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Case Study – Methods, Examples and Guide

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

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

Types of Case Study

Types and Methods of Case Study are as follows:

Single-Case Study

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

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

Multiple-Case Study

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

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

Exploratory Case Study

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

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

Descriptive Case Study

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

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

Instrumental Case Study

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

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

Case Study Data Collection Methods

Here are some common data collection methods for case studies:

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

Observations

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

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

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

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

How to conduct Case Study Research

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

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

Examples of Case Study

Here are some examples of case study research:

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

Application of Case Study

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

Business and Management

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

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

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

Social Sciences

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

Law and Ethics

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

Purpose of Case Study

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

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

Case studies can also serve other purposes, including:

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

Advantages of Case Study Research

There are several advantages of case study research, including:

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

Limitations of Case Study Research

There are several limitations of case study research, including:

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

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• What Is a Case Study? | Definition, Examples & Methods

What Is a Case Study? | Definition, Examples & Methods

Published on May 8, 2019 by Shona McCombes . Revised on November 20, 2023.

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

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

Table of contents

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

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

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

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

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

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

TipIf your research is more practical in nature and aims to simultaneously investigate an issue as you solve it, consider conducting action research instead.

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

Example of an outlying case studyIn the 1960s the town of Roseto, Pennsylvania was discovered to have extremely low rates of heart disease compared to the US average. It became an important case study for understanding previously neglected causes of heart disease.

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

Example of a representative case studyIn the 1920s, two sociologists used Muncie, Indiana as a case study of a typical American city that supposedly exemplified the changing culture of the US at the time.

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

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

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

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

Example of a mixed methods case studyFor a case study of a wind farm development in a rural area, you could collect quantitative data on employment rates and business revenue, collect qualitative data on local people’s perceptions and experiences, and analyze local and national media coverage of the development.

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

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

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

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

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

If you want to know more about statistics , methodology , or research bias , make sure to check out some of our other articles with explanations and examples.

• Normal distribution
• Degrees of freedom
• Null hypothesis
• Discourse analysis
• Control groups
• Mixed methods research
• Non-probability sampling
• Quantitative research
• Ecological validity

Research bias

• Rosenthal effect
• Implicit bias
• Cognitive bias
• Selection bias
• Negativity bias
• Status quo bias

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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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• Knowledge Base
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• Case Study | Definition, Examples & Methods

Case Study | Definition, Examples & Methods

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

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

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

Table of contents

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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What the Case Study Method Really Teaches

• Nitin Nohria

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

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

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

• Nitin Nohria is the George F. Baker Jr. and Distinguished Service University Professor. He served as the 10th dean of Harvard Business School, from 2010 to 2020.

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Understanding Case Study Method in Research: A Comprehensive Guide

Table of Contents

Have you ever wondered how researchers uncover the nuanced layers of individual experiences or the intricate workings of a particular event? One of the keys to unlocking these mysteries lies in the qualitative research focusing on a single subject in its real-life context.">case study method , a research strategy that might seem straightforward at first glance but is rich with complexity and insightful potential. Let’s dive into the world of case studies and discover why they are such a valuable tool in the arsenal of research methods.

What is a Case Study Method?

At its core, the case study method is a form of qualitative research that involves an in-depth, detailed examination of a single subject, such as an individual, group, organization, event, or phenomenon. It’s a method favored when the boundaries between phenomenon and context are not clearly evident, and where multiple sources of data are used to illuminate the case from various perspectives. This method’s strength lies in its ability to provide a comprehensive understanding of the case in its real-life context.

Historical Context and Evolution of Case Studies

Case studies have been around for centuries, with their roots in medical and psychological research. Over time, their application has spread to disciplines like sociology, anthropology, business, and education. The evolution of this method has been marked by a growing appreciation for qualitative data and the rich, contextual insights it can provide, which quantitative methods may overlook.

Characteristics of Case Study Research

What sets the case study method apart are its distinct characteristics:

• Intensive Examination: It provides a deep understanding of the case in question, considering the complexity and uniqueness of each case.
• Contextual Analysis: The researcher studies the case within its real-life context, recognizing that the context can significantly influence the phenomenon.
• Multiple Data Sources: Case studies often utilize various data sources like interviews, observations, documents, and reports, which provide multiple perspectives on the subject.
• Participant’s Perspective: This method often focuses on the perspectives of the participants within the case, giving voice to those directly involved.

Types of Case Studies

There are different types of case studies, each suited for specific research objectives:

• Exploratory: These are conducted before large-scale research projects to help identify questions, select measurement constructs, and develop hypotheses.
• Descriptive: These involve a detailed, in-depth description of the case, without attempting to determine cause and effect.
• Explanatory: These are used to investigate cause-and-effect relationships and understand underlying principles of certain phenomena.
• Intrinsic: This type is focused on the case itself because the case presents an unusual or unique issue.
• Instrumental: Here, the case is secondary to understanding a broader issue or phenomenon.
• Collective: These involve studying a group of cases collectively or comparably to understand a phenomenon, population, or general condition.

The Process of Conducting a Case Study

Conducting a case study involves several well-defined steps:

• Defining Your Case: What or who will you study? Define the case and ensure it aligns with your research objectives.
• Selecting Participants: If studying people, careful selection is crucial to ensure they fit the case criteria and can provide the necessary insights.
• Data Collection: Gather information through various methods like interviews, observations, and reviewing documents.
• Data Analysis: Analyze the collected data to identify patterns, themes, and insights related to your research question.
• Reporting Findings: Present your findings in a way that communicates the complexity and richness of the case study, often through narrative.

Case Studies in Practice: Real-world Examples

Case studies are not just academic exercises; they have practical applications in every field. For instance, in business, they can explore consumer behavior or organizational strategies. In psychology, they can provide detailed insight into individual behaviors or conditions. Education often uses case studies to explore teaching methods or learning difficulties.

Advantages of Case Study Research

While the case study method has its critics, it offers several undeniable advantages:

• Rich, Detailed Data: It captures data too complex for quantitative methods.
• Contextual Insights: It provides a better understanding of the phenomena in its natural setting.
• Contribution to Theory: It can generate and refine theory, offering a foundation for further research.

Limitations and Criticism

However, it’s important to acknowledge the limitations and criticisms:

• Generalizability : Findings from case studies may not be widely generalizable due to the focus on a single case.
• Subjectivity: The researcher’s perspective may influence the study, which requires careful reflection and transparency.
• Time-Consuming: They require a significant amount of time to conduct and analyze properly.

Concluding Thoughts on the Case Study Method

The case study method is a powerful tool that allows researchers to delve into the intricacies of a subject in its real-world environment. While not without its challenges, when executed correctly, the insights garnered can be incredibly valuable, offering depth and context that other methods may miss. Robert K\. Yin ’s advocacy for this method underscores its potential to illuminate and explain contemporary phenomena, making it an indispensable part of the researcher’s toolkit.

Reflecting on the case study method, how do you think its application could change with the advancements in technology and data analytics? Could such a traditional method be enhanced or even replaced in the future?

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Research Methods in Psychology

1 Introduction to Psychological Research – Objectives and Goals, Problems, Hypothesis and Variables

• Nature of Psychological Research
• The Context of Discovery
• Context of Justification
• Characteristics of Psychological Research
• Goals and Objectives of Psychological Research

2 Introduction to Psychological Experiments and Tests

• Independent and Dependent Variables
• Extraneous Variables
• Experimental and Control Groups
• Introduction of Test
• Types of Psychological Test
• Uses of Psychological Tests

3 Steps in Research

• Research Process
• Identification of the Problem
• Review of Literature
• Formulating a Hypothesis
• Identifying Manipulating and Controlling Variables
• Formulating a Research Design
• Constructing Devices for Observation and Measurement
• Sample Selection and Data Collection
• Data Analysis and Interpretation
• Hypothesis Testing
• Drawing Conclusion

4 Types of Research and Methods of Research

• Historical Research
• Descriptive Research
• Correlational Research
• Qualitative Research
• Ex-Post Facto Research
• True Experimental Research
• Quasi-Experimental Research

5 Definition and Description Research Design, Quality of Research Design

• Research Design
• Purpose of Research Design
• Design Selection
• Criteria of Research Design
• Qualities of Research Design

6 Experimental Design (Control Group Design and Two Factor Design)

• Experimental Design
• Control Group Design
• Two Factor Design

7 Survey Design

• Survey Research Designs
• Steps in Survey Design
• Structuring and Designing the Questionnaire
• Interviewing Methodology
• Data Analysis
• Final Report

8 Single Subject Design

• Single Subject Design: Definition and Meaning
• Phases Within Single Subject Design
• Requirements of Single Subject Design
• Characteristics of Single Subject Design
• Types of Single Subject Design
• Advantages of Single Subject Design
• Disadvantages of Single Subject Design

9 Observation Method

• Definition and Meaning of Observation
• Characteristics of Observation
• Types of Observation
• Advantages and Disadvantages of Observation
• Guides for Observation Method

10 Interview and Interviewing

• Definition of Interview
• Types of Interview
• Aspects of Qualitative Research Interviews
• Interview Questions
• Convergent Interviewing as Action Research
• Research Team

11 Questionnaire Method

• Definition and Description of Questionnaires
• Types of Questionnaires
• Purpose of Questionnaire Studies
• Designing Research Questionnaires
• The Methods to Make a Questionnaire Efficient
• The Types of Questionnaire to be Included in the Questionnaire
• Advantages and Disadvantages of Questionnaire
• When to Use a Questionnaire?

12 Case Study

• Definition and Description of Case Study Method
• Historical Account of Case Study Method
• Designing Case Study
• Requirements for Case Studies
• Guideline to Follow in Case Study Method
• Other Important Measures in Case Study Method
• Case Reports

13 Report Writing

• Purpose of a Report
• Writing Style of the Report
• Report Writing – the Do’s and the Don’ts
• Format for Report in Psychology Area
• Major Sections in a Report

14 Review of Literature

• Purposes of Review of Literature
• Sources of Review of Literature
• Types of Literature
• Writing Process of the Review of Literature
• Preparation of Index Card for Reviewing and Abstracting

15 Methodology

• Definition and Purpose of Methodology
• Participants (Sample)
• Apparatus and Materials

16 Result, Analysis and Discussion of the Data

• Definition and Description of Results
• Statistical Presentation
• Tables and Figures

17 Summary and Conclusion

• Summary Definition and Description
• Guidelines for Writing a Summary
• Writing the Summary and Choosing Words
• A Process for Paraphrasing and Summarising
• Summary of a Report
• Writing Conclusions

18 References in Research Report

• Reference List (the Format)
• References (Process of Writing)
• Reference List and Print Sources
• Electronic Sources
• Book on CD Tape and Movie
• Reference Specifications
• General Guidelines to Write References

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What is the Case Study Method?

Overview Dropdown up

Overview dropdown down, celebrating 100 years of the case method at hbs.

The 2021-2022 academic year marks the 100-year anniversary of the introduction of the case method at Harvard Business School. Today, the HBS case method is employed in the HBS MBA program, in Executive Education programs, and in dozens of other business schools around the world. As Dean Srikant Datar's says, the case method has withstood the test of time.

Case Discussion Preparation Details Expand All Collapse All

In self-reflection in self-reflection dropdown down, in a small group setting in a small group setting dropdown down, in the classroom in the classroom dropdown down, beyond the classroom beyond the classroom dropdown down, how the case method creates value dropdown up, how the case method creates value dropdown down, in self-reflection, in a small group setting, in the classroom, beyond the classroom.

How Cases Unfold In the Classroom

How cases unfold in the classroom dropdown up, how cases unfold in the classroom dropdown down, preparation guidelines expand all collapse all, read the professor's assignment or discussion questions read the professor's assignment or discussion questions dropdown down, read the first few paragraphs and then skim the case read the first few paragraphs and then skim the case dropdown down, reread the case, underline text, and make margin notes reread the case, underline text, and make margin notes dropdown down, note the key problems on a pad of paper and go through the case again note the key problems on a pad of paper and go through the case again dropdown down, how to prepare for case discussions dropdown up, how to prepare for case discussions dropdown down, read the professor's assignment or discussion questions, read the first few paragraphs and then skim the case, reread the case, underline text, and make margin notes, note the key problems on a pad of paper and go through the case again, case study best practices expand all collapse all, prepare prepare dropdown down, discuss discuss dropdown down, participate participate dropdown down, relate relate dropdown down, apply apply dropdown down, note note dropdown down, understand understand dropdown down, case study best practices dropdown up, case study best practices dropdown down, participate, what can i expect on the first day dropdown down.

Most programs begin with registration, followed by an opening session and a dinner. If your travel plans necessitate late arrival, please be sure to notify us so that alternate registration arrangements can be made for you. Please note the following about registration:

HBS campus programs – Registration takes place in the Chao Center.

India programs – Registration takes place outside the classroom.

Other off-campus programs – Registration takes place in the designated facility.

