009 , ch. 6; and Simons, 2010 ). The principles are translated into specific procedures to guide the collection, validation, and dissemination of data in the field. These include:

engaging participants and stakeholders in identifying issues to explore and sometimes also in interpreting the data;

documenting how different people interpret and value the program;

negotiating what data become public, respecting both the individual’s “right to privacy” and the public’s “right to know”;

offering participants opportunities to check how their data are used in the context of reporting;

reporting in language and forms accessible to a wide range of audiences; and

disseminating to audiences within and beyond the case.

For further discussion of the ethics of democratic case study evaluation and examples of their use in practice, see Simons ( 2000 , 2006 , 2009 , ch. 6, 2010 ).

Getting It All Together

Case study is so often associated with story or with a report of some event or program that it is easy to forget that much analysis and interpretation has gone on before we reach this point. In many case study reports, this process is hidden, leaving the reader with little evidence on which to assess the validity of the findings and having to trust the one who wrote the tale.

This section briefly outlines possibilities, first, for analyzing and interpreting data, and second, for how to communicate the findings to others. However, it is useful to think of them together and indeed, at the start, because decisions about how you report may influence how you choose to make sense of the data. Your choice may also vary according to the context of the study—what is expected or acceptable—and your personal predilections, whether you prefer a more rational than intuitive mode of analysis, for example, or a formal or informal style of writing up that includes images, metaphor, narratives, or poetic forms.

Analyzing and Interpreting Data

When it comes to making sense of data, I make a distinction between analysis—a formal inductive process that seeks to explain—and interpretation, a more intuitive process that gains understanding and insight from an holistic grasp of data, although they may interact and overlap at different stages.

The process, whichever emphasis you choose, is one of reducing or transforming a large amount of data to themes that can encapsulate the overarching meaning in the data. This involves sorting, refining, and refocusing data until they make sense. It starts at the beginning with preliminary hunches, sometimes called interpretative asides or working hypotheses , later moving to themes, analytic propositions, or a theory of the case.

There are many ways to conduct this process. Two strategies often employed are concept mapping —a means of representing data visually to explore links between related concepts—and progressive focusing (Parlett & Hamilton, 1976 ), the gradual reframing of initially identified issues into themes that are then further interpreted to generate findings. Each of these strategies tends to have three stages: initial sense making, identification of themes, and examination of patterns and relationships between them.

If taking a formal analytic approach to the task, the data would likely be broken down into segments or data sets (coded and categorized) and then reordered and explored for themes, patterns, and possible propositions. If adopting a more intuitive process, you might focus on identifying insights through metaphors and images, lateral thinking, or puzzling over paradoxes and ambiguities in the data, after first immersing yourself in the total data set and reading and rereading interview scripts, observations, and field notes to get a sense of the whole. Trying different forms of making sense through poetry, vignettes, cameos, narratives, collages, and drawing are further creative ways to interpret data, as are photographs taken in the case arranged to explain or tell the story of the case.

Reporting Case Study Research

Narrative structure and story.

As indicated in the introduction, telling a story is often associated with case study and some think this is what a case study is. In one sense it is, and, given that story is the natural way in which we learn (Okri, 1997 ), it is a useful framework both for gathering data and for communicating case study findings. Not any story will do, however. To count as research, it must be authentic, grounded in data, interpreted and analyzed to convey the meaning of the case.

There are several senses in which story is appropriate in qualitative case study: in capturing stories participants tell, in generating a narrative structure that makes sense of the case (i.e., the story you will tell), and in deciding how you communicate this narrative (i.e., in story form). If you choose a written story form, Harrington ( 2003 ) and Caulley ( 2008 ) are useful authors to consult to ensure the story is clearly structured, well written, and contains only the detail that is necessary to give readers the vicarious experience of what it was like in the case. Harrington ( 2003 ) reminds us, among other things, that it is not only in the technical sense that good writing is required—using plain, precise, direct language and grammar—but also how we convey meaning—“‘selecting telling details’ … ‘balancing the particular and the universal’ … ‘structuring stories so insight emerges’” (p. 97). If the story is to be communicated in other ways, through, for example, audio or videotape or computer or personal interaction, the same applies, substituting visual and interpersonal skill for written. In addition to these authors, I often get inspiration for constructing a story or a portrayal of a person from novelists who write well.

Matching Forms of Reporting to Audience

The art of reporting is strongly connected to usability, so forms of reporting need to connect to the audiences we hope to inform: how they learn, what kind of evidence they value, and what kind of reporting maximizes the chances they will use the findings to promote policies and programs in the interests of beneficiaries. As Okri ( 1997 ) further reminds us “The writer only does half the work, the reader does the other” (p. 41).

There may be other considerations as well: How open are commissioners to receiving stories of difficulties as well as success stories? What might they need to hear beyond what is sought in the technical brief? And through what style of reporting would you try to persuade them? If you are conducting noncommissioned case study research, the scope for different forms of reporting is wider. In academia, for instance, many institutions these days accept creative and artistic forms of reporting when supported by supervisors and appreciated by examiners.

Styles of Reporting

The most obvious form of reporting is linear , often starting with a short executive summary and a brief description of focus and context, followed by methodology, the case study itself in its totality, or demonstrated in the thematic analysis, findings, and conclusions or implications. Conclusion-led reporting is similar in terms of its formality, but simply starts the other way around. From the conclusions drawn from the analyzed data, it works backward to tell the story through narrative, verbatim, and observational data of how these conclusions were reached. Both have a strong storyline. The intent is analytic and explanatory.

Quite a different approach is to engage the reader in the experience and veracity of the case. Rather like constructing a portrait or editing a documentary film, this involves the sifting, constructing, and reordering of frames, events, and episodes to tell a coherent story primarily through interview excerpts, observations, vignettes, and critical incidents that depict what transpired in the case. Interpretation is indirect through the weaving of the data. The story can start at any point, provided the underlying narrative structure is maintained to establish coherence (House, 1980 , p. 116).

Different again, and from the other end of a continuum, is a highly interpretative account that may use similar ways of presenting data but weaves a story from the outset that is highly interpretative. Engaging metaphor, images, short stories, contradictions, paradoxes, and puzzles, it is invariably interesting to read and can be most persuasive. However, the evidence is less visible and therefore less open to alternative interpretations.

Even more persuasive is a case study that uses artistic forms to communicate the story of the case. Paintings, poetic form, drawings, photography, collage, and movement can all be adopted to report findings, whether the data were acquired using these forms or by other means. The arts-based inquiry movement (Mullen & Finley, 2003 ) has contributed hugely to the validation and legitimation of artistic and creative ways of representing qualitative research findings. The journal Qualitative Inquiry contains many good examples, but see also Liamputtong & Rumbold ( 2008 ). Such artistic forms of representation may not be for everyone or appropriate in some contexts, but they do have the power to engage an audience and the potential to facilitate use.