What happens in class if nobody talks? Dropdown down

Professors are here to push everyone to learn, but not to embarrass anyone. If the class is quiet, they'll often ask a participant with experience in the industry in which the case is set to speak first. This is done well in advance so that person can come to class prepared to share. Trust the process. The more open you are, the more willing you’ll be to engage, and the more alive the classroom will become.

Does everyone take part in "role-playing"? Dropdown down

Professors often encourage participants to take opposing sides and then debate the issues, often taking the perspective of the case protagonists or key decision makers in the case.

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What Is a Case Study?

Weighing the pros and cons of this method of research

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

Cara Lustik is a fact-checker and copywriter.

Verywell / Colleen Tighe

• Pros and Cons

What Types of Case Studies Are Out There?

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

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

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

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

At a Glance

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

What Are the Benefits and Limitations of Case Studies?

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

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

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

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

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

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

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

Case Study Examples

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

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

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

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

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

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

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

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

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

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

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

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

Section 1: A Case History

This section will have the following structure and content:

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

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

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

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

Section 2: Treatment Plan

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

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

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

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

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

Need More Tips?

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

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

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

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

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

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

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

Case Study Research Method in Psychology

Saul Mcleod, PhD

Editor-in-Chief for Simply Psychology

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

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

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Olivia Guy-Evans, MSc

Associate Editor for Simply Psychology

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On This Page:

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

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

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

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

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

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

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

 Famous Case Studies

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

Clinical Case Studies

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

Child Psychology Case Studies

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

Types of Case Studies

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

Where Do You Find Data for a Case Study?

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

1. Primary sources

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

2. Secondary sources

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

3. Archival records

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

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

4. Organizational records

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

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

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

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

How do I Write a Case Study in Psychology?

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

1. Introduction

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

2. Case Presentation

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

3. Management and Outcome

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

4. Discussion

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

5. Additional Items

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

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

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

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

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

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

Limitations

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Further Information

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

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• Open access
• Published: 27 June 2011

The case study approach

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

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

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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.

Peer Review reports

Introduction

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

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

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

What is a case study?

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

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

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

What are case studies used for?

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

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

How are case studies conducted?

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

Defining the case

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

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

Selecting the case(s)

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

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

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

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

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

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

Collecting the data

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

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

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

Analysing, interpreting and reporting case studies

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

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

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

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

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

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

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

Conclusions

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

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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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5 Benefits of Learning Through the Case Study Method

• 28 Nov 2023

While several factors make HBS Online unique —including a global Community and real-world outcomes —active learning through the case study method rises to the top.

In a 2023 City Square Associates survey, 74 percent of HBS Online learners who also took a course from another provider said HBS Online’s case method and real-world examples were better by comparison.

Here’s a primer on the case method, five benefits you could gain, and how to experience it for yourself.

Access your free e-book today.

What Is the Harvard Business School Case Study Method?

The case study method , or case method , is a learning technique in which you’re presented with a real-world business challenge and asked how you’d solve it. After working through it yourself and with peers, you’re told how the scenario played out.

HBS pioneered the case method in 1922. Shortly before, in 1921, the first case was written.

“How do you go into an ambiguous situation and get to the bottom of it?” says HBS Professor Jan Rivkin, former senior associate dean and chair of HBS's master of business administration (MBA) program, in a video about the case method . “That skill—the skill of figuring out a course of inquiry to choose a course of action—that skill is as relevant today as it was in 1921.”

Originally developed for the in-person MBA classroom, HBS Online adapted the case method into an engaging, interactive online learning experience in 2014.

In HBS Online courses , you learn about each case from the business professional who experienced it. After reviewing their videos, you’re prompted to take their perspective and explain how you’d handle their situation.

You then get to read peers’ responses, “star” them, and comment to further the discussion. Afterward, you learn how the professional handled it and their key takeaways.

HBS Online’s adaptation of the case method incorporates the famed HBS “cold call,” in which you’re called on at random to make a decision without time to prepare.

“Learning came to life!” said Sheneka Balogun , chief administration officer and chief of staff at LeMoyne-Owen College, of her experience taking the Credential of Readiness (CORe) program . “The videos from the professors, the interactive cold calls where you were randomly selected to participate, and the case studies that enhanced and often captured the essence of objectives and learning goals were all embedded in each module. This made learning fun, engaging, and student-friendly.”

If you’re considering taking a course that leverages the case study method, here are five benefits you could experience.

5 Benefits of Learning Through Case Studies

1. take new perspectives.

The case method prompts you to consider a scenario from another person’s perspective. To work through the situation and come up with a solution, you must consider their circumstances, limitations, risk tolerance, stakeholders, resources, and potential consequences to assess how to respond.

Taking on new perspectives not only can help you navigate your own challenges but also others’. Putting yourself in someone else’s situation to understand their motivations and needs can go a long way when collaborating with stakeholders.

2. Hone Your Decision-Making Skills

Another skill you can build is the ability to make decisions effectively . The case study method forces you to use limited information to decide how to handle a problem—just like in the real world.

Throughout your career, you’ll need to make difficult decisions with incomplete or imperfect information—and sometimes, you won’t feel qualified to do so. Learning through the case method allows you to practice this skill in a low-stakes environment. When facing a real challenge, you’ll be better prepared to think quickly, collaborate with others, and present and defend your solution.

3. Become More Open-Minded

As you collaborate with peers on responses, it becomes clear that not everyone solves problems the same way. Exposing yourself to various approaches and perspectives can help you become a more open-minded professional.

When you’re part of a diverse group of learners from around the world, your experiences, cultures, and backgrounds contribute to a range of opinions on each case.

On the HBS Online course platform, you’re prompted to view and comment on others’ responses, and discussion is encouraged. This practice of considering others’ perspectives can make you more receptive in your career.

“You’d be surprised at how much you can learn from your peers,” said Ratnaditya Jonnalagadda , a software engineer who took CORe.

In addition to interacting with peers in the course platform, Jonnalagadda was part of the HBS Online Community , where he networked with other professionals and continued discussions sparked by course content.

“You get to understand your peers better, and students share examples of businesses implementing a concept from a module you just learned,” Jonnalagadda said. “It’s a very good way to cement the concepts in one's mind.”

4. Enhance Your Curiosity

One byproduct of taking on different perspectives is that it enables you to picture yourself in various roles, industries, and business functions.

“Each case offers an opportunity for students to see what resonates with them, what excites them, what bores them, which role they could imagine inhabiting in their careers,” says former HBS Dean Nitin Nohria in the Harvard Business Review . “Cases stimulate curiosity about the range of opportunities in the world and the many ways that students can make a difference as leaders.”

Through the case method, you can “try on” roles you may not have considered and feel more prepared to change or advance your career .

5. Build Your Self-Confidence

Finally, learning through the case study method can build your confidence. Each time you assume a business leader’s perspective, aim to solve a new challenge, and express and defend your opinions and decisions to peers, you prepare to do the same in your career.

According to a 2022 City Square Associates survey , 84 percent of HBS Online learners report feeling more confident making business decisions after taking a course.

“Self-confidence is difficult to teach or coach, but the case study method seems to instill it in people,” Nohria says in the Harvard Business Review . “There may well be other ways of learning these meta-skills, such as the repeated experience gained through practice or guidance from a gifted coach. However, under the direction of a masterful teacher, the case method can engage students and help them develop powerful meta-skills like no other form of teaching.”

How to Experience the Case Study Method

If the case method seems like a good fit for your learning style, experience it for yourself by taking an HBS Online course. Offerings span seven subject areas, including:

• Business essentials
• Leadership and management
• Entrepreneurship and innovation
• Finance and accounting
• Business in society

No matter which course or credential program you choose, you’ll examine case studies from real business professionals, work through their challenges alongside peers, and gain valuable insights to apply to your career.

Are you interested in discovering how HBS Online can help advance your career? Explore our course catalog and download our free guide —complete with interactive workbook sections—to determine if online learning is right for you and which course to take.

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Methodology or method? A critical review of qualitative case study reports

Despite on-going debate about credibility, and reported limitations in comparison to other approaches, case study is an increasingly popular approach among qualitative researchers. We critically analysed the methodological descriptions of published case studies. Three high-impact qualitative methods journals were searched to locate case studies published in the past 5 years; 34 were selected for analysis. Articles were categorized as health and health services ( n= 12), social sciences and anthropology ( n= 7), or methods ( n= 15) case studies. The articles were reviewed using an adapted version of established criteria to determine whether adequate methodological justification was present, and if study aims, methods, and reported findings were consistent with a qualitative case study approach. Findings were grouped into five themes outlining key methodological issues: case study methodology or method, case of something particular and case selection, contextually bound case study, researcher and case interactions and triangulation, and study design inconsistent with methodology reported. Improved reporting of case studies by qualitative researchers will advance the methodology for the benefit of researchers and practitioners.

Case study research is an increasingly popular approach among qualitative researchers (Thomas, 2011 ). Several prominent authors have contributed to methodological developments, which has increased the popularity of case study approaches across disciplines (Creswell, 2013b ; Denzin & Lincoln, 2011b ; Merriam, 2009 ; Ragin & Becker, 1992 ; Stake, 1995 ; Yin, 2009 ). Current qualitative case study approaches are shaped by paradigm, study design, and selection of methods, and, as a result, case studies in the published literature vary. Differences between published case studies can make it difficult for researchers to define and understand case study as a methodology.

Experienced qualitative researchers have identified case study research as a stand-alone qualitative approach (Denzin & Lincoln, 2011b ). Case study research has a level of flexibility that is not readily offered by other qualitative approaches such as grounded theory or phenomenology. Case studies are designed to suit the case and research question and published case studies demonstrate wide diversity in study design. There are two popular case study approaches in qualitative research. The first, proposed by Stake ( 1995 ) and Merriam ( 2009 ), is situated in a social constructivist paradigm, whereas the second, by Yin ( 2012 ), Flyvbjerg ( 2011 ), and Eisenhardt ( 1989 ), approaches case study from a post-positivist viewpoint. Scholarship from both schools of inquiry has contributed to the popularity of case study and development of theoretical frameworks and principles that characterize the methodology.

The diversity of case studies reported in the published literature, and on-going debates about credibility and the use of case study in qualitative research practice, suggests that differences in perspectives on case study methodology may prevent researchers from developing a mutual understanding of practice and rigour. In addition, discussion about case study limitations has led some authors to query whether case study is indeed a methodology (Luck, Jackson, & Usher, 2006 ; Meyer, 2001 ; Thomas, 2010 ; Tight, 2010 ). Methodological discussion of qualitative case study research is timely, and a review is required to analyse and understand how this methodology is applied in the qualitative research literature. The aims of this study were to review methodological descriptions of published qualitative case studies, to review how the case study methodological approach was applied, and to identify issues that need to be addressed by researchers, editors, and reviewers. An outline of the current definitions of case study and an overview of the issues proposed in the qualitative methodological literature are provided to set the scene for the review.

Definitions of qualitative case study research

Case study research is an investigation and analysis of a single or collective case, intended to capture the complexity of the object of study (Stake, 1995 ). Qualitative case study research, as described by Stake ( 1995 ), draws together “naturalistic, holistic, ethnographic, phenomenological, and biographic research methods” in a bricoleur design, or in his words, “a palette of methods” (Stake, 1995 , pp. xi–xii). Case study methodology maintains deep connections to core values and intentions and is “particularistic, descriptive and heuristic” (Merriam, 2009 , p. 46).

As a study design, case study is defined by interest in individual cases rather than the methods of inquiry used. The selection of methods is informed by researcher and case intuition and makes use of naturally occurring sources of knowledge, such as people or observations of interactions that occur in the physical space (Stake, 1998 ). Thomas ( 2011 ) suggested that “analytical eclecticism” is a defining factor (p. 512). Multiple data collection and analysis methods are adopted to further develop and understand the case, shaped by context and emergent data (Stake, 1995 ). This qualitative approach “explores a real-life, contemporary bounded system (a case ) or multiple bounded systems (cases) over time, through detailed, in-depth data collection involving multiple sources of information … and reports a case description and case themes ” (Creswell, 2013b , p. 97). Case study research has been defined by the unit of analysis, the process of study, and the outcome or end product, all essentially the case (Merriam, 2009 ).

The case is an object to be studied for an identified reason that is peculiar or particular. Classification of the case and case selection procedures informs development of the study design and clarifies the research question. Stake ( 1995 ) proposed three types of cases and study design frameworks. These include the intrinsic case, the instrumental case, and the collective instrumental case. The intrinsic case is used to understand the particulars of a single case, rather than what it represents. An instrumental case study provides insight on an issue or is used to refine theory. The case is selected to advance understanding of the object of interest. A collective refers to an instrumental case which is studied as multiple, nested cases, observed in unison, parallel, or sequential order. More than one case can be simultaneously studied; however, each case study is a concentrated, single inquiry, studied holistically in its own entirety (Stake, 1995 , 1998 ).