Before leaving reporting, it is important to mention that in recent years, not surprisingly given the rapid growth and ever-changing technology at our disposal, there has been an increase in the use of data visualization techniques, both to present data and to report findings. See, for example, some of the excellent ideas offered by Stephanie Evergreen ( 2013 , 2016 ) using graphics and charts of different kinds to summarize data effectively. Telling the story of the case, then, can be visual as well as literary. Using these techniques, linked often with quotations from interviews and pictorial evidence of context, it is possible to communicate the findings of a case in a few pages, or even just one page. This can be of immense benefit to policy makers who may have little time to read long case reports or those who value visual learning as much as written. Such techniques are unlikely to replace the narrative form. Given the importance of people and context in case study, the need to represent participants’ voices and the sociopolitical context will invariably demand a longer and integrated story. Data visualization is an added strength and an option for those who are persuaded by visual means or who have little time.

Generalization in Case Study Research

One of the potential limitations of case study often proposed is that it is impossible to generalize. This is not so. However, the way in which one generalizes from a case is different from that adopted in traditional forms of social science research that utilize large samples (randomly selected) and statistical procedures and that assume regularities in the social world that allow cause and effect to be determined. In this form of research, inferences from data are stated as formal propositions that apply to all in the target population. See Donmoyer ( 1990 ) for an argument on the restricted nature of this form of generalization when considering single-case studies.

Making inferences from cases with a qualitative data set arises more from a process of interpretation in context, appealing to tacit and situated understanding for acceptance of their validity. Such inferences are possible where the context and experience of the case is richly described so the reader can recognize and connect with the events and experiences portrayed. There are two ways to examine how to reach these generalized understandings. One is to generalize from the case to other cases of a similar or dissimilar nature. The other is to see what we learn in depth from the uniqueness of the single case itself.

Generalizing from the Single Case

A common approach to generalization and one most akin to a propositional form is cross-case generalization. In a collective or multisite case study, each case is explored to see if issues that arise in one case also exist in other cases and what interconnecting themes exist between them. This kind of generalization has a degree of abstraction and potential for theorizing and is often welcomed by commissioners of research concerned that findings from the single case do not provide an adequate or “safe” basis for policy determination.

However, there are four additional ways to generalize from the single case, all of which draw more on tacit knowledge and recognition of context, although in different ways. In naturalistic generalization , first proposed by Stake ( 1978 ), generalization is reached on the basis of recognition of similarities and differences to cases with which we are familiar. To enable such recognition, the case should feature rich description; people’s voices; and enough detail of time, place, and context to provide a vicarious experience to help readers discern what is similar and dissimilar to their own context (Stake, 1978 ).

Situated generalization (Simons, Kushner, Jones, & James, 2003 ) is close to the concept of naturalistic generalization in relying for its generality on retaining a connectedness with the context in which it first evolved. However, it has an extra dimension in a practice context. This notion of generalization was identified in an evaluation of a research project that engaged teachers in and with research. Here, in addition to the usual validity criteria to establish the methodological warrant for the findings, the generalization was seen as dependable if trust existed between those who conducted the research (teachers, in this example) and those thinking about using it (other teachers). In other words, beyond the technical validity of the research, teachers considered using the findings in their own practice because they had confidence in those who generated them. This is a useful way to think about generalization if we wish research findings to improve professional practice.

The next two concepts of generalization— concept and process generalization —relate more to what you discover in making sense of the case. As you interpret and analyze, you begin to generate a theory of the case that makes sense of the whole. Concepts may be identified that make sense in the one case but have equal significance in other cases of a similar kind, even if the contexts are different. It is the concept that generalizes, not the specific content or context. This may be similar to the process Donmoyer ( 2008 ) identifies of “intellectual generalization” (as cited in Butler-Kisber, 2010 , p. 15) to indicate the cognitive understanding one can gain from qualitative accounts even if settings are quite different.

The same is true for generalization of a process. It is possible to identify a significant process in one case (or several cases) that is transferable to other contexts, irrespective of the precise content and contexts of those other cases. An example here is the collaborative model for sustainable school self-evaluation I identified in researching school self-evaluation in a number of schools and countries (Simons, 2002 ). Schools that successfully sustained school self-evaluation had an infrastructure that was collaborative at all stages of the evaluation process from design to conduct of the study, to analyzing and interpreting the results, and to reporting the findings. This ensured that the whole school was involved and that results were discussed and built into the ongoing development of school policies and practice. In other cases, different processes may be discovered that have applicability in a range of contexts. As with concept generalization, it is the process that generalizes not the substantive content or specific context.

Particularization

The forms of generalization discussed above are useful when we have to justify case study in a research or policy context. But the overarching justification for how we learn from case study is particularization —a rich portrayal of insights and understandings interpreted in the particular context. Several authors have made this point (Flyvberg, 2006 ; Simons, 2009 ; Stake, 1995 , 2006 ). Stake (2005) puts it most sharply when he observes that “the real business of case study is particularization, not generalization” (p. 8), referring here to the main reason for studying the singular, which is to understand the uniqueness of the case itself.

My perspective (explored further in Simons, 1996 , 2009 , p. 239; Simons & McCormack, 2007 ) is similar in that I believe the “real” strength of case study lies in the insights we gain from in-depth study of the particular. But I also argue for the universality of such insights—if we get it “right,” by which I mean that if we are able to capture and report the uniqueness, the essence of the case, in all its particularity and present it in a way we can all recognize, we will discover something of universal significance. This is something of a paradox. The more you learn in depth about the particularity of one person, situation, or context, the more likely you are to discover something universal. This process of reaching understanding has support both from the way in which many discoveries are made in science and in how we learn from artists, poets, and novelists, who reach us by communicating a recognizable truth about individuals, human relationships, and/or social contexts.

This concept of particularization is far from new, as the quotation below from a preface to a book written in 1908 attests. Stephen Reynolds, the author of A Poor Man’s House (Reynolds, 1908 ) noted in the preface that the substance of the book was first recorded in a journal, kept for purposes of fiction and in letters to one of his friends, but fiction proved an inappropriate medium. He felt that the life and the people were so much better than anything he could invent. The book therefore consists of the journal and letters drawn together to present a picture of a typical poor man’s house and life, much as we might draw together a range of data to present a case study. It is not the substance of the book that concerns us here, but the methodological relevance to case study research. Reynolds pointed out that the conclusions in his book were tentative and possibly went beyond this man’s life, so he thought some explanation of the way he arrived at them was needed:

Educated people usually deal with the poor man’s life deductively; they reason from the general to the particular; and, starting with a theory, religious, philanthropic, political, or what not, they seek, and too easily find, among the millions of poor, specimens—very frequently abnormal—to illustrate their theories. With anything but human beings, that is an excellent method. Human beings, unfortunately, have individualities. They do what, theoretically, they ought not to do, and leave undone those things they ought to do. They are even said to possess souls—untrustworthy things beyond the reach of sociologists. The inductive method—reasoning from the particular to the general … should at least help to counterbalance the psychological superficiality of the deductive method. (Reynolds, 1908 , preface) 1

Slightly overstated, perhaps, but the point is well made. In our search for general laws, we not only lose sight of the uniqueness and humanity of individuals, but also reduce them in the process, failing to present their experience in any “real” sense. What is astonishing about the quotation is that it was written over a century ago, and yet many still argue that you cannot generalize from the particular.

Going even further back to 1798, Blake proclaimed that ‘To generalise is to be an idiot; to particularise is the alone distinction of merit&quot; (Blake,1798, cited by Keynes (1957). In research, we may not wish to make such a strong distinction; these processes both have their uses in different kinds of research. But there is a major point here for the study of the particular that Wilson ( 2008 ) notes in commenting on Blake’s perception when he says, “Favouring the abstract over the concrete, one ‘sees all things only thro’ the narrow chinks of his cavern’ ” (referring here to Blake’s The Marriage of Heaven and Hell [1793], as cited in Wilson, 2008 , p. 62). The danger Wilson is pointing to here is that abstraction relies heavily on what we know from our past understanding of things, and this may prevent us experiencing a concrete event directly or “apprehend[ing] a particular moment” (Wilson, 2008 , p. 63).

Blake had a different mission, of course, from case researchers, and he was not himself free from abstractions, as Wilson points out, although he [Blake] fought hard “to break through mental barriers to something unique and living” (Wilson, 2008 , p. 65). It is this search for the “unique and living” and experiencing the “isness” of the particular that we should take from the Blake example to remind us of the possibility of discovering something “new,” beyond our current understanding of the way things are.

Focusing on particularization does not diminish the usefulness of case study research for policy makers or practitioners. Grounded in recognizable experience, the potential is there to reach a range of audiences and to facilitate use of the findings. It may be more difficult for those who seek formal generalizations that seem to offer a safe basis for policy making to accept case study reports. However, particular stories often hold the key to why policies have or have not worked well in the past. It is not necessary to present long cases—a criticism frequently leveled—to demonstrate the story of the case. Such case stories can be most insightful for policy makers who, like many of us in everyday life, often draw inferences from a single instance or case, whatever the formal evidence presented “I am reminded of the story of …” Stake ( 2006 , pp. 197–198) also reminds us that we are constantly making small generalizations from particular situations as we go about our professional work and life. These may not survive systematic research scrutiny, but the point Stake is making here is that it is our natural tendency to generalize from the particular in making sense of our worlds. In case study research that aspires to represent “lived experience,” this seems a natural way to proceed.

The case for studying the particular to inform practice in professional contexts needs less persuasion because practitioners can recognize the content and context quite readily and make the inference to their own particular context (Simons et al., 2003 ). In both sets of circumstances—policy and practice—it is more a question of whether the readers of our case research accept the validity of findings determined in this way, how they choose to learn, and our skill in telling the case study story.

Conclusion and Future Directions

In this chapter, I have presented an argument for case study research, making the case, in particular, for using qualitative methods to highlight what qualitative case study research can bring to the study of social and educational programs. I outlined the various ways in which case study is commonly used before focusing directly on case study as a major mode of research inquiry, noting characteristics it shares with other qualitative methodologies, as well as its difference and the difficulties it is often perceived to have. The chapter emphasizes the importance of thinking through what the case is to be sure that the issues explored and the data generated do illuminate this case and not any other.

But there is still more to be done. In particular, I think we need to be more adventurous in how we craft and report the case, and I have made several suggestions in the text as to how this could be done. I suspect also that we may have been too cautious in the past in how we justified case study research, borrowing concepts from other disciplines and forms of educational research. Fifty years on, it is time to take a greater risk—in demonstrating the intrinsic nature of case study research and what it can offer our understanding of human and social situations.

I have already drawn attention to the need to design the case, although this could be developed further to accentuate the uniqueness of the particular case. One way to do this is to feature individuals more in the design itself, not only to explore programs and policies through perspectives of key actors or groups and transactions between them, which to some extent happens already, but also to get them to characterize what makes the context unique. This is the reversal of many a design framework that starts with the logic of a program and takes forward the argument for personalizing evaluation (Kushner, 2000 ) on the grounds that it is through individuals that programs and policies are enacted. Apart from this attention to design, there are three other issues I think we need to explore further: the warrant for creative methods in case study, more imaginative reporting, and how we learn from a study of the singular.

Warrant for More Creative Methods in Case Study Research

The promise that creative methods have for eliciting in-depth understanding and capturing the unusual, the idiosyncratic, the uniqueness of the case, was mentioned in the methods section. Yet, in case study research, particularly in program and policy contexts, we have few good examples of the use of artistic approaches for eliciting and interpreting data, although there are more, indicated below for presenting it. This may be because case study research is often conducted in academic or policy environments, where propositional ways of knowing are more valued.

Using creative and artistic forms in generating and interpreting case study data offers a form of evidence that acknowledges experiential understanding in illuminating the uniqueness of the case. The question is how to establish the warrant for this way of knowing and persuade others of its virtue. The answer is simple: by demonstrating the use of these methods in action, by arguing for a different form of validity that matches the intrinsic nature of the method, and, above all, by good examples. I earlier noted the impact that Elliott’s CD of men with brain damage had on audiences beyond the case. Rugang ( 2006 ) also used the CD form, two in this instance, presenting contrasting photographs of a “new” culture and an old culture in one province in China. These told the story well, as did a narrative poem by Duke ( 2007 ) of her leadership illustrating how she performed her role as a nurse consultant with responsibility to help other nurses research concurrent with her usual job as a senior nurse.

Re-presenting Findings to Engage Audiences in Learning

In evaluative and research policy contexts, where case study is often the main mode of inquiry or part of a broader study, case study reports often take a formal structure or, sometimes, where the context is receptive, a portrayal or interpretative form. But, too often, the qualitative is an add-on to a story told by other means or reduced to issues in which the people who gave rise to the data are no longer seen. However, there are many ways to put them center stage.

Tell good stories and tell them well. Or, let key actors tell their own stories in narrative or on video. Explore the different ways technology can help. Make video clips that demonstrate events in context, illustrate interactions between people, give voice to participants—show the reality of the program, in other words. Use graphics to summarize key issues and interactive cartoon technology, as seen on some TED presentations, to summarize and visually show the complexity of the case. Explore the data visualization techniques now becoming widely available. Video diaries were mentioned in the methods section: seeing individuals tell their tales directly is a powerful way of communicating, unhindered by “our” sense making. Tell photo stories. Let the photos convey the narrative, but make sure the structure of the narrative is evident to ensure coherence. These are just the beginnings. Those skilled in information technology could no doubt stretch our imagination further.

One problem and a further question concerns our audiences. In your thesis you may well have scope to experiment with some of these alternative forms of presentation. In other contexts—I am thinking here of policy makers and commissioners—it may be more challenging, and you may wonder if they will accept these alternative modes of communication. Maybe not, in some cases. However, there are three points I wish to leave you with. First, if people are fully present in the story and the complexity is not diminished, those reading, watching, or hearing about the case will get the message. If you are worried about how commissioners might respond, remember that they are no different from any other stakeholder or participant when it comes to how they learn from human experience. Witness the reference to Okri ( 1997 ) earlier about how we learn and Stake’s ( 2010 ) reminder of how we generalize from the particular in everyday life.

Second, when you detect that the context requires a more formal presentation of findings, respond according to expectation, but also include elements of other forms of presentation. Nudge a little in the direction of creativity. Third, simply take a chance. Challenge the status quo. Find situations and contexts where you can fully represent the qualitative nature of the experience in the cases you study with creative forms of interpretation and representation. And let the audience decide.