Researchers who use case study are urged to seek out what is common and what is particular about the case. This involves careful and in-depth consideration of the nature of the case, historical background, physical setting, and other institutional and political contextual factors (Stake, 1998 ). An interpretive or social constructivist approach to qualitative case study research supports a transactional method of inquiry, where the researcher has a personal interaction with the case. The case is developed in a relationship between the researcher and informants, and presented to engage the reader, inviting them to join in this interaction and in case discovery (Stake, 1995 ). A postpositivist approach to case study involves developing a clear case study protocol with careful consideration of validity and potential bias, which might involve an exploratory or pilot phase, and ensures that all elements of the case are measured and adequately described (Yin, 2009 , 2012 ).

Current methodological issues in qualitative case study research

The future of qualitative research will be influenced and constructed by the way research is conducted, and by what is reviewed and published in academic journals (Morse, 2011 ). If case study research is to further develop as a principal qualitative methodological approach, and make a valued contribution to the field of qualitative inquiry, issues related to methodological credibility must be considered. Researchers are required to demonstrate rigour through adequate descriptions of methodological foundations. Case studies published without sufficient detail for the reader to understand the study design, and without rationale for key methodological decisions, may lead to research being interpreted as lacking in quality or credibility (Hallberg, 2013 ; Morse, 2011 ).

There is a level of artistic license that is embraced by qualitative researchers and distinguishes practice, which nurtures creativity, innovation, and reflexivity (Denzin & Lincoln, 2011b ; Morse, 2009 ). Qualitative research is “inherently multimethod” (Denzin & Lincoln, 2011a , p. 5); however, with this creative freedom, it is important for researchers to provide adequate description for methodological justification (Meyer, 2001 ). This includes paradigm and theoretical perspectives that have influenced study design. Without adequate description, study design might not be understood by the reader, and can appear to be dishonest or inaccurate. Reviewers and readers might be confused by the inconsistent or inappropriate terms used to describe case study research approach and methods, and be distracted from important study findings (Sandelowski, 2000 ). This issue extends beyond case study research, and others have noted inconsistencies in reporting of methodology and method by qualitative researchers. Sandelowski ( 2000 , 2010 ) argued for accurate identification of qualitative description as a research approach. She recommended that the selected methodology should be harmonious with the study design, and be reflected in methods and analysis techniques. Similarly, Webb and Kevern ( 2000 ) uncovered inconsistencies in qualitative nursing research with focus group methods, recommending that methodological procedures must cite seminal authors and be applied with respect to the selected theoretical framework. Incorrect labelling using case study might stem from the flexibility in case study design and non-directional character relative to other approaches (Rosenberg & Yates, 2007 ). Methodological integrity is required in design of qualitative studies, including case study, to ensure study rigour and to enhance credibility of the field (Morse, 2011 ).

Case study has been unnecessarily devalued by comparisons with statistical methods (Eisenhardt, 1989 ; Flyvbjerg, 2006 , 2011 ; Jensen & Rodgers, 2001 ; Piekkari, Welch, & Paavilainen, 2009 ; Tight, 2010 ; Yin, 1999 ). It is reputed to be the “the weak sibling” in comparison to other, more rigorous, approaches (Yin, 2009 , p. xiii). Case study is not an inherently comparative approach to research. The objective is not statistical research, and the aim is not to produce outcomes that are generalizable to all populations (Thomas, 2011 ). Comparisons between case study and statistical research do little to advance this qualitative approach, and fail to recognize its inherent value, which can be better understood from the interpretive or social constructionist viewpoint of other authors (Merriam, 2009 ; Stake, 1995 ). Building on discussions relating to “fuzzy” (Bassey, 2001 ), or naturalistic generalizations (Stake, 1978 ), or transference of concepts and theories (Ayres, Kavanaugh, & Knafl, 2003 ; Morse et al., 2011 ) would have more relevance.

Case study research has been used as a catch-all design to justify or add weight to fundamental qualitative descriptive studies that do not fit with other traditional frameworks (Merriam, 2009 ). A case study has been a “convenient label for our research—when we ‘can't think of anything ‘better”—in an attempt to give it [qualitative methodology] some added respectability” (Tight, 2010 , p. 337). Qualitative case study research is a pliable approach (Merriam, 2009 ; Meyer, 2001 ; Stake, 1995 ), and has been likened to a “curious methodological limbo” (Gerring, 2004 , p. 341) or “paradigmatic bridge” (Luck et al., 2006 , p. 104), that is on the borderline between postpositivist and constructionist interpretations. This has resulted in inconsistency in application, which indicates that flexibility comes with limitations (Meyer, 2001 ), and the open nature of case study research might be off-putting to novice researchers (Thomas, 2011 ). The development of a well-(in)formed theoretical framework to guide a case study should improve consistency, rigour, and trust in studies published in qualitative research journals (Meyer, 2001 ).

Assessment of rigour

The purpose of this study was to analyse the methodological descriptions of case studies published in qualitative methods journals. To do this we needed to develop a suitable framework, which used existing, established criteria for appraising qualitative case study research rigour (Creswell, 2013b ; Merriam, 2009 ; Stake, 1995 ). A number of qualitative authors have developed concepts and criteria that are used to determine whether a study is rigorous (Denzin & Lincoln, 2011b ; Lincoln, 1995 ; Sandelowski & Barroso, 2002 ). The criteria proposed by Stake ( 1995 ) provide a framework for readers and reviewers to make judgements regarding case study quality, and identify key characteristics essential for good methodological rigour. Although each of the factors listed in Stake's criteria could enhance the quality of a qualitative research report, in Table I we present an adapted criteria used in this study, which integrates more recent work by Merriam ( 2009 ) and Creswell ( 2013b ). Stake's ( 1995 ) original criteria were separated into two categories. The first list of general criteria is “relevant for all qualitative research.” The second list, “high relevance to qualitative case study research,” was the criteria that we decided had higher relevance to case study research. This second list was the main criteria used to assess the methodological descriptions of the case studies reviewed. The complete table has been preserved so that the reader can determine how the original criteria were adapted.

Framework for assessing quality in qualitative case study research.

Adapted from Stake ( 1995 , p. 131).

Study design

The critical review method described by Grant and Booth ( 2009 ) was used, which is appropriate for the assessment of research quality, and is used for literature analysis to inform research and practice. This type of review goes beyond the mapping and description of scoping or rapid reviews, to include “analysis and conceptual innovation” (Grant & Booth, 2009 , p. 93). A critical review is used to develop existing, or produce new, hypotheses or models. This is different to systematic reviews that answer clinical questions. It is used to evaluate existing research and competing ideas, to provide a “launch pad” for conceptual development and “subsequent testing” (Grant & Booth, 2009 , p. 93).

Qualitative methods journals were located by a search of the 2011 ISI Journal Citation Reports in Social Science, via the database Web of Knowledge (see m.webofknowledge.com). No “qualitative research methods” category existed in the citation reports; therefore, a search of all categories was performed using the term “qualitative.” In Table II , we present the qualitative methods journals located, ranked by impact factor. The highest ranked journals were selected for searching. We acknowledge that the impact factor ranking system might not be the best measure of journal quality (Cheek, Garnham, & Quan, 2006 ); however, this was the most appropriate and accessible method available.

International Journal of Qualitative Studies on Health and Well-being.

Search strategy

In March 2013, searches of the journals, Qualitative Health Research , Qualitative Research , and Qualitative Inquiry were completed to retrieve studies with “case study” in the abstract field. The search was limited to the past 5 years (1 January 2008 to 1 March 2013). The objective was to locate published qualitative case studies suitable for assessment using the adapted criterion. Viewpoints, commentaries, and other article types were excluded from review. Title and abstracts of the 45 retrieved articles were read by the first author, who identified 34 empirical case studies for review. All authors reviewed the 34 studies to confirm selection and categorization. In Table III , we present the 34 case studies grouped by journal, and categorized by research topic, including health sciences, social sciences and anthropology, and methods research. There was a discrepancy in categorization of one article on pedagogy and a new teaching method published in Qualitative Inquiry (Jorrín-Abellán, Rubia-Avi, Anguita-Martínez, Gómez-Sánchez, & Martínez-Mones, 2008 ). Consensus was to allocate to the methods category.

Outcomes of search of qualitative methods journals.

In Table III , the number of studies located, and final numbers selected for review have been reported. Qualitative Health Research published the most empirical case studies ( n= 16). In the health category, there were 12 case studies of health conditions, health services, and health policy issues, all published in Qualitative Health Research . Seven case studies were categorized as social sciences and anthropology research, which combined case study with biography and ethnography methodologies. All three journals published case studies on methods research to illustrate a data collection or analysis technique, methodological procedure, or related issue.

The methodological descriptions of 34 case studies were critically reviewed using the adapted criteria. All articles reviewed contained a description of study methods; however, the length, amount of detail, and position of the description in the article varied. Few studies provided an accurate description and rationale for using a qualitative case study approach. In the 34 case studies reviewed, three described a theoretical framework informed by Stake ( 1995 ), two by Yin ( 2009 ), and three provided a mixed framework informed by various authors, which might have included both Yin and Stake. Few studies described their case study design, or included a rationale that explained why they excluded or added further procedures, and whether this was to enhance the study design, or to better suit the research question. In 26 of the studies no reference was provided to principal case study authors. From reviewing the description of methods, few authors provided a description or justification of case study methodology that demonstrated how their study was informed by the methodological literature that exists on this approach.

The methodological descriptions of each study were reviewed using the adapted criteria, and the following issues were identified: case study methodology or method; case of something particular and case selection; contextually bound case study; researcher and case interactions and triangulation; and, study design inconsistent with methodology. An outline of how the issues were developed from the critical review is provided, followed by a discussion of how these relate to the current methodological literature.

Case study methodology or method

A third of the case studies reviewed appeared to use a case report method, not case study methodology as described by principal authors (Creswell, 2013b ; Merriam, 2009 ; Stake, 1995 ; Yin, 2009 ). Case studies were identified as a case report because of missing methodological detail and by review of the study aims and purpose. These reports presented data for small samples of no more than three people, places or phenomenon. Four studies, or “case reports” were single cases selected retrospectively from larger studies (Bronken, Kirkevold, Martinsen, & Kvigne, 2012 ; Coltart & Henwood, 2012 ; Hooghe, Neimeyer, & Rober, 2012 ; Roscigno et al., 2012 ). Case reports were not a case of something, instead were a case demonstration or an example presented in a report. These reports presented outcomes, and reported on how the case could be generalized. Descriptions focussed on the phenomena, rather than the case itself, and did not appear to study the case in its entirety.

Case reports had minimal in-text references to case study methodology, and were informed by other qualitative traditions or secondary sources (Adamson & Holloway, 2012 ; Buzzanell & D'Enbeau, 2009 ; Nagar-Ron & Motzafi-Haller, 2011 ). This does not suggest that case study methodology cannot be multimethod, however, methodology should be consistent in design, be clearly described (Meyer, 2001 ; Stake, 1995 ), and maintain focus on the case (Creswell, 2013b ).

To demonstrate how case reports were identified, three examples are provided. The first, Yeh ( 2013 ) described their study as, “the examination of the emergence of vegetarianism in Victorian England serves as a case study to reveal the relationships between boundaries and entities” (p. 306). The findings were a historical case report, which resulted from an ethnographic study of vegetarianism. Cunsolo Willox, Harper, Edge, ‘My Word’: Storytelling and Digital Media Lab, and Rigolet Inuit Community Government (2013) used “a case study that illustrates the usage of digital storytelling within an Inuit community” (p. 130). This case study reported how digital storytelling can be used with indigenous communities as a participatory method to illuminate the benefits of this method for other studies. This “case study was conducted in the Inuit community” but did not include the Inuit community in case analysis (Cunsolo Willox et al., 2013 , p. 130). Bronken et al. ( 2012 ) provided a single case report to demonstrate issues observed in a larger clinical study of aphasia and stroke, without adequate case description or analysis.

Case study of something particular and case selection

Case selection is a precursor to case analysis, which needs to be presented as a convincing argument (Merriam, 2009 ). Descriptions of the case were often not adequate to ascertain why the case was selected, or whether it was a particular exemplar or outlier (Thomas, 2011 ). In a number of case studies in the health and social science categories, it was not explicit whether the case was of something particular, or peculiar to their discipline or field (Adamson & Holloway, 2012 ; Bronken et al., 2012 ; Colón-Emeric et al., 2010 ; Jackson, Botelho, Welch, Joseph, & Tennstedt, 2012 ; Mawn et al., 2010 ; Snyder-Young, 2011 ). There were exceptions in the methods category ( Table III ), where cases were selected by researchers to report on a new or innovative method. The cases emerged through heuristic study, and were reported to be particular, relative to the existing methods literature (Ajodhia-Andrews & Berman, 2009 ; Buckley & Waring, 2013 ; Cunsolo Willox et al., 2013 ; De Haene, Grietens, & Verschueren, 2010 ; Gratton & O'Donnell, 2011 ; Sumsion, 2013 ; Wimpenny & Savin-Baden, 2012 ).