Learning from a Study of the Singular

Finally, to return to the issue of “generalization” in case study that worries some audiences. I pointed out in the generalization section several ways in which it is possible to generalize from case study research, not in a formal propositional sense or from a case to a population, but by retaining a connection with the context in which the generalization first arose—that is, to realize in-depth understanding in context in different circumstances and situations. However, I also emphasized that, in many instances, it is particularization from which we learn. That is the point of the singular case study, and it is an art to perceive and craft the case in ways that we can.

Acknowledgments

Parts of this chapter build on ideas first explored in Simons ( 2009 ).

I am grateful to Bob Williams for pointing out the relevance of this quotation from Reynolds to remind us that “there is nothing new under the sun” and that we sometimes continue to engage endlessly in debates that have been well rehearsed before.

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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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The case study approach

Sarah crowe.

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

Kathrin Cresswell

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

Ann Robertson

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

Anthony Avery

Aziz sheikh.

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

Introduction

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

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

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

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

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

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

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

What is a case study?

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

Definitions of a case study

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

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

What are case studies used for?

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

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

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

How are case studies conducted?

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

Defining the case

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

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

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

Selecting the case(s)

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

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

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

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

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

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

Collecting the data

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

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

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

Analysing, interpreting and reporting case studies

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

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

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

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

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

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

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

Potential pitfalls and mitigating actions when undertaking case study research

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

Conclusions

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

Competing interests

The authors declare that they have no competing interests.

Authors' contributions

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

Pre-publication history

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

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

Acknowledgements

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

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• Open access
• Published: 09 May 2024

Examining the feasibility of assisted index case testing for HIV case-finding: a qualitative analysis of barriers and facilitators to implementation in Malawi

• Caroline J. Meek 1 , 2 ,
• Tiwonge E. Mbeya Munkhondya 3 ,
• Mtisunge Mphande 4 ,
• Tapiwa A. Tembo 4 ,
• Mike Chitani 4 ,
• Milenka Jean-Baptiste 2 ,
• Dhrutika Vansia 4 ,
• Caroline Kumbuyo 4 ,
• Jiayu Wang 2 ,
• Katherine R. Simon 4 ,
• Sarah E. Rutstein 5 ,
• Clare Barrington 2 ,
• Maria H. Kim 4 ,
• Vivian F. Go 2 &
• Nora E. Rosenberg 2  

BMC Health Services Research volume  24 , Article number:  606 ( 2024 ) Cite this article

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Metrics details

Assisted index case testing (ICT), in which health care workers take an active role in referring at-risk contacts of people living with HIV for HIV testing services, has been widely recognized as an evidence-based intervention with high potential to increase status awareness in people living with HIV. While the available evidence from eastern and southern Africa suggests that assisted ICT can be an effective, efficient, cost-effective, acceptable, and low-risk strategy to implement in the region, it reveals that feasibility barriers to implementation exist. This study aims to inform the design of implementation strategies to mitigate these feasibility barriers by examining “assisting” health care workers’ experiences of how barriers manifest throughout the assisted ICT process, as well as their perceptions of potential opportunities to facilitate feasibility.

In-depth interviews were conducted with 26 lay health care workers delivering assisted ICT in Malawian health facilities. Interviews explored health care workers’ experiences counseling index clients and tracing these clients’ contacts, aiming to inform development of a blended learning implementation package. Transcripts were inductively analyzed using Dedoose coding software to identify and describe key factors influencing feasibility of assisted ICT. Analysis included multiple rounds of coding and iteration with the data collection team.

Participants reported a variety of barriers to feasibility of assisted index case testing implementation, including sensitivities around discussing ICT with clients, privacy concerns, limited time for assisted index case testing amid high workloads, poor quality contact information, and logistical obstacles to tracing. Participants also reported several health care worker characteristics that facilitate feasibility (knowledge, interpersonal skills, non-stigmatizing attitudes and behaviors, and a sense of purpose), as well as identified process improvements with the potential to mitigate barriers.

Conclusions

Maximizing assisted ICT’s potential to increase status awareness in people living with HIV requires equipping health care workers with effective training and support to address and overcome the many feasibility barriers that they face in implementation. Findings demonstrate the need for, as well as inform the development of, implementation strategies to mitigate barriers and promote facilitators to feasibility of assisted ICT.

Trial registration

NCT05343390. Date of registration: April 25, 2022.

Peer Review reports

Introduction

To streamline progress towards its goal of ending AIDS as a public health threat by 2030, the Joint United Nations Programme on HIV/AIDS (UNAIDS) launched a set of HIV testing and treatment targets [ 1 ]. Adopted by United Nations member states in June 2021, the targets call for 95% of all people living with HIV (PLHIV) to know their HIV status, 95% of all PLHIV to be accessing sustained antiretroviral therapy (ART), and 95% of all people receiving ART to achieve viral suppression by 2025 [ 2 ]. Eastern and southern Africa has seen promising regional progress towards these targets in recent years, and the region is approaching the first target related to status awareness in PLHIV- in 2022, 92% of PLHIV in the region were aware of their status [ 3 ]. However, several countries in the region lag behind [ 4 ], and as 2025 approaches, it is critical to scale up adoption of evidence-based interventions to sustain and accelerate progress.

Index case testing (ICT), which targets provision of HIV testing services (HTS) for sexual partners, biological children, and other contacts of known PLHIV (“index clients”), is a widely recognized evidence-based intervention used to identify PLHIV by streamlining testing efforts to populations most at risk [ 5 , 6 , 7 ]. Traditional approaches to ICT rely on passive referral, in which index clients invite their contacts for testing [ 5 ]. However, the World Health Organization (WHO) and the President’s Emergency Plan for HIV/AIDS Relief (PEPFAR) have both recommended assisted approaches to ICT [ 6 , 8 , 9 , 10 ], in which health care workers (HCWs) take an active role in referral of at-risk contacts for testing, due to evidence of improved effectiveness in identifying PLHIV compared to passive approaches [ 10 , 11 , 12 , 13 , 14 ]. As a result, there have been several efforts to scale assisted ICT throughout eastern and southern Africa in recent years [ 15 , 16 , 17 , 18 , 19 , 20 ]. In addition to evidence indicating that assisted ICT can be effective in increasing HIV testing and case-finding [ 16 , 17 , 21 , 22 , 23 , 24 ], implementation evidence [ 25 ] from the region suggests that assisted ICT can be an efficient [ 14 ], acceptable [ 5 , 13 , 15 , 18 , 20 , 21 , 26 ], cost-effective [ 27 ], and low-risk [ 21 , 22 , 24 , 28 , 29 ] strategy to promote PLHIV status awareness. However, the few studies that focus on feasibility, or the extent to which HCWs can successfully carry out assisted ICT [ 25 ], suggest that barriers exist to feasibility of effective implementation [ 18 , 19 , 20 , 30 , 31 , 32 ]. Developing informed implementation strategies to mitigate these barriers requires more detailed examination of how these barriers manifest throughout the assisted ICT process, as well as of potential opportunities to facilitate feasibility, from the perspective of the HCWs who are doing the “assisting”.

This qualitative analysis addresses this need for further detail by exploring “assisting” HCWs’ perspectives of factors that influence the feasibility of assisted ICT, with a unique focus on informing development of effective implementation strategies to best support assisted ICT delivery in the context of an implementation science trial in Malawi.