Case selection processes were sometimes insufficient to understand why the case was selected from the global population of cases, or what study of this case would contribute to knowledge as compared with other possible cases (Adamson & Holloway, 2012 ; Bronken et al., 2012 ; Colón-Emeric et al., 2010 ; Jackson et al., 2012 ; Mawn et al., 2010 ). In two studies, local cases were selected (Barone, 2010 ; Fourie & Theron, 2012 ) because the researcher was familiar with and had access to the case. Possible limitations of a convenience sample were not acknowledged. Purposeful sampling was used to recruit participants within the case of one study, but not of the case itself (Gallagher et al., 2013 ). Random sampling was completed for case selection in two studies (Colón-Emeric et al., 2010 ; Jackson et al., 2012 ), which has limited meaning in interpretive qualitative research.

To demonstrate how researchers provided a good justification for the selection of case study approaches, four examples are provided. The first, cases of residential care homes, were selected because of reported occurrences of mistreatment, which included residents being locked in rooms at night (Rytterström, Unosson, & Arman, 2013 ). Roscigno et al. ( 2012 ) selected cases of parents who were admitted for early hospitalization in neonatal intensive care with a threatened preterm delivery before 26 weeks. Hooghe et al. ( 2012 ) used random sampling to select 20 couples that had experienced the death of a child; however, the case study was of one couple and a particular metaphor described only by them. The final example, Coltart and Henwood ( 2012 ), provided a detailed account of how they selected two cases from a sample of 46 fathers based on personal characteristics and beliefs. They described how the analysis of the two cases would contribute to their larger study on first time fathers and parenting.

Contextually bound case study

The limits or boundaries of the case are a defining factor of case study methodology (Merriam, 2009 ; Ragin & Becker, 1992 ; Stake, 1995 ; Yin, 2009 ). Adequate contextual description is required to understand the setting or context in which the case is revealed. In the health category, case studies were used to illustrate a clinical phenomenon or issue such as compliance and health behaviour (Colón-Emeric et al., 2010 ; D'Enbeau, Buzzanell, & Duckworth, 2010 ; Gallagher et al., 2013 ; Hooghe et al., 2012 ; Jackson et al., 2012 ; Roscigno et al., 2012 ). In these case studies, contextual boundaries, such as physical and institutional descriptions, were not sufficient to understand the case as a holistic system, for example, the general practitioner (GP) clinic in Gallagher et al. ( 2013 ), or the nursing home in Colón-Emeric et al. ( 2010 ). Similarly, in the social science and methods categories, attention was paid to some components of the case context, but not others, missing important information required to understand the case as a holistic system (Alexander, Moreira, & Kumar, 2012 ; Buzzanell & D'Enbeau, 2009 ; Nairn & Panelli, 2009 ; Wimpenny & Savin-Baden, 2012 ).

In two studies, vicarious experience or vignettes (Nairn & Panelli, 2009 ) and images (Jorrín-Abellán et al., 2008 ) were effective to support description of context, and might have been a useful addition for other case studies. Missing contextual boundaries suggests that the case might not be adequately defined. Additional information, such as the physical, institutional, political, and community context, would improve understanding of the case (Stake, 1998 ). In Boxes 1 and 2 , we present brief synopses of two studies that were reviewed, which demonstrated a well bounded case. In Box 1 , Ledderer ( 2011 ) used a qualitative case study design informed by Stake's tradition. In Box 2 , Gillard, Witt, and Watts ( 2011 ) were informed by Yin's tradition. By providing a brief outline of the case studies in Boxes 1 and 2 , we demonstrate how effective case boundaries can be constructed and reported, which may be of particular interest to prospective case study researchers.

Article synopsis of case study research using Stake's tradition

Ledderer ( 2011 ) used a qualitative case study research design, informed by modern ethnography. The study is bounded to 10 general practice clinics in Denmark, who had received federal funding to implement preventative care services based on a Motivational Interviewing intervention. The researcher question focussed on “why is it so difficult to create change in medical practice?” (Ledderer, 2011 , p. 27). The study context was adequately described, providing detail on the general practitioner (GP) clinics and relevant political and economic influences. Methodological decisions are described in first person narrative, providing insight on researcher perspectives and interaction with the case. Forty-four interviews were conducted, which focussed on how GPs conducted consultations, and the form, nature and content, rather than asking their opinion or experience (Ledderer, 2011 , p. 30). The duration and intensity of researcher immersion in the case enhanced depth of description and trustworthiness of study findings. Analysis was consistent with Stake's tradition, and the researcher provided examples of inquiry techniques used to challenge assumptions about emerging themes. Several other seminal qualitative works were cited. The themes and typology constructed are rich in narrative data and storytelling by clinic staff, demonstrating individual clinic experiences as well as shared meanings and understandings about changing from a biomedical to psychological approach to preventative health intervention. Conclusions make note of social and cultural meanings and lessons learned, which might not have been uncovered using a different methodology.

Article synopsis of case study research using Yin's tradition

Gillard et al. ( 2011 ) study of camps for adolescents living with HIV/AIDs provided a good example of Yin's interpretive case study approach. The context of the case is bounded by the three summer camps of which the researchers had prior professional involvement. A case study protocol was developed that used multiple methods to gather information at three data collection points coinciding with three youth camps (Teen Forum, Discover Camp, and Camp Strong). Gillard and colleagues followed Yin's ( 2009 ) principles, using a consistent data protocol that enhanced cross-case analysis. Data described the young people, the camp physical environment, camp schedule, objectives and outcomes, and the staff of three youth camps. The findings provided a detailed description of the context, with less detail of individual participants, including insight into researcher's interpretations and methodological decisions throughout the data collection and analysis process. Findings provided the reader with a sense of “being there,” and are discovered through constant comparison of the case with the research issues; the case is the unit of analysis. There is evidence of researcher immersion in the case, and Gillard reports spending significant time in the field in a naturalistic and integrated youth mentor role.

This case study is not intended to have a significant impact on broader health policy, although does have implications for health professionals working with adolescents. Study conclusions will inform future camps for young people with chronic disease, and practitioners are able to compare similarities between this case and their own practice (for knowledge translation). No limitations of this article were reported. Limitations related to publication of this case study were that it was 20 pages long and used three tables to provide sufficient description of the camp and program components, and relationships with the research issue.

Researcher and case interactions and triangulation

Researcher and case interactions and transactions are a defining feature of case study methodology (Stake, 1995 ). Narrative stories, vignettes, and thick description are used to provoke vicarious experience and a sense of being there with the researcher in their interaction with the case. Few of the case studies reviewed provided details of the researcher's relationship with the case, researcher–case interactions, and how these influenced the development of the case study (Buzzanell & D'Enbeau, 2009 ; D'Enbeau et al., 2010 ; Gallagher et al., 2013 ; Gillard et al., 2011 ; Ledderer, 2011 ; Nagar-Ron & Motzafi-Haller, 2011 ). The role and position of the researcher needed to be self-examined and understood by readers, to understand how this influenced interactions with participants, and to determine what triangulation is needed (Merriam, 2009 ; Stake, 1995 ).

Gillard et al. ( 2011 ) provided a good example of triangulation, comparing data sources in a table (p. 1513). Triangulation of sources was used to reveal as much depth as possible in the study by Nagar-Ron and Motzafi-Haller ( 2011 ), while also enhancing confirmation validity. There were several case studies that would have benefited from improved range and use of data sources, and descriptions of researcher–case interactions (Ajodhia-Andrews & Berman, 2009 ; Bronken et al., 2012 ; Fincham, Scourfield, & Langer, 2008 ; Fourie & Theron, 2012 ; Hooghe et al., 2012 ; Snyder-Young, 2011 ; Yeh, 2013 ).

Study design inconsistent with methodology

Good, rigorous case studies require a strong methodological justification (Meyer, 2001 ) and a logical and coherent argument that defines paradigm, methodological position, and selection of study methods (Denzin & Lincoln, 2011b ). Methodological justification was insufficient in several of the studies reviewed (Barone, 2010 ; Bronken et al., 2012 ; Hooghe et al., 2012 ; Mawn et al., 2010 ; Roscigno et al., 2012 ; Yeh, 2013 ). This was judged by the absence, or inadequate or inconsistent reference to case study methodology in-text.

In six studies, the methodological justification provided did not relate to case study. There were common issues identified. Secondary sources were used as primary methodological references indicating that study design might not have been theoretically sound (Colón-Emeric et al., 2010 ; Coltart & Henwood, 2012 ; Roscigno et al., 2012 ; Snyder-Young, 2011 ). Authors and sources cited in methodological descriptions were inconsistent with the actual study design and practices used (Fourie & Theron, 2012 ; Hooghe et al., 2012 ; Jorrín-Abellán et al., 2008 ; Mawn et al., 2010 ; Rytterström et al., 2013 ; Wimpenny & Savin-Baden, 2012 ). This occurred when researchers cited Stake or Yin, or both (Mawn et al., 2010 ; Rytterström et al., 2013 ), although did not follow their paradigmatic or methodological approach. In 26 studies there were no citations for a case study methodological approach.

The findings of this study have highlighted a number of issues for researchers. A considerable number of case studies reviewed were missing key elements that define qualitative case study methodology and the tradition cited. A significant number of studies did not provide a clear methodological description or justification relevant to case study. Case studies in health and social sciences did not provide sufficient information for the reader to understand case selection, and why this case was chosen above others. The context of the cases were not described in adequate detail to understand all relevant elements of the case context, which indicated that cases may have not been contextually bounded. There were inconsistencies between reported methodology, study design, and paradigmatic approach in case studies reviewed, which made it difficult to understand the study methodology and theoretical foundations. These issues have implications for methodological integrity and honesty when reporting study design, which are values of the qualitative research tradition and are ethical requirements (Wager & Kleinert, 2010a ). Poorly described methodological descriptions may lead the reader to misinterpret or discredit study findings, which limits the impact of the study, and, as a collective, hinders advancements in the broader qualitative research field.

The issues highlighted in our review build on current debates in the case study literature, and queries about the value of this methodology. Case study research can be situated within different paradigms or designed with an array of methods. In order to maintain the creativity and flexibility that is valued in this methodology, clearer descriptions of paradigm and theoretical position and methods should be provided so that study findings are not undervalued or discredited. Case study research is an interdisciplinary practice, which means that clear methodological descriptions might be more important for this approach than other methodologies that are predominantly driven by fewer disciplines (Creswell, 2013b ).

Authors frequently omit elements of methodologies and include others to strengthen study design, and we do not propose a rigid or purist ideology in this paper. On the contrary, we encourage new ideas about using case study, together with adequate reporting, which will advance the value and practice of case study. The implications of unclear methodological descriptions in the studies reviewed were that study design appeared to be inconsistent with reported methodology, and key elements required for making judgements of rigour were missing. It was not clear whether the deviations from methodological tradition were made by researchers to strengthen the study design, or because of misinterpretations. Morse ( 2011 ) recommended that innovations and deviations from practice are best made by experienced researchers, and that a novice might be unaware of the issues involved with making these changes. To perpetuate the tradition of case study research, applications in the published literature should have consistencies with traditional methodological constructions, and deviations should be described with a rationale that is inherent in study conduct and findings. Providing methodological descriptions that demonstrate a strong theoretical foundation and coherent study design will add credibility to the study, while ensuring the intrinsic meaning of case study is maintained.

The value of this review is that it contributes to discussion of whether case study is a methodology or method. We propose possible reasons why researchers might make this misinterpretation. Researchers may interchange the terms methods and methodology, and conduct research without adequate attention to epistemology and historical tradition (Carter & Little, 2007 ; Sandelowski, 2010 ). If the rich meaning that naming a qualitative methodology brings to the study is not recognized, a case study might appear to be inconsistent with the traditional approaches described by principal authors (Creswell, 2013a ; Merriam, 2009 ; Stake, 1995 ; Yin, 2009 ). If case studies are not methodologically and theoretically situated, then they might appear to be a case report.

Case reports are promoted by university and medical journals as a method of reporting on medical or scientific cases; guidelines for case reports are publicly available on websites ( http://www.hopkinsmedicine.org/institutional_review_board/guidelines_policies/guidelines/case_report.html ). The various case report guidelines provide a general criteria for case reports, which describes that this form of report does not meet the criteria of research, is used for retrospective analysis of up to three clinical cases, and is primarily illustrative and for educational purposes. Case reports can be published in academic journals, but do not require approval from a human research ethics committee. Traditionally, case reports describe a single case, to explain how and what occurred in a selected setting, for example, to illustrate a new phenomenon that has emerged from a larger study. A case report is not necessarily particular or the study of a case in its entirety, and the larger study would usually be guided by a different research methodology.

This description of a case report is similar to what was provided in some studies reviewed. This form of report lacks methodological grounding and qualities of research rigour. The case report has publication value in demonstrating an example and for dissemination of knowledge (Flanagan, 1999 ). However, case reports have different meaning and purpose to case study, which needs to be distinguished. Findings of our review suggest that the medical understanding of a case report has been confused with qualitative case study approaches.

In this review, a number of case studies did not have methodological descriptions that included key characteristics of case study listed in the adapted criteria, and several issues have been discussed. There have been calls for improvements in publication quality of qualitative research (Morse, 2011 ), and for improvements in peer review of submitted manuscripts (Carter & Little, 2007 ; Jasper, Vaismoradi, Bondas, & Turunen, 2013 ). The challenging nature of editor and reviewers responsibilities are acknowledged in the literature (Hames, 2013 ; Wager & Kleinert, 2010b ); however, review of case study methodology should be prioritized because of disputes on methodological value.

Authors using case study approaches are recommended to describe their theoretical framework and methods clearly, and to seek and follow specialist methodological advice when needed (Wager & Kleinert, 2010a ). Adequate page space for case study description would contribute to better publications (Gillard et al., 2011 ). Capitalizing on the ability to publish complementary resources should be considered.

Limitations of the review

There is a level of subjectivity involved in this type of review and this should be considered when interpreting study findings. Qualitative methods journals were selected because the aims and scope of these journals are to publish studies that contribute to methodological discussion and development of qualitative research. Generalist health and social science journals were excluded that might have contained good quality case studies. Journals in business or education were also excluded, although a review of case studies in international business journals has been published elsewhere (Piekkari et al., 2009 ).

The criteria used to assess the quality of the case studies were a set of qualitative indicators. A numerical or ranking system might have resulted in different results. Stake's ( 1995 ) criteria have been referenced elsewhere, and was deemed the best available (Creswell, 2013b ; Crowe et al., 2011 ). Not all qualitative studies are reported in a consistent way and some authors choose to report findings in a narrative form in comparison to a typical biomedical report style (Sandelowski & Barroso, 2002 ), if misinterpretations were made this may have affected the review.

Case study research is an increasingly popular approach among qualitative researchers, which provides methodological flexibility through the incorporation of different paradigmatic positions, study designs, and methods. However, whereas flexibility can be an advantage, a myriad of different interpretations has resulted in critics questioning the use of case study as a methodology. Using an adaptation of established criteria, we aimed to identify and assess the methodological descriptions of case studies in high impact, qualitative methods journals. Few articles were identified that applied qualitative case study approaches as described by experts in case study design. There were inconsistencies in methodology and study design, which indicated that researchers were confused whether case study was a methodology or a method. Commonly, there appeared to be confusion between case studies and case reports. Without clear understanding and application of the principles and key elements of case study methodology, there is a risk that the flexibility of the approach will result in haphazard reporting, and will limit its global application as a valuable, theoretically supported methodology that can be rigorously applied across disciplines and fields.

Conflict of interest and funding

The authors have not received any funding or benefits from industry or elsewhere to conduct this study.

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• 07 May 2024
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Lessons in Business Innovation from Legendary Restaurant elBulli

Ferran Adrià, chef at legendary Barcelona-based restaurant elBulli, was facing two related decisions. First, he and his team must continue to develop new and different dishes for elBulli to guarantee a continuous stream of innovation, the cornerstone of the restaurant's success. But they also need to focus on growing the restaurant’s business. Can the team balance both objectives? Professor Michael I. Norton discusses the connections between creativity, emotions, rituals, and innovation – and how they can be applied to other domains – in the case, “elBulli: The Taste of Innovation,” and his new book, The Ritual Effect.

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• 30 May 2023

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• 24 Apr 2023

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• 07 Apr 2023

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• 10 Feb 2023

COVID-19 Lessons: Social Media Can Nudge More People to Get Vaccinated

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• 02 Feb 2023

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• 29 Nov 2022

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• 26 Oct 2022

How Paid Promos Take the Shine Off YouTube Stars (and Tips for Better Influencer Marketing)

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• 25 Oct 2022

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• 18 Oct 2022

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Being assertive: Reduce stress, communicate better

Assertiveness can help you control stress and anger and improve coping skills. Recognize and learn assertive behavior and communication.

Being assertive is a core communication skill. Assertiveness can help you express yourself effectively and stand up for your point of view. It can also help you do this while respecting the rights and beliefs of others.

Being assertive can also help boost your self-esteem and earn others' respect. This can help with stress management. It may especially help you reduce stress if you tend to take on too many responsibilities because you have a hard time saying no.

Some people seem to be naturally assertive. But if you're not assertive, you can learn to be.

Why assertive communication makes sense

Because assertiveness is based on mutual respect, it's an effective and diplomatic communication style. Being assertive shows that you respect yourself because you're willing to stand up for your interests and express your thoughts and feelings. It also demonstrates that you're aware of others' rights and willing to work on resolving conflicts.

Of course, it's not just what you say — your message — but also how you say it that's important. Assertive communication is direct and respectful. Being assertive gives you the best chance of successfully delivering your message. If you communicate in a way that's too passive or too aggressive, your message may get lost because people are too busy reacting to your delivery.

Assertive vs. passive behavior

If your style is passive or nonassertive, you may seem to be shy or overly easygoing. You may routinely say things such as "I'll just go with whatever the group decides." You tend to avoid conflict. Why is that a problem? Because the message you're sending is that your thoughts and feelings aren't as important as those of other people. In essence, when you're too passive, you allow others to ignore your wants and needs.

Consider this example: You say yes when a colleague asks you to take over a project, even though you're already busy. The extra work means you'll have to work overtime and miss your daughter's soccer game. Your intention may be to keep the peace. But always saying yes can poison your relationships. And worse, it may cause you internal conflict because your needs and those of your family always come second.

The internal conflict that can be created by passive behavior can lead to:

• Seething anger
• Feelings of victimization
• Desire to exact revenge
• Doubting or questioning our own judgment

Assertive vs. aggressive behavior

Now consider the other side. If your style is aggressive, you may come across as a bully who ignores others' needs, feelings and opinions. You may appear self-righteous or superior. Very aggressive people embarrass, intimidate and scare others and may even be physically threatening.

You may think that being aggressive gets you what you want. However, it comes at a cost. Aggression weakens trust and mutual respect. Others may come to resent you, leading them to avoid or oppose you.

Assertive vs. passive-aggressive behavior

Now consider passive-aggressive behavior. If you communicate in a passive-aggressive manner, you may say yes when you want to say no. You may be sarcastic or complain about others behind their backs. Rather than confront an issue directly, you may show your anger and feelings through your actions or negative attitude. You may have developed a passive-aggressive style because you're uncomfortable being direct about your needs and feelings.

What are the drawbacks of a passive-aggressive communication style? Over time, passive-aggressive behavior damages relationships and weakens mutual respect. This makes it difficult for you to get your goals and needs met.

The benefits of being assertive

Being assertive is usually viewed as a healthier communication style. Assertiveness offers many benefits. It helps you keep people from taking advantage of you. It can also help you from acting like a bully to others.

Behaving assertively can help you:

• Gain self-confidence and self-esteem
• Gain a sense of empowerment
• Understand and recognize your feelings
• Earn respect from others
• Improve communication
• Create win-win situations
• Improve your decision-making skills
• Create honest relationships
• Gain more job satisfaction

Learning to be more assertive can also help you effectively express your feelings when communicating with others about issues.

Learning to be more assertive

People develop different styles of communication based on their life experiences. Your style may be so ingrained that you're not even aware of what it is. People tend to stick to the same communication style over time. But if you want to change your communication style, you can learn to communicate in healthier and more effective ways.

Here are some tips to help you become more assertive:

• Assess your style. Do you voice your opinions or remain silent? Do you say yes to additional work even when your schedule is full? Are you quick to judge or blame? Do people seem to dread or fear talking to you? Understand your style before you begin making changes.
• Use 'I' statements. Using I statements lets others know what you're thinking or feeling without sounding accusatory. For instance, say, "I disagree," rather than, "You're wrong." If you have a request, say, "I would like you to help with this" rather than, "You need to do this." Keep your requests simple, specific and clear.
• Practice saying no. If you have a hard time turning down requests, try saying, "No, I can't do that now." Remember that no is a complete sentence and you don't need to explain why you choose to say no. Don't hesitate — be direct. If an explanation is appropriate, keep it brief.
• Rehearse what you want to say. If it's challenging to say what you want or think, practice general scenarios you encounter. Say what you want to say out loud. It may help to write it out first, too, so you can practice from a script. Consider role-playing with a friend or colleague and asking for clear feedback.
• Use body language. Communication isn't just verbal. Act confident even if you aren't feeling it. Keep an upright posture, but lean forward a bit. Make regular eye contact. Maintain a neutral or positive facial expression. Don't cross your arms or legs. Face the person. Practice assertive body language in front of a mirror or with a friend or colleague. In addition to what you say, your body language and facial expressions are also important.
• Keep emotions in check. Conflict is hard for most people. Maybe you get angry or frustrated, or maybe you feel like crying. Although these feelings are typical, they can get in the way of resolving conflict. If you feel too emotional going into a situation, wait a bit if possible. Then work on remaining calm. Breathe slowly. Keep your voice even and firm.
• Start small. At first, practice your new skills in situations that are low risk. For instance, try out your assertiveness on a partner or friend before tackling a difficult situation at work. Evaluate yourself afterward and adjust your approach as needed.

When you need help being assertive

Remember, learning to be assertive takes time and practice. If you've spent years silencing yourself, becoming more assertive probably won't happen overnight. Or if anger leads you to be too aggressive, you may need to learn some anger management techniques.

If despite your best efforts you're not making progress toward becoming more assertive, consider formal assertiveness training. And if certain issues such as anger, stress, anxiety or fear are getting in your way, consider talking with a mental health professional. The payoff will be worth it. By becoming more assertive, you can begin to express your true feelings and needs more easily. You may even find that you get more of what you want as a result.

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• Seaward BL. Simple assertiveness and healthy boundaries. In: Essentials of Managing Stress. 5th ed. Jones & Bartlett Learning; 2021.
• Seaward BL. Healthy boundaries: Behavior modification. In: Managing Stress: Skills for Self-Care, Personal Resiliency and Work-Life Balance in a Rapidly Changing World. 10th ed. Jones & Bartlett Learning; 2022.
• Bourne EJ. Being assertive. In: The Anxiety and Phobia Workbook. 7th ed. New Harbinger Publications; 2020.
• Olpin M, et al. Social support, relationships, and communication. In: Stress Management for Life. 5th ed. Cengage Learning; 2020.
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Open Access

Peer-reviewed

Research Article

COVID-19 contact tracing and quarantine policies in the Indo-Pacific Region: A mixed-methods study of experiences of public health professionals

Roles Conceptualization, Formal analysis, Investigation, Methodology, Project administration, Supervision, Visualization, Writing – original draft, Writing – review & editing

Affiliations National Centre for Epidemiology and Population Health, ANU College of Health and Medicine, The Australian National University, Canberra, Australian Capital Territory, Australia, School of Population Health, Faculty of Medicine and Health, University of New South Wales, Sydney, Australia

Roles Formal analysis, Methodology, Project administration, Supervision, Writing – review & editing

Affiliations Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia, Sydney Infectious Diseases Institute, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia

Roles Conceptualization, Formal analysis, Investigation, Methodology, Project administration, Resources, Supervision, Validation, Visualization, Writing – review & editing

* E-mail: [email protected]

Affiliations National Centre for Epidemiology and Population Health, ANU College of Health and Medicine, The Australian National University, Canberra, Australian Capital Territory, Australia, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia, Sydney Infectious Diseases Institute, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia

• Md. Saiful Islam, 
• Florian Vogt, 
• Catherine King, 

• Published: May 31, 2024
• https://doi.org/10.1371/journal.pgph.0003121
• Reader Comments

Contact tracing and quarantine are valuable public health tools to prevent the transmission of SARS-CoV-2 and control the epidemic. Many low-and middle-income countries (LMICs) adopted global contact tracing and quarantine guidelines but were unable to contextualise the guidance into policies and practices that were relevant to their setting. Therefore, we examine contact tracing policies and practices in the Indo-Pacific region and the need to design context-specific policies. We conducted a mixed-methods study, including a cross-sectional online survey followed by key-informant interviews (KIIs). Using convenience snowball sampling, we invited public health professionals primarily involved in COVID-19 pandemic response from the Indo-Pacific region. We undertook descriptive analyses using counts and percentages for survey data and framework analysis for qualitative data. Seventy-seven public health professionals participated in the survey, of whom ten also participated in the KIIs. The study identified significant gaps between policies and the local contexts. Factors that broaden the gaps were limited knowledge of the changing dynamics of COVID-19 transmission, poor leadership, and coordination, little or no formal training on contact tracing, poor understanding of the guideline recommendations, limited resources, community resistance and mistrust, social stigmatisation and fear of being ostracised, and discrimination. This study revealed substantial disparities between policies and local contexts, significantly influencing policy implementation at national, provincial, and district levels across the studied countries. To bridge these gaps, we advocate for national contact tracing and quarantine guidelines explicitly addressing the quarantine needs of specific demographics, including children, pregnant women, prisoners, and individuals affected by social exclusion issues. Furthermore, we propose strengthening contact tracing training programs, urging revised guidelines to account for social, cultural, and infrastructural nuances influencing contact tracing and quarantine implementation. We also recommend engaging local NGOs, faith-based organisations, and local administrations to reinforce community connections and strengthen contact tracing.