This study was conducted in the Machinga and Balaka districts of Malawi. Malawi is a country in southeastern Africa in which 7.1% of the population lives with HIV and 94% of PLHIV know their status [ 4 ]. Machinga and Balaka are two relatively densely populated districts in the southern region of Malawi [ 33 ] with HIV prevalence rates similar to the national average [ 34 ]. We selected Machinga and Balaka because they are prototypical of districts in Malawi implementing Ministry of Health programs with support from an implementing partner.

Malawi has a long-established passive ICT program, and in 2019 the country also adopted an assisted component, known as voluntary assisted partner notification, as part of its national HIV testing policy [ 32 ]. In Malawi, ICT is conducted through the following four methods, voluntarily selected by the index client: 1) passive referral, in which HCWs encourage the index client to refer partners for voluntary HTS, 2) contract referral, in which HCWs establish an informal ‘contract’ with index clients that agrees upon a date that the HCW can contact the contact clients if they have not yet presented for HTS; 3) provider referral, in which HCWs contact and offer voluntary HTS to contact clients; and 3) dual referral, in which HCWs accompany and provide support to index clients in disclosing their status and offering HTS to their partners [ 8 ]. 

While Malawi has one of the lowest rates of qualified clinical HCWs globally (< 5 clinicians per 100,000 people) [ 35 ], the country has a strong track record of shifting HTS tasks to lay HCWs, who have been informally trained to perform certain health care delivery functions but do not have a formal professional/para-professional certification or tertiary education degree, in order to mitigate this limited medical workforce capacity [ 32 , 36 ]. In Malawi, lay HCW roles include HIV Diagnostic Assistants (who are primarily responsible for HIV testing and counseling, including index case counseling) and community health workers (who are responsible for a wider variety of tasks, including index case counseling and contact tracing) [ 32 ]. Non-governmental organization implementing partners, such as the Tingathe Program, play a critical role in harnessing Malawian lay HCW capacity to rapidly and efficiently scale up HTS, including assisted ICT [ 32 , 37 , 38 , 39 ].

Study design

Data for this analysis were collected as part of formative research for a two-arm cluster randomized control trial examining a blended learning implementation package as a strategy for building HCW capacity in assisted ICT [ 40 ]. Earlier work [ 32 ] established the theoretical basis for testing the blended learning implementation package, which combines individual asynchronous modules with synchronous small-group interactive sessions to enhance training and foster continuous quality improvement. The formative research presented in this paper aimed to further explore factors influencing feasibility of the assisted ICT from the perspective of HCWs in order to inform development of the blended learning implementation package.

Prior to the start of the trial (October-December 2021), the research team conducted 26 in-depth interviews (IDIs) with lay HCWs at 14 of the 34 facilities included in the parent trial. We purposively selected different types of facilities (hospitals, health centers, and dispensaries) in both districts and from both randomization arms, as this served as a qualitative baseline for a randomized trial. Within these facilities, we worked with facility supervisors to purposively select HCWs who were actively engaged in Malawi’s ICT program from the larger sample of HCWs eligible for the parent trial (had to be at least 18 years old, employed full-time at one of the health facilities included in the parent trial, and involved in counseling index clients and/or tracing their contacts). The parent trial enrolled 306 HCWs, who were primarily staff hired by Tingathe Program to support facilities implementing Malawi’s national HIV program.

Data collection

IDIs were conducted by three trained Malawian interviewers in a private setting using a semi-structured guide. IDIs were conducted over the phone when possible ( n  = 18) or in-person at sites with limited phone service ( n  = 8). The semi-structured guide was developed for this study through a series of rigorous, iterative discussions among the research team (Additional file 1 ). The questions used for this analysis were a subset of a larger interview. The interview guide questions for this analysis explored HCWs’ experiences with assisted ICT, including barriers and facilitators to implementation. Probing separately about the processes of counseling index clients and tracing their contacts, interviewers asked questions such as “What is the first thing that comes to mind when you think of counseling index clients/tracing contacts?”, “What aspects do you [like/not like] about…?” and “What do your colleagues say about…?”. When appropriate, interviewers probed further about how specific factors mentioned by the participant facilitate or impede the ICT implementation experience.

The IDIs lasted from 60–90 min and were conducted in Chichewa, a local language in Malawi. Eleven audio recordings were transcribed verbatim in Chichewa before being translated into English and 15 recordings were directly translated and transcribed into English. Interviewers summarized each IDI after it was completed, and these summaries were discussed with the research team routinely.

Data analysis

The research team first reviewed all of the interview summaries individually and then met multiple times to discuss initial observations, refining the research question and scope of analysis. A US-based analyst (CJM) with training in qualitative analysis used an inductive approach to develop a codebook, deriving broad codes from the implementation factors mentioned by participants throughout their interviews. Along with focused examination of the transcripts, she consulted team members who had conducted the IDIs with questions or clarifications. CJM regularly met with Malawian team members (TEMM, MM, TAT) who possess the contextual expertise necessary to verify and enhance meaning. She used the Dedoose (2019) web application to engage in multiple rounds of coding, starting with codes representing broad implementation factors and then further refining the codebook as needed to capture the nuanced manifestations of these barriers and facilitators. Throughout codebook development and refinement, the analyst engaged in memoing to track first impressions, thought processes, and coding decisions. The analyst presented the codebook and multiple rounds of draft results to the research team. All transcripts and applied codes were also reviewed in detail by additional team members (MJB, DV). Additional refinements to the codebook and results interpretations were iteratively made based on team feedback.

Ethical clearance

Ethical clearance was provided by UNC’s IRB, Malawi’s National Health Sciences Research Committee, and the Baylor College of Medicine IRB. Written informed consent was obtained from all participants in the main study and interviewers confirmed verbal consent before starting the IDIs.

Participant characteristics are described in Table  1 below.

Factors influencing feasibility of assisted ICT: barriers and facilitators

Participants described a variety of barriers and facilitators to feasibility of assisted ICT, manifesting across the index client counseling and contact client tracing phases of the implementation process. Identified barriers included sensitivities around discussing ICT with clients, privacy concerns, limited time for ICT amid high workloads, poor quality contact information, and logistical obstacles to tracing. In addition to these barriers, participants also described several HCW characteristics that facilitated feasibility: ICT knowledge, interpersonal skills, positive attitudes towards clients, and sense of purpose. Barriers and facilitators are mapped to the ICT process in Fig.  1 and described in greater detail in further sections.

Conceptual diagram mapping feasibility barriers and facilitators to the ICT process

Feasibility barriers

Sensitivities around discussing ict with clients.

Participants described ICT as a highly sensitive topic to approach with clients. Many expressed a feeling of uncertainty around how open index clients will be to sharing information about their contacts, as well as how contacts will react when approached for HTS. When asked about difficult aspects of counseling index clients, many HCWs mentioned clients’ hesitance or declination to participate in assisted ICT and share their contacts. Further, several HCWs mentioned that some index clients would provide false contact information. These index client behaviors were often attributed to confidentiality concerns, fear of unwanted status disclosure, and fear of the resulting implications of status disclosure: “They behave that way because they think you will be telling other people about their status…they also think that since you know it means their life is done, you will be looking at them differently .” Populations commonly identified as particularly likely to hesitate, refuse, or provide false information included youth (described as “ shy ” “ thinking they know a lot ” and “ difficult to reveal their contacts ”) and newly diagnosed clients (“it may be hard for them to accept [their HIV diagnosis]” ). One participant suggested that efforts to pair index clients with same-sex HCWs could make them more comfortable to discuss their contacts.

When asked about the first things that come to mind when starting to trace contacts, many participants discussed wondering how they will be received by the contact and preparing themselves to approach the contact. When conducting provider or contract referral, HCWs described a variety of challenging reactions that can occur when they approach a contact for HTS- including delay or refusal of testing, excessive questioning about the identity of the index client who referred them for testing, and even anger or aggression. Particularly mentioned in the context of male clients, these kinds of reactions can lead to stress and uncertain next steps for HCWs: “I was very tensed up. I was wondering to myself what was going to happen…he was talking with anger.”

Participants also noted the unique sensitivities inherent in conducting dual referral and interacting with sexual partners of index clients, explaining that HIV disclosure can create acute conflict in couples due to perceived blame and assumptions of infidelity. They recounted these scenarios as particularly difficult to navigate, with high stakes that require high-quality counseling skills: “sometimes if you do not have good counseling the marriage happens to get to an end.” . Some participants discussed concern about index client risk of intimate partner violence (IPV) upon partner disclosure: “they think that if they go home and [disclose their HIV status], the marriage will end right there, or for some getting to a point of [being] beaten.”

Privacy concerns

Participants also reported that clients highly value privacy, which can be difficult to secure throughout the ICT process. In the facility, while participants largely indicated that counseling index clients was much more successful when conducted in a private area, many reported limited availability of private counseling space. One participant described this challenge: “ if I’m counseling an index client and people keep coming into the room…this compromises the whole thing because the client becomes uncomfortable in the end.” Some HCWs mentioned working around this issue through use of screens, “do-not-disturb” signs, outdoor spots, and tents.

Participants also noted maintaining privacy as a challenge when tracing contact clients in the field, as they sometimes find clients in a situation that is not conducive to private conversations. One participant described: “ we get to the house and find that there are 4, 5 people with our [contact client]…it doesn’t go well…That is a mission gone wrong. ” Participants also noted that HCWs are also often easily recognizable in the community due to their bikes and cars, which exacerbates the risk of compromising privacy. To address privacy challenges in the community, participants reported strategies to increase discretion, including dressing to blend in with the community, preparing an alternate reason to be looking for the client, and offering HTS to multiple people or households to avoid singling out one person.

Limited time for ICT amid high workloads

Some participants indicated that strained staffing capacity leads HCWs to have to perform multiple roles, expressing challenges in balancing their ICT work with their other tasks. As one participant described, “Sometimes it is found that you are assigned a task here at the hospital to screen anyone who comes for blood testing, but you are also supposed to follow up [with] the contacts the same day- so it becomes a problem…you fail to follow up [with] the contacts.” Some also described being the only, or one of few staff responsible for ICT: “You’re doing this work alone, so you can see that it is a big task to do it single-handedly.” The need to counsel each index client individually, as a result of confidentiality concerns, further increases workload for the limited staff assigned to this work. Further, HCWs often described contact tracing in the field as time-consuming and physically taxing, which leaves them less time and energy for counseling. Many HCWs noted the need to hire more staff dedicated to ICT work.

High workloads also resulted in shorter appointments and less time to counsel index clients, which participants reported limits the opportunity for rapport that facilitates openness or probes for detailed information about sexual partners. Participants emphasized the importance of having enough time to meaningfully engage with index clients: “For counseling you cannot have a limit to say, ‘I will talk to him for 5 min only.’ …That is not counseling then. You are supposed to stay up until…you feel that this [person] is fulfilled.” . In addition, high workload can reduce the capacity of HCWs to deliver quality counseling: “So you find that as you go along with the counseling, you can do better with the first three clients but the rest, you are tired and you do short cuts.”

High workloads also lead to longer queues, which may deter clients from coming into the clinic or cause them to leave before receiving services: “Sometimes because of shortage of staff, it happens that you have been assigned a certain task that you were supposed to do but at the same time there are clients who were supposed to be counseled. As a result, because you spent more time on the other task as a result you lose out some of the clients because you find that they have gone.” In response to long queues, several participants described ‘fast-tracking’ contact clients who come in for HTS in effort to maximize case-finding by prioritizing those who have been identified as at risk of HIV.

Poor quality contact information

Participants repeatedly discussed the importance of eliciting accurate information about a person’s sexual partners, including where, when, and how to best contact them. As one participant said, “ Once the index has given us the wrong information then everything cannot work, it becomes wrong…if he gives us full information [with] the right details then everything becomes successful and happens without a problem. ” Adequate information is a critical component of the ICT process, and incorrect or incomplete information delays or prevents communication with contact clients.

Inadequate information, which can include incorrect or incomplete names, phone numbers, physical addresses, and contextual details, can arise from a variety of scenarios. Most participants mentioned index clients providing incorrect information as a concern. This occurred either intentionally to avoid disclosure or unintentionally if information was not known. Poor quality contact information also results from insufficient probing and poor documentation, which is often exacerbated by aforementioned HCW time and energy constraints. In one participant’s words, “The person who has enlisted the contact…is the key person who can make sure that our tracing is made easy.” Participants noted the pivotal role of the original HCW who first interacts with the index client in not only eliciting correct locator information but also eliciting detailed contextual information. For example, details about a contact client’s profession are helpful to trace the client at a time when they will likely be at home. Other helpful information included nicknames, HIV testing history, and notes about confidentiality concerns.

Logistical obstacles to tracing

Some contact clients are reached by phone whereas others must be physically traced in the community. Some participants reported difficulty with tracing via phone, frequently citing network problems and lack of sufficient airtime allocated by the facility. Participants also reported that some clients were unreachable by phone, necessitating physical tracing. Physically tracing a contact client requires a larger investment of resources than phone tracing, especially when the client lives at a far distance from the clinic. Participants frequently discussed having to travel far distances to reach contact clients, an issue some saw as exacerbated by people who travel to clinics at far distances due to privacy concerns.

While most participants reported walking or biking to reach contact clients in the community, some mentioned using a motorcycle or Tingathe vehicle. However, access to vehicles is often limited and these transportation methods require additional expenses for fuel. Walking or biking was also reported to expose HCWs to inclement weather, including hot or rainy seasons, and potential safety risks such as violence.

Participants reported that traveling far distances can be physically taxing and time-consuming, sometimes rendering them too tired or busy to attend to other tasks. Frequent travel influenced HCW morale, particularly when a tracing effort did not result in successfully recruiting a contact client. Participants frequently described this perception of wasted time and energy as “ painful ”, with the level of distress often portrayed as increasing with the distance travelled. As one HCW said, “You [can] find out that he gave a false address. That is painful because it means you have done nothing for the person, you travelled for nothing.”

HCWs described multiple approaches used to strategically allocate limited resources for long distances. These approaches included waiting to physically trace until there are multiple clients in a particular area, reserving vehicle use for longer trips, and coordinating across HCWs to map out contact client locations. HCWs also mentioned provision of rain gear and sun protection to mitigate uncomfortable travel. Another approach involved allocating contact tracing to HCWs based in the same communities as the contact clients.