Citation: Islam MS, Vogt F, King C, Sheel M (2024) COVID-19 contact tracing and quarantine policies in the Indo-Pacific Region: A mixed-methods study of experiences of public health professionals. PLOS Glob Public Health 4(5): e0003121. https://doi.org/10.1371/journal.pgph.0003121

Editor: Collins Otieno Asweto, University of Embu, KENYA

Received: November 17, 2023; Accepted: March 27, 2024; Published: May 31, 2024

Copyright: © 2024 Islam et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: All relevant data are within the paper. We are unable to provide any raw data due to the qualitative and identifiable nature of the data. For researchers who meet the criteria for access to confidential data, the data are available on request from the Human Ethics Officer at the Australian National University Human Research Ethics Committee, email: [email protected] .

Funding: The authors received no specific funding for the work.

Competing interests: The authors have declared that no competing interests exist.

Introduction

COVID-19 is an emerging infectious disease caused by SARS-CoV-2 that transmits from person-to-person through respiratory droplets and aerosols [ 1 ]. Contact tracing and quarantine are essential public health tools to prevent transmission of infectious diseases and control outbreaks. Contact tracing involves identifying, assessing, and managing contacts defined as people who have exposure to someone infected with an infectious disease, and quarantine involves the separation of contacts [ 2 ]. Quarantine measures can be voluntary or legally enforced by law and often applied to an individual, family, group, or community level [ 3 ].

During the initial phases of the COVID-19 pandemic, contact tracing and quarantine played pivotal roles in controlling SARS-CoV-2 morbidity and mortality [ 4 , 5 ]. In a natural experimental study examining the effectiveness of COVID-19 contact tracing and quarantine in England during 2020, Fetzer and Graeber demonstrated that timely and comprehensive contact tracing could potentially reduce approximately 63% of new infections and 66% of COVID-19 related mortality [ 6 ]. A systematic review corroborated these findings, indicating that contact tracing and quarantine prevented 44% to 81% of new cases and reduced mortality by 31% to 63% [ 7 ]. A more recent mathematical model by Wu et al. (2023) further supported these outcomes, suggesting that implementing contact tracing and quarantine policies can reduce the overall size of the epidemic [ 8 ]. Additionally, in a recent systematic review assessing the real-world effectiveness of these measures, consistent findings emerged across studies, indicating that testing, contact tracing, and quarantine measures were associated with decreased morbidity and mortality. The effectiveness was observed through reduced case growth, lower cases per capita, and decreased population-level mortality rates [ 9 ].

Despite the known effectiveness of contact tracing, it remains a resource-intensive process, requiring a skilled workforce and good public health infrastructure. Likewise, quarantine requires space for separation, food and medicine supplies, effective communication, and a trained workforce to manage them. Therefore, the implementation of contact tracing and quarantine can put significant pressure on health systems, especially in low-and middle-income countries (LMICs) or resource-constrained settings [ 10 ].

The implementation of global and national contact tracing and quarantine policies can vary significantly at the sub-national level, especially in decentralised health systems where infrastructural capabilities differ [ 11 ]. These challenges were magnified during the COVID-19 pandemic, wherein many LMICs adopted or attempted to adopt global policies, guidance and norms, developed by global agencies, for example, the World Health Organization (WHO), and the United States Centers for Disease Control and Prevention (CDC). However, our collective field experiences suggested that numerous LMICs encountered challenges contextualising this guidance into policies and practices relevant to their unique circumstances [ 10 , 12 ]. There was an expectation to align policies with those from resource-rich settings or past experiences with other infectious diseases. Many countries encountered difficulties sustaining contact tracing efforts as the COVID-19 caseload surged [ 12 , 13 ].

Numerous studies have investigated community perceptions and experiences related to isolation, quarantine, and the experiences of public health responders, utilising qualitative research methods within specific country contexts [ 12 , 14 – 16 ]. However, at the time this study was initiated, there were no studies examining contact tracing and quarantine policies from the perspective of public health professionals. We used a mixed-methods study to collect data on contact tracing and quarantine policies in the Indo-Pacific region and collect data from LMICs in the region. This study aimed to explore future opportunities for designing and implementing contact tracing policies, offering perspectives from public health professionals, epidemiologists, and frontline workers directly involved in these efforts. Our study aimed to examine contact tracing policies and practices in the Indo-Pacific region, to understand the extent to which context-specific policies were being used and explore any related barriers.

Methodology

Study design, study setting and population.

The study, conducted between March and October 2022, employed a mixed-methods approach, commencing with a cross-sectional online survey and followed by a qualitative study utilizing key informant interviews (KIIs) of survey participants ( Fig 1 ). We invited professionals aged 18 years and above who were involved in COVID-19 contact tracing and quarantine activities. The target population was professionals working within Ministries of Health, international organisations’ national representatives, research organisations, and local health service workers from the Indo-Pacific region, including countries such as Australia, Bangladesh, Cambodia, Fiji, India, Indonesia, Japan, Kiribati, Malaysia, Nepal, New Zealand, Palau, Papua New Guinea, the Philippines, Thailand, and Vietnam. We limited the scope of the study to these countries due to cultural, geographical, and economic connection and similarities, and due to a similar approach to COVID-19 mitigation measures in 2020 [ 17 ]. Recruitment for the online survey was done by sharing the link to the survey via investigators’ networks, social media, and operational partners-TEPHINET (Training Programs in Epidemiology and Public Health Interventions Network, ( https://www.tephinet.org/ ) - a global professional network of field epidemiology training programs. Recruitment was continued through convenience sampling, including snowballing, as the link to the survey was shared across professional networks and among collaborators.

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Data collection

The quantitative online survey link was open for 3 months (21 April-22 July 2022) and included both structured and unstructured questions. The survey contained four key domains: (a) socio-demographic characteristics and professional experience; (b) COVID-19 contact tracing and quarantine policies and practices; (c) contact tracing processes; (d) implementation of quarantine policies and the challenges experienced. Feedback on the questionnaire was sought from the study team and TEPHINET. The questionnaire was piloted and revised before implementation. Data were collected and collated online using REDCap, a web-based application for public health research, databases and projects [ 18 ].

At the end of the survey, respondents were given an option to participate in a KII. Those who responded ‘Yes’, were invited to participate in a short interview via email. We sought informed oral consent before the interview. We used an open-ended topic guide to support the interview which was developed by a social scientist and epidemiologists and piloted in an LMIC for cognitive understanding. The topic guide included participants’ current role in contact tracing, different steps of contact tracing and identification of cases and contacts, attitudes toward contact tracing policies, gaps, and challenges in contact tracing. Interviews were conducted by MSI using video conferencing software and recorded for note taking purposes. MSI was aware of each country’s context and health infrastructure, which allowed him to practice cultural and social considerations during the data collection process.

Data management and analysis

We conducted descriptive analyses on the survey data, utilising counts and percentages. For analytical purposes, we categorised the respondents’ countries into ’LMIC’ and ’high-income’ groups, following the World Bank’s gross national income (GNI) criteria. LMICs encompass countries with a GNI per capita between $1,136 and $13,845, while high-income economies are those with a GNI per capita of $13,846 or more [ 19 ]. Chi-square test and Fisher’s exact test was used to compare if the differences between LMICs and high-income countries were statistically significant. Survey data were analysed using STATA v.13 and the open-source statistical package R version 4.2.0. We used the R package ‘rworldmap’ to develop a map ( Fig 2 ).

The base map was created with R package “rworldmap” ( https://cran.r-project.org/web/packages/rworldmap/ ). Country borders are derived from natural Earth data v 1.4.0 in “rworldmap”.

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For qualitative data, we used both deductive and inductive coding for the analysis; the former was guided by the question categories and the latter emerged from the KIIs findings [ 20 ]. MSI transcribed the interview audio recordings verbatim before deleting, organised the notes, and compiled them into a written report format. MSI and CK independently read all the interview transcriptions and reviewed one transcript in detail and developed an initial code list. MSI coded the rest of the interviews using the code list as an initial basis. MSI created new codes to accommodate new findings that were beyond the scope of the initial codes. These were discussed with CK, MS and consensus reached on their final inclusion. This iterative process minimised individual biases and enhanced the reliability of our qualitative analysis.

We used a framework approach, which is well suited to policy description and analysis to structure and further analyse data in Microsoft Excel [ 21 ]. MSI entered the interview IDs into rows, the codes in the column headings and then extracted data under the relevant codes. The output of this matrix spreadsheet allowed us to summarise data systematically and analyse according to sources, codes and by themes [ 22 ]. This approach also allowed us to compare data by pre-produced codes and emerging themes and sub-themes across countries. All authors reviewed the categories and sub-categories for consensus and reliability.

Ethics approval and consent to participate

Participation in this study was voluntary. Respondents were directed to plain language information sheets available online in English before accessing the survey. Interested participants were directed to complete the informed consent form via Research Electronic Data Capture (REDCap). Consenting participants were then directed to access the survey. Only those who provided consent were able to access and submit the survey. At the end of the survey, participants were asked if they would be interested and willing to participate in a KII. For those consenting participants, another participant information sheet and an oral consent form were shared via email. Then at the time of the online interview, the information sheet was again read out to participants to ensure they understood the study. Thereafter participants expressed their oral consent to participate in the KII. Ethical approval to conduct the study was approved by the Australian National University Human Research Ethics Committee (protocol number 2021–795)

Survey results

One hundred nineteen public health professionals consented to participate in the survey. Of those, data from 77 (65%) respondents was included in the final analyses. Of the 42 surveys that were excluded, 90.5% (38) had considerable missing data, or respondents (N = 4, 9.5%) were outside of the Indo-Pacific region and did not meet the study eligibility criteria. Of the 77 respondents, 49% (38/77) were male and the median age of all respondents was 36 years (range 22–65 years) ( Table 1 ). Data from respondents represents 16 countries ( Fig 2 ), of which the majority were from Bangladesh (21%;16/77), India (17%; 13/77) and Australia (17%;13/77). Seventy-eight percent (60/77) of respondents were from LMICs. Sixty-nine percent (53/77) of the respondents worked within a Ministry of Health (MoH) or another government agency. Thirty-six percent (19/53) of the government employees were from the national level, 34% (18/53) were divisional/provincial, and 30% (16/53) were from district and sub-district levels ( Table 1 ).

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Current role, professional experience, and training

During the survey, some of the respondents identified as having more than one role. Among the respondents, 36% (28/77) self-identified as contact tracing officers, 36% (28/77) as epidemiologists, 26% (20/77) as public health officers, 31% (24/77) as Field Epidemiology Training Program (FETP) fellows or alumni, 27% (21/77) as nurses and doctors including interns, and 27% (21/77) as community health workers, volunteers, and others. As most respondents were public health professionals even prior to the pandemic, just over half (51%, 39/77) had prior contact tracing experience. Forty-nine per cent (38/77) of the respondents reported that they had received formal training for contact tracing, and among those who received the training, almost all (97%; 37/38) found it very useful ( Table 1 ). In LMICs, more people were quarantined at home (67% vs 41%) and government facilities (50% vs 24%) in comparison to HICs ( Fig 3 ). About 29% of the respondents from HICs mentioned that they provided financial support to people quarantined at home whereas only 7% from LMICs mentioned that. In addition, 10% respondents from LMICs reported that they did not provide any support to people who were quarantined at home ( Fig 4 ).

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More than half of the respondents (52%; 40/77) reported that they routinely conducted contact tracing during COVID-19 ( Table 2 ). Over 50% of the respondents (40/77) said they faced challenges while conducting contact tracing activities ( Table 2 ). Table 3 showed that the participants from HICs had more years of experience in contact tracing than participants from LMICs, and the difference was statistically significant (P>0.01). The results also showed that more respondents from HICs received formal training for contact tracing compared to respondents from LMICs, and the difference was statistically significant (p<0.01).

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Policies and procedures

Most respondents reported their organisation had COVID-19 contact tracing policies (69%, 53/77) and standard operating procedures (SOPs) (57%, 44/77). When asked to differentiate, 4% (3/77) respondents said only contact tracing policies and 5% (4/77) reported that they only had policies for quarantine in their country. Ten percent (8/77) reported that they had neither or were unsure if they had any. Similarly, only 9% (7/77) respondents reported having an SOPs for contact tracing, 5% (4/77) only for quarantine, and 17% (13/77) said that they had neither or were unsure if they had any ( Table 2 ).

Findings from key-informant interviews

Among the 77 included survey participants, 32 initially agreed to be contacted for KII. However, interviews could only be conducted with 10 participants from eight LMICs who responded positively when contacted between July to October 2022. Overall, the KIIs provided more in-depth insights about the respondents’ everyday activities and roles that included COVID-19 case and contact monitoring and surveillance, contact investigation and quarantine, coordination of emergency response and contact tracing team, and data management at the national, state/province and district levels. Further, the KII findings provided rich data about participants’ thoughts towards contact tracing policies and procedures, along with the challenges they faced while implementing them.