Feasibility facilitators

Hcw knowledge about ict.

Participants reported that HCWs with a thorough understanding of ICT’s rationale and purpose can facilitate client openness. Clients were more likely to engage with HCWs about assisted ICT if they understood the benefits to themselves and their loved ones. One HCW stated, “If the person understands why we need the information, they will give us accurate information.”

Participants also discussed the value of deep HCW familiarity with ICT procedures and processes, particularly regarding screening clients for IPV and choosing referral method. One participant described the importance of clearly explaining various referral methods to clients: “So…people come and choose the method they like…when you explain things clearly it is like the index client is free to choose a method which the contact can use for testing”. Thorough knowledge of available referral methods allows HCWs to actively engage with index clients to discuss strategies to refer contacts in a way that fits their unique confidentiality needs, which was framed as particularly important when IPV is identified as a concern. Multiple participants suggested the use of flipcharts or videos, saying these would save limited HCW time and energy, fill information gaps, and provide clients with a visual aid to supplement the counseling. Others suggested recurring opportunities for training, to continuously “refresh” their ICT knowledge in order to facilitate implementation.

HCW interpersonal skills

In addition, HCWs’ ability to navigate sensitive conversations about HIV was noted as a key facilitator of successful implementation. Interpersonal skills were mentioned as mitigating the role’s day-to-day uncertainty by preparing HCWs to engage with clients, especially newly diagnosed clients: “ I need to counsel them skillfully so that they understand what I mean regardless that they have just tested positive for HIV.”

When discussing strategies to build HCW skills in counseling index clients and tracing contact clients, participants suggested establishing regular opportunities to discuss challenges and share approaches to address these challenges: “ I think that there should be much effort on the [HCWs] doing [ICT]. For example, what do I mean, they should be having a meeting with the facility people to ask what challenges are you facing and how can we end them?”. Another participant further elaborated, saying “We should be able to share experiences with our [colleagues] so that we can all learn from one another. And also, there are other people who are really brilliant at their job. Those people ought to come visit us and see how we are doing. That is very motivating.”

HCW non-stigmatizing attitudes and behaviors

Participants also highlighted the role of empathy and non-judgement in building trust with clients: “ Put yourself in that other person’s shoes. In so doing, the counseling session goes well. Understanding that person, that what is happening to them can also happen to you. ”. Participants viewed trust-building as critical to facilitating client comfort and openness: “if they trust you enough, they will give you the right information.” Further, participants associated HCW assurance of confidentiality with promoting trust and greater information sharing: “ Also assuring them on the issue of confidentiality because confidentiality is a paramount. If there will not be confidentiality then the clients will not reveal.”

HCW sense of purpose

Lastly, several participants reported that a sense of purpose and desire to help people motivated them to overcome the challenges of delivering assisted ICT. One participant said, “ Some of these jobs are a ministry. Counseling is not easy. You just need to tell yourself that you are there to help that person. ” Many seemed to take comfort in the knowledge that their labors, however taxing, would ultimately allow people to know their status, take control of their health, and prevent the spread of HIV. Participants framed the sense of fulfillment from successful ICT implementation as a mitigating factor amidst challenges: “ If [the contact client] has accepted it then I feel that mostly I have achieved the aim of being in the health field…that is why it is appealing to me ”.

Participants described a variety of barriers to assisted ICT implementation, including sensitivities around discussing ICT with clients, privacy concerns, limited time for ICT amid high workloads, poor quality contact information, and logistical obstacles to tracing. These barriers manifested across each step of the process of counseling index clients and tracing contacts. However, participants also identified HCW characteristics and process improvements that can mitigate these barriers.

Further, participants’ descriptions of the assisted ICT process revealed the intimately interconnected nature of factors that influence feasibility of assisted ICT. Sensitivities around HIV, privacy limitations, time constraints, and HCW characteristics all contribute to the extent to which counseling index clients elicits adequate information to facilitate contact tracing. Information quality has implications for HCW capacity, as inadequate information can lead to wasted resources, including HCW time and energy, on contact tracing. The opportunity cost of wasted efforts, which increases as the distance from which the contact client lives from the clinic increases, depletes HCW morale. The resulting acceleration of burnout, which is already fueled by busy workloads and the inherent uncertainty of day-to-day ICT work, further impairs HCW capacity to effectively engage in quality counseling that elicits adequate information from index clients. This interconnectedness suggests that efforts to mitigate barriers at any step of the assisted ICT process may have the potential to ripple across the whole process.

Participants’ descriptions of client confidentiality and privacy concerns, as well as fear of consequences of disclosure, align with previous studies that emphasize stigma as a key barrier to assisted ICT [ 15 , 18 , 19 , 20 , 30 , 31 ] and the overall HIV testing and treatment cascade [ 41 ]. Our findings suggest that anticipated stigma, or the fear of discrimination upon disclosure [ 42 ], drives several key barriers to feasibility of assisted ICT implementation. Previous studies also highlight the key role of HCWs in mitigating barriers related to anticipated stigma; noting the key role of HCW ICT knowledge, interpersonal skills, and non-stigmatizing attitudes/behaviors in securing informed consent from clients for ICT, tailoring the referral strategy to minimize risk to client confidentiality and safety, building trust and rapport with the client, and eliciting accurate contact information from index clients to facilitate contact tracing [ 18 , 19 , 20 , 30 ].

Our findings also reflect previous evidence of logistical challenges related to limited time, space, and resources that can present barriers to feasibility for HCWs [ 18 , 19 , 20 , 30 , 31 ]. Participants in the current study described these logistical challenges as perpetuating HCW burnout, making it harder for them to engage in effective counseling. Cumulative evidence of barriers across different settings (further validated by this study) suggests that assisted ICT implementation may pose greater burden on HCWs than previously thought [ 7 ]. However, our findings also suggest that strategic investment in targeted implementation strategies has the potential to help overcome these feasibility barriers.

In our own work, these findings affirmed the rationale for and informed the development of the blended learning implementation package tested in our trial [ 40 , 43 ]. Findings indicated the need for evidence-based training and support to promote HCW capacity to foster facilitating characteristics. Participants discussed the value of "refresher" opportunities in building knowledge, as well as the value of learning from other’s experiences. The blended learning implementation package balances both needs by providing time for HCWs to master ICT knowledge and skills with a combination of asynchronous, digitally delivered content (which allows for continuous review as a "refresher") and in-person sessions (which allow for sharing, practicing, and feedback). Our findings also highlight the value of flexible referral methods that align with the client’s needs, so our training content includes a detailed description of each referral method process. Further, our training content emphasizes client-centered, non-judgmental counseling as our findings add to cumulative evidence of stigma as a key barrier to assisted ICT implementation [ 41 ].

In addition, participants frequently mentioned informal workarounds currently in use to mitigate barriers or offered up ideas for potential solutions to try. Our blended learning implementation package streamlines these problem-solving processes by offering monthly continuous quality improvement sessions at each facility in our enhanced arm. These sessions allow for structured time to discuss identified barriers, share ideas to mitigate barriers, and develop solutions for sustained process improvement tailored to their specific setting. Initial focus areas for continuous quality improvement discussions include use of space, staffing, allocation of airtime and vehicles, and documentation, which were identified as barriers to feasibility in the current study.