Case confirmation, contact identification and quarantine

Almost all the key informants reported using the WHO definition to define a case, namely a person with positive laboratory or rapid antigen test results suggestive of COVID-19 infection. However, the contact tracing processes were not uniform across all countries and provinces and differed according to context and resources. Unlike a ‘case’, the definition of a ‘contact’ had been revised and updated over time and varied by country. For example, one participant mentioned that they defined contact as individuals who had exposure to a case two weeks from the onset of symptoms.

“ So , we always identify people in contact with a case in the last two weeks of symptom onset . The family members , the people the case met in shops , local markets , and wherever the case visited were identified as contacts . We collected the phone numbers of all contacts and called them for symptom screening . ” A Medical Officer

The key informants reported that once contacts were traced, they were quarantined and followed up for 28 to 21 days initially, then 14 days to seven to five days. A few countries also conducted case-based contact tracing as explained by one participant:

" At one point , we had a case who travelled from XX Island to Brisbane to one of the outer islands in this country where at that time no COVID-19 case had been detected . In that instance , we thought there would be a public health benefit of identifying the source of a delta outbreak and potentially avoiding any onward transmission . We then conducted a contact investigation . ” A Public Health Physician.

Evolution of quarantine facilities

From the survey, we learned the types of facilities used for quarantining ( Fig 3 ). The interviews revealed how the use of these evolved overtime. All but one participant mentioned that at the beginning of the COVID-19 pandemic, contacts were quarantined in hotels and hospitals. Some participants added that as the number of cases increased, the government started acquiring different institutions, empty buildings, TB hospitals, camps, schools, colleges, party halls and community centres, and using them as quarantine facilities; however, the quarantine process was not uniform across all countries and changed over time. Some participants mentioned that home quarantine policies came after the second wave of COVID-19 when the government could not manage quarantine facilities for larger numbers of people. In one country, many community organisations reportedly came forward to support people quarantined at home by providing food. Nine of the ten participants preferred home quarantine over quarantine facilities and described the advantages of home quarantine, including psychological support and low cost.

Challenges in contact tracing and quarantine

All the KII participants noted that the challenges of dealing with a novel disease with limited information initially about transmission dynamics. According to the participants, political interference, lack of coordination, limited human resources, difficult logistics, and limited epidemiologists in the emergency response team were some of the challenges at the national level in some countries. At the provincial and community level, lack of context-appropriate policies, limited human resources, a lack of training, a lack of incentives and motivation, incomplete information on cases and contacts, delays in receiving laboratory results, difficulties with timely identification of cases, language, lack of community cooperation and trust, limited transport facilities, lack of protective gears, stigma, fear and discrimination, were some of the challenges related to COVID-19 contact tracing and quarantine.

The participants also mentioned that limited training on contact tracing affected policy implementation. Two participants mentioned that the policies or SOPs on contact tracing were developed around six months after the onset of the COVID-19 pandemic. They had to conduct contact tracing without any training or SOPs. Once the SOPs were developed, a few at the national level received their training online so that they could train others at the sub-national level. One participant said, “ Training was done after five-six months of the onset of COVID-19 . In the initial days , no one knew what to do . In the human resources side , in the control room also , the people managing the contact tracing control room , they did not have much experience . People from different departments joined the contact tracing team . They did not know how to handle the cases of people who had caste issues , who had fears . No one was trained . ” - A Contact Tracing Coordination Officer

Non-cooperation from the community affected the contact tracing. In some instances, the contacts often did not show up when the team visited the house, often closed the doors, or sent dogs around that attacked the contact tracing and quarantine team. Regarding community cooperation, one participant said, “ One of the challenges we faced regarding contact tracing was that the people gave us wrong names , addresses , or locations . They used to provide a general location between several villages . When we visited the community and asked around to find the contacts , villagers said they did not know anyone with that name . ” A Contact Tracing Officer

In the initial stages of the pandemic, most cases were imported, and language was a barrier to communicating with foreign nationals. Some countries did not have a system to record passengers’ information. One of the participants shared, “ Most of the cases were imported… . We had difficulties tracing them as we needed a system to record all passengers’ addresses and phone numbers . Many foreigners travelled in the same plane and then went to different provinces . We had to contact the embassy , tourist agencies and local authorities to find these people and let them know they were on a flight with a COVID-19 Case . ” A Data Manager

Outbreaks occurred in schools and congregated settings and there was a lack of clear guidance on how to quarantine school children and prisoners. A key informant described the challenges this way- “There were outbreaks in schools , prisons , and other congregated settings that host many people . There were so many prisoners within a limited space . We cannot take these prisoners outside to quarantine in facilities . … . The whole prison was used as a quarantine facility . Due to restrictions in prison , we could not implement public health measures easily . ” A Surveillance Officer

Many participants reported stigma, fear and discrimination associated with COVID-19 disease and were directed to the contact tracing team and community members, which manifested in many ways. When there was a case in a house, the community started rejecting all the members in that household. Two participants shared that many people died during the Delta outbreak, which triggered fear of death among the team members, who were terrified to visit patients, and do case investigation and contact tracing. The participants also mentioned that, even in hospitals, the team members feared conducting in-person case investigations to identify potential contacts. People stopped testing themselves to avoid COVID-19-related social stigma and being ostracised by community members. The healthcare workers working in quarantine facilities were stigmatised and faced discrimination in the community. The broader community rejected health workers as they perceived them as bringing COVID-19 from hospitals to the community. There was also fear among refugees and ethnic minorities that the government would sterilise the people through food or another mechanism if they went to the quarantine facilities.

Lack of coordination between public and private hospitals and laboratories during the initial days of the pandemic affected the contact tracing. Two participants mentioned that there was a limited number of public health specialists and epidemiologists in the MoH, and communication and leadership issues made it difficult to take effective public health measures during the COVID-19 surge.

One participant said, “ We didn’t have a clear leadership from the beginning . We had a conflict of interest between the national and provincial teams . When my team leader communicated with the provincial lead , it worked well . But it did not work with others . It was often difficult to communicate with the community health workers because they did not know who we were . I had to explain again and again who we were . ” -A Rapid Response Team Member.

Eight participants mentioned that data entry, management and timely data analysis affected policy implementation. Seven participants said they did not have a database and entered data in hard copy forms, spreadsheets, or Google sheets. One participant stated- “So much valuable information was still there . They were in a paper-based format or soft copies but were not linked to each other . Integration was not there . We knew the USA’s and UK’s transmission dynamics because the CDC and UK health authority did that . But we did not know the transmission dynamics in our settings due to poor data management and a lack of analysis . ”- A Surveillance Officer.

Seven participants mentioned policy gaps by highlighting the imprecise definition of contacts, absence of role clarification of tracers and the lack of guidance on how to quarantine people in congregated settings, breastfeeding mothers, infection prevention and control in quarantine facilities and in high-community transmission areas. In contrast, two participants said that they regularly adapted the policies for the local context and did not see any gaps in the guidelines. One of the participants also shared that people involved in contact tracing were not invited to assist with guideline development, and thus field challenges needed to be reflected in the guidelines.

One participant said, “ the people involved in contact tracing and quarantine guidelines development should have lived experience of contact tracing… how the provinces were going , and what challenges they faced . In my country , people involved in guideline development never conducted contact tracing . After drafting the guidelines , the MoH organised a workshop and invited leaders from other provinces to comment on the document . Again , these leaders did not have contact tracing experience and were unaware of field challenges . ”-A Rapid Response Team member .

Importance of risk communication and community engagement in contact tracing and quarantine

Three participants added that risk communication would reduce the stigma associated with COVID infection, and community engagement would improve contact tracing and quarantine. As described by one participant, otherwise, “ When the community does not accept what we’re trying to do , the compliance will be minimum .” A Surveillance Officer

They also highlighted the importance of social and print media and daily briefings on COVID-19 on television to engage the public. Two participants mentioned that local NGOs, faith-based organisations, and local panchayet (committee) could be involved in contact tracing as they knew the context and had good access to the community. Four participants shared mixed experiences of engaging law enforcement agencies in contact tracing. One participant said that police were engaged in contact tracing in their province. They added that the police were not medical personnel trained for contact tracing. Involving the police in the team was not accepted well by the community. They said, “It was done by the police , who were not medical groups . They were implementing strict laws . They were identifying people like the cases or contacts who did something wrong . Community members also felt very bad when police visited their homes and asked for quarantine . ”- A Training and Telemedicine Officer.

To the best of our knowledge, this is the first study employing a mixed-methods approach to examine the implementation of COVID-19 contact tracing and quarantine policies in the Indo-Pacific region. The study revealed substantial gaps between global guidance vs national and sub-national policies and local contexts, significantly influencing operationalisation at national, provincial, and district levels across the studied countries. These gaps encompassed limited understanding of COVID-19 transmission dynamics, inadequate leadership and coordination, insufficient training for contact tracing, poor comprehension of guideline recommendations, resource constraints, community resistance, and societal stigmas based on religion, ethnicity, and health conditions. These findings correspond with a 2020 rapid review, identifying insufficient training, coordination issues, mistrust, and stigmatisation as barriers to COVID-19 contact tracing [ 23 ].

Between April and July 2022 when the survey was conducted, 14 of the 16 countries that the respondents worked in had both contact tracing and quarantine guidelines, demonstrating the willingness and motivation to use public health tools for control of the pandemic. However, due to evolving transmission dynamics and multiple variants, several member states encountered challenges in contextualising and adapting policy recommendations. Insufficient country-level data analysis and limited involvement of field-level officers in guiding policy development led to a partial reflection of the local context in national policies, widening policy gaps. These gaps included poor understanding of the policy recommendations among field teams due to a lack of formal training; varied public health infrastructures and COVID-19 burdens across countries and regions, scarcity of resources with no dedicated staffing or funding for contact tracing, unclear role delineation for public health workers, hierarchical challenges between national and local team members, and the absence of an integrated data system for timely analysis of transmission dynamics, morbidity, mortality, and high-risk groups. Conversely, countries successfully adopting policies in their local contexts experienced fewer implementation challenges.

WHO recommended prioritising those at the highest risk of COVID-19 impacts and ensuring equity in contact tracing recommendations [ 24 ]. Published literature showed that people with comorbidities, older adults, low-income groups and ethnic minorities were disproportionately affected by COVID-19 [ 25 , 26 ]. Limited integrated databases and data analyses hindered timely identification of vulnerable groups, differing significantly from those in high-income countries. Yet, due to insufficient local data, many countries relied on mathematical models from high-income countries for forecasting, prioritising contact tracing strategies, and making quarantine decisions [ 27 ].

The presence of mistrust, social and self-stigma, fear, and discrimination against ethnic minorities suggests that the risk communication and community engagement strategies were inadequate in addressing and preventing COVID-19 related stigma and discrimination in some countries. WHO recommended embedding risk communication and community engagement (RCCE) into contact tracing efforts [ 28 ]. Due to limited RCCE activities in contact tracing initiatives, mistrust arose between community members and contact tracing teams, resulting in fear, discrimination, and reluctance to undergo tracing and quarantine. Our study underscores that engaging local NGOs, faith-based organisations, and local administrations reinforce community connections and strengthened contact tracing, and these findings are consistent with prior literature [ 29 ]. Future policies should consider engaging these entities in contact tracing initiatives at the outset.

Our study found that participants from high-income countries had more experience and formal training in contact tracing. Limited training in LMICs led to unclear understanding of policy recommendations, particularly regarding quarantine guidelines for specific groups such as pregnant or breastfeeding mothers and caste-based distinctions. Lack of standardised training resulted in varied definitions of contacts and oversight of exposure duration in contact identification. Additionally, unclear role delineation within policy documents complicated coordination among ministries and multi-level officers, causing delays in contact tracing.

Our study’s strengths include participants from 16 countries providing diverse COVID-19 contact tracing experiences. We engaged participants at national, regional, and local levels, including epidemiologists, public health officers, physicians, nurses, FETP fellows, surveillance officers, and data managers, ensuring robust and credible data. The utilisation of mixed-method approaches involving a subset of survey respondents and KII participants reinforced the internal validity of our data. Moreover, cross-checking with selected participants ensured the thorough inclusion of their responses, enhancing the interpretative rigor of our research.

Our study had several limitations. First, our study might be prone to recruitment bias due to unknown source population and convenience sampling, limiting the sample’s representativeness. To mitigate this bias, we took several measures. We clearly defined the study population that our research aimed to represent. Additionally, we diversified our sampling approach by leveraging various sources, including networks of study investigators, social media platforms, and esteemed operational partners like TEPHINET. This strategy aimed to broaden the diversity of our sample. Furthermore, to minimise reporting bias, we employed multiple data collection tools, such as online surveys and key-informant interviews. These methods allowed us to verify the information gathered, ensuring a more comprehensive understanding of the subject matter. Second, as the study was conducted during the COVID-19 pandemic, many public health professionals were involved in emergency responses, limiting their participation or response completion. Therefore, the high non-response rate that we encountered might introduce bias, potentially affecting representativeness and generalisability. Nevertheless, our findings align with prior research on contact tracing and quarantine procedures, suggesting minimal impact from the high non-response rate [ 10 , 14 , 30 ]. Third, exclusion of 42 respondents due to missing information or being outside the Indo-Pacific region might have biased our analyses; however, data collected through KIIs helped address this gap and provided critical information on the barriers. Yet, our defined study population and eligibility criteria in participant recruitment materials and use of multiple sources ensured diverse participation from HICs and LMICs. Despite limitations, our mixed-methods findings can drive improvements in ongoing and future contact tracing efforts, addressing persisting gaps and challenges. Despite our efforts to ensure comprehensiveness, the study had very few or no participants from some of the countries in the Indo-Pacific region. Therefore, interpreting our findings should be approached cautiously, as generalising them to the entire region might be contextually misleading.