Our study provides a uniquely in-depth examination of HCWs’ experiences implementing assisted ICT, exploring how barriers can manifest and interact with each other at each step of the process to hinder successful implementation. Further, our study has a highly actionable focus on informing development of implementation strategies to support HCWs implementing assisted ICT. Our study also has limitations. Firstly, while our sole focus on HCWs allowed for deeper exploration of assisted ICT from the perspective of those actually implementing it on the ground, this meant that our analysis did not include perspectives of index or contact clients. In addition, we did not conduct sub-group analyses as interpretation of results would be limited by our small sample size.

Assisted ICT has been widely recognized as an evidence-based intervention with high promise to increase PLHIV status awareness [ 5 , 6 , 7 , 10 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , 23 , 24 , 26 , 27 , 28 , 29 ], which is important as countries in eastern and southern Africa strive to reach global UNAIDS targets. Study findings support cumulative evidence that HCWs face a variety of feasibility barriers to assisted ICT implementation in the region; further, the study’s uniquely in-depth focus on the experiences of those doing the “assisting” enhances understanding of how these barriers manifest and informs the development of implementation strategies to mitigate these barriers. Maximizing assisted ICT’s potential to increase HIV testing requires equipping HCWs with effective training and support to address and overcome the many feasibility barriers they face in implementation. Findings demonstrate the need for, as well as inform the development of, implementation strategies to mitigate barriers and promote facilitators to feasibility of assisted ICT.

Availability of data and materials

Qualitative data on which this analysis is based, as well as data collection materials and codebooks, are available from the last author upon reasonable request. The interview guide is included as an additional file.

Abbreviations

Acquired Immunodeficiency Syndrome

Antiretroviral Therapy

Health Care Worker

Human Immunodeficiency Virus

HIV Testing Services

Index Case Testing

In-Depth Interview

Intimate Partner Violence

Institutional Review Board

President’s Emergency Plan for HIV/AIDS Relief

People Living With HIV

Joint United Nations Programme on HIV/AIDS

World Health Organization

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Acknowledgements

We are grateful to the Malawian health care workers who shared their experiences through in-depth interviews, as well as to the study team members in Malawi and the United States for their contributions.

Research reported in this publication was funded by the National Institutes of Health (R01 MH124526) with support from the University of North Carolina at Chapel Hill Center for AIDS Research (P30 AI50410) and the Fogarty International Center of the National Institutes of Health (D43 TW010060 and R01 MH115793-04). The funders had no role in trial design, data collection and analysis, decision to publish or preparation of the manuscript.

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Caroline J. Meek

Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA

Caroline J. Meek, Milenka Jean-Baptiste, Jiayu Wang, Clare Barrington, Vivian F. Go & Nora E. Rosenberg

Kamuzu University of Health Sciences, Blantyre, Malawi

Tiwonge E. Mbeya Munkhondya

Baylor College of Medicine Children’s Foundation, Lilongwe, Malawi

Mtisunge Mphande, Tapiwa A. Tembo, Mike Chitani, Dhrutika Vansia, Caroline Kumbuyo, Katherine R. Simon & Maria H. Kim

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Contributions

TAT, KRS, SER, MHK, VFG, and NER contributed to overall study conceptualization, with CJM, CB, and NER leading conceptualization of the analysis presented in this study. Material preparation and data collection were performed by TEMM, MM, TAT, MC, and CK. Analysis was led by CJM with support from MJB and DV. The first draft of the manuscript was written by CJM with consultation from NER, TEMM, MM, TAT, MJB, and DV. JW provided quantitative analysis support for participant characteristics. All authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

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Correspondence to Caroline J. Meek .

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Ethical clearance was provided by the Malawi National Health Science Research Committee (NHSRC; #20/06/2566), University of North Carolina Institution Review Board (UNC IRB; #20–1810) and the Baylor College of Medicine institutional review board (Baylor IRB; H-48800). The procedures used in this study adhere to the tenets of the Declaration of Helsinki. Written informed consent for participation was obtained from all study participants prior to enrollment in the parent study. Interviewers also engaged in informal verbal discussion of consent immediately ahead of in-depth interviews.

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Meek, C.J., Munkhondya, T.E.M., Mphande, M. et al. Examining the feasibility of assisted index case testing for HIV case-finding: a qualitative analysis of barriers and facilitators to implementation in Malawi. BMC Health Serv Res 24 , 606 (2024). https://doi.org/10.1186/s12913-024-10988-z

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Received : 31 August 2023

Accepted : 12 April 2024

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DOI : https://doi.org/10.1186/s12913-024-10988-z

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Exploring variations in the implementation of a health system level policy intervention to improve maternal and child health outcomes in resource limited settings: A qualitative multiple case study from Uganda

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Background Despite growing literature, few studies have explored the implementation of policy interventions to reduce maternal and perinatal mortality in low- and middle-income countries (LMICs). Even fewer studies explicitly articulate the theoretical approaches used to understand contextual influences on policy implementation. This under-use of theory may account for the limited understanding of the variations in implementation processes and outcomes. We share findings from a study exploring how a health system-level policy intervention was implemented to improve maternal and child health outcomes in a resource limited LMIC. Methods Our qualitative multiple case study was informed by the Normalization Process Theory (NPT). It was conducted across eight districts and among ten health facilities in Uganda, with 48 purposively selected participants. These included health care workers located at each of the case sites, policy makers from the Ministry of Health, and from agencies and professional associations. Data were collected using semi-structured, in-depth interviews to understand uptake and use of Uganda’s maternal and perinatal death surveillance and response (MPDSR) policy and were inductively and deductively analyzed using NPT constructs and subconstructs. Results We identified six broad themes that may explain the observed variations in the implementation of the MPDSR policy. These include: 1) perception of the implementation of the policy, 2) leadership of the implementation process, 3) structural arrangements and coordination, 4) extent of management support and adequacy of resources, 5) variations in appraisal and reconfiguration efforts and 6) variations in barriers to implementation of the policy. Conclusion and recommendations The variations in sense making and relational efforts, especially perceptions of the implementation process and leadership capacity, had ripple effects across operational and appraisal efforts. Adopting theoretically informed approaches to assessing the implementation of policy interventions is crucial, especially within resource limited settings.

Competing Interest Statement

The authors have declared no competing interest.

Funding Statement

This study was undertaken with no funding.

Author Declarations

I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained.

The details of the IRB/oversight body that provided approval or exemption for the research described are given below:

Ethics approval for this study was sought from the Health Sciences Research Ethics Board (HSREB, IRB 00000940) Delegated Review of the University of Western Ontario. Additional ethical approval was sought from the School of Medicine Research and Ethics Committee, Makerere University College of Health Sciences (REC REF No. 2018-018), the Uganda National Council for Science and Technology (HS 2393) and the Ugandan Ministry of Health (ADM 130/313/05). Participation in the study was completely voluntary and written informed consent was sought at all times. Study participants were assured of privacy and confidentiality and approved the use of information for improving public health, clinical practices and policy implementation. The manuscript does not include details, images, or videos relating to individual participants.

I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals.

I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance).

I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable.

Data Availability

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

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