Our study recommends context-appropriate and implementable measures for LMICs. We propose a convention of regional stakeholders led by peak international agencies to discuss implementation challenges, experiences, and ideas related to contact tracing and quarantine policies. These discussions can inform policy development at the national level, considering contextual nuances. Annual refresher training on contact tracing and quarantine for public health professionals involved in outbreak prevention and control can be considered. This could especially include behavioral and communication skills, and database integration, to strengthen the workforce. National quarantine guidelines should explicitly address the quarantine of specific groups such as children, pregnant mothers, prisoners and people those experiencing social exclusions, and revised guidelines should consider social, cultural, and infrastructural contexts influencing contact tracing and quarantine. We recommend that local NGOs, faith-based organisations, and local administrations are engaged early on to bolster community connections and enhance the effectiveness of contact tracing efforts. Considering the need for a ‘whole of society response’ during pandemics, similar studies understanding the role of non-health workforce should be considered. Finally, conducting future studies employing a mixed-methods design and incorporating a co-design approach can ensure the development of contextually appropriate and feasible contact tracing and quarantine policies.

Our study examining the first two years of contact tracing and quarantine measures revealed that while most countries adopted global guidance on contact tracing policies, modifications to local contexts were minimal, resulting in implementation gaps. Despite these gaps and challenges, local strategies and community initiatives contributed to success. The findings of this study can aid in revising contact tracing and quarantine policies by addressing gaps and developing strategies to implement culturally acceptable and contextually appropriate contact tracing and quarantine activities during future pandemics.

Supporting information

S1 checklist. inclusivity in global research..

https://doi.org/10.1371/journal.pgph.0003121.s001

Acknowledgments

The authors would like to acknowledge TEPHINET, the global network of Field Epidemiology Training Programs, for its support in reviewing and helping to disseminate the survey. The authors also appreciate the contribution of Tsheten Tsheten for his support in developing the survey. Finally, we thank all the study participants for their valuable time and support.

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• Open access
• Published: 05 June 2024

Experiences of medical students and faculty regarding the use of long case as a formative assessment method at a tertiary care teaching hospital in a low resource setting: a qualitative study

• Jacob Kumakech 1 ,
• Ian Guyton Munabi 2 ,
• Aloysius Gonzaga Mubuuke 3 &
• Sarah Kiguli 4  

BMC Medical Education volume  24 , Article number:  621 ( 2024 ) Cite this article

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Introduction

The long case is used to assess medical students’ proficiency in performing clinical tasks. As a formative assessment, the purpose is to offer feedback on performance, aiming to enhance and expedite clinical learning. The long case stands out as one of the primary formative assessment methods for clinical clerkship in low-resource settings but has received little attention in the literature.

To explore the experiences of medical students and faculty regarding the use of the Long Case Study as a formative assessment method at a tertiary care teaching hospital in a low-resource setting.

Methodology

A qualitative study design was used. The study was conducted at Makerere University, a low-resource setting. The study participants were third- and fifth-year medical students as well as lecturers. Purposive sampling was utilized to recruit participants. Data collection comprised six Focus Group Discussions with students and five Key Informant Interviews with lecturers. The qualitative data were analyzed by inductive thematic analysis.

Three themes emerged from the study: ward placement, case presentation, and case assessment and feedback. The findings revealed that students conduct their long cases at patients’ bedside within specific wards/units assigned for the entire clerkship. Effective supervision, feedback, and marks were highlighted as crucial practices that positively impact the learning process. However, challenges such as insufficient orientation to the long case, the super-specialization of the hospital wards, pressure to hunt for marks, and inadequate feedback practices were identified.

The long case offers students exposure to real patients in a clinical setting. However, in tertiary care teaching hospitals, it’s crucial to ensure proper design and implementation of this practice to enable students’ exposure to a variety of cases. Adequate and effective supervision and feedback create valuable opportunities for each learner to present cases and receive corrections.

Peer Review reports

The long case serves as an authentic assessment method for evaluating medical students’ competence in clinical tasks [ 1 ]. This form of assessment requires students to independently spend time with patients taking their medical history, conducting physical examinations, and formulating diagnosis and management plans. Subsequently, students present their findings to senior clinicians for discussion and questioning [ 2 , 3 ]. While developed countries increasingly adopt simulation-based assessments for formative evaluation, logistical challenges hinder the widespread use of such methods in developing countries [ 4 ]. Consequently, the low-resource countries heavily rely on real patient encounters for formative assessment. The long case is one such method predominantly used as a primary formative assessment method during clinical clerkship and offers a great opportunity for feedback [ 5 ]. The assessment grounds students’ learning into practice by providing them with rich opportunities to interact with patients and have the feel of medical practice. The long case thus bridges the gap between theory and practice, immersing students in the real tasks of a physician [ 1 ]. The complexity of clinical scenarios and the anxiety associated with patient encounters may not be well replicated in simulation-based assessments because diseases often have atypical presentations not found in textbooks. Assessment methods should thus utilize authentic learning experiences to provide learners with applications of learning that they would expect to encounter in real life [ 6 ]. This requires medical education and the curriculum to focus attention on assessment because it plays a significant role in driving learning [ 7 ]. The long case thus remains crucial in medical education as one of the best ways of preparing for practice. It exposes the student repeatedly to taking medical history, examining patients, making clinical judgments, deciding treatment plans, and collaborating with senior clinicians.

The long case, however, has faced significant criticism in the medical education literature due to perceived psychometric deficiencies [ 8 , 9 , 10 ]. Consequently, many universities have begun to adopt assessment methods that yield more reliable and easily defensible results [ 2 ] due to concerns over the low reliability, generalizability, and validity of the long case, coupled with rising litigations and student appeals [ 11 , 12 ]. Despite these shortcomings, the long case remains an educationally valuable assessment tool that provides diagnostic feedback essential for the learning process during clinical clerkship [ 13 ]. Teachers can utilize long-case results to pinpoint neglected areas or teaching deficiencies and align with course outcomes.

However, there is a paucity of research into the long case as a formative assessment tool. A few studies conducted in developed countries highlighted its role in promoting a holistic approach to patient care, fostering students’ clinical skills, and a driving force for students to spend time with patients [ 2 , 13 ], . There is a notable absence of literature on the use of long case as a formative assessment method in low-resource countries, and no published work is available at Makerere University where it has been used for decades. This underscores the importance of conducting research in this area to provide insight into the effectiveness, challenges, and potentials for improvement. Therefore, this study aimed to investigate the experiences of medical students and faculty regarding the utilization of the long case as a formative assessment method within the context of a tertiary care teaching hospital in a low-resource setting.

Study design

This was an exploratory qualitative study.

Study setting

The research was conducted at Makerere University within the Department of Internal Medicine. The Bachelor of Medicine and Bachelor of Surgery (MBChB) degree at Makerere University is a five-year program with the first two years for pre-clinical (biomedical Sciences) course and the last three years dedicated to clinical clerkship. Medical students do Internal Medicine clerkships in third- and fifth-year at the two tertiary teaching hospitals namely; Mulago and Kiruddu National Referral Hospitals. The students are introduced to the long case in third-year as Junior Clerks and later in the fifth-year as Senior Clerks. During clerkship, students are assigned to various medical wards, where they interact with patients, take medical history from them, perform physical examinations, and develop diagnosis and management plans. Subsequently, students present their long cases to lecturers or postgraduate students, often in the presence of their peers, followed by feedback and comprehensive case discussions. Students are afforded ample time to prepare and present their cases during ward rounds, at their discretion. The students are formatively assessed and a mark is awarded on a scale of one to ten in the student’s logbook. Each student is required to make a minimum of ten long cases over the seven weeks of clerkship.

Study participants

The study participants were third- and fifth-year medical students who had completed junior and senior clerkship respectively, as well as lecturers who possessed at least five years of experience with the long case. The participants were selected through purposive sampling. The sample size for the study was determined by data saturation.

Data collection

Data were collected through Focus Group Discussions (FGDs) and Key Informant Interviews (KIIs). A total of 36 medical students participated in FGDs, reflecting on their experiences with the long case. Five faculty members participated in individual KIIs. The students were mobilized by their class representative and a brief recruitment presentation was made at the study site while the lecturers were approached via email and telephone invitation.

Six FGDs were conducted, three for junior clerks and three for senior clerks. Each FGD comprised of 5–7 participants with balanced male and female gender representation. Data saturation was achieved by the fifth FGD, at which point no additional new information emerged. A research assistant proficient in qualitative research methods moderated the FGDs. The discussions lasted between 55 min and 1 h 10 min and were audio recorded. The Principal Investigator attended all the FGDs to document interactions and record his perspectives and non-verbal cues of participants.

Semi-structured KIIs were used to collect data from Internal Medicine faculty. Five KIIs were conducted, and data saturation was achieved by the fourth interview, at which point no new theme emerged. The Principal Investigator conducted the KIIs via Zoom. Each interview lasted between 25 and 50 min and all were audio recorded. A research assistant proficient in qualitative methods attended all the Zoom meetings. The data collected were securely stored on a hard drive and Google Drive with password protection to prevent unauthorized access.

Data analysis

Data analysis was done through inductive thematic analysis method. Following each FGD or KII session, the data collection team listened to the recordings to familiarize themselves with the data and develop general ideas regarding the participants’ perspectives. The data were transcribed verbatim by the researchers to generate text data. Two separate transcripts were generated by the Principal Investigator and a research assistant. The transcripts were then compared and manually reviewed by the research team to compare the accuracy with the audio recordings. After transcript harmonization, data cleaning was done for both FGDs and KIIs transcripts.

The transcribed data from both FGDs and KIIs underwent inductive thematic analysis as aggregated data. This involved initial line-by-line coding, followed by focused coding where the relationships between initial codes were explored and similar codes were grouped. Throughout the analysis, the principle of constant comparison was applied, where emerging codes were compared for similarities and differences.

Study results

Socio-demographics.

A total of 36 medical students participated in the FGDs, comprising 18 junior clerks and 19 senior clerks. The participants were aged between 21 and 25 years except two participants who were aged above 25 (30 and 36 years old). Among the third-year students, there were 10 male and 9 female participants while the fifth-year student comprised of 8 male and 10 female participants.

Five lecturers participated in the Key Informant Interviews, three of whom were females and two male participants. They were aged between 40 and 50 years, and all had over 10 years of experience with the long case. The faculty members included one consultant physician, one associate professor, two senior lecturers, and one lecturer.

Themes that emerged

Three themes emerged from the study: ward placement, case presentations, and case assessment and feedback.

Theme 1: Ward placement

The study findings disclosed that medical students are assigned to specific wards for the duration of their clerkship. The specialization of medical wards was found to significantly restrict students’ exposure to limited disease conditions found only in their allocated ward.

With the super-specialization of the units, there is some bias on what they do learn; if a particular group is rotating on the cardiology unit, they will obviously have a bias to learn the history and physical exam related to cardiovascular disease (KII 1).

The students, particularly junior clerks, expressed dissatisfaction with the lack of proper and standardized orientation to the long case on the wards. This deficiency led to wastage of time and a feeling of being unwelcome in the clerkship.

Some orient you when you reach the ward but others you reach and you are supposed to pick up on your own. I expect orientation, then taking data from us, what they expect us to do, and what we expect from them, taking us through the clerkship sessions (FGD 4 Participant 1).

Students’ exposure to cases in other wards poses significant challenges; the study found that as some lecturers facilitate visits to different wards for scheduled teaching sessions, others don’t, resulting in missed learning opportunities. Additionally, some lecturers leave the burden on students’ personal initiative to explore cases in other wards.

We actually encourage them to go through the different specialties because when you are faced with a patient, you will not have to choose which one to see and not to see (KII 4).

Imagine landing on a stroke patient when you have been in the infectious disease ward or getting a patient with renal condition when you have been in the endocrinology ward can create problems (FGD 6 Participant 3).

Theme 2 Case presentation

Medical students present their long case to lecturers and postgraduate students. However, participants revealed variations among lecturers regarding their preferences on how they want students to present their cases. While some prefer to listen to the entire history and examination, others prefer only a summary, and some prefer starting from the diagnosis.

The practice varies depending on the lecturer, as everyone does it their own way. There are some, who listen to your history, examination, and diagnosis, and then they go into basic discussion of the case; others want only a summary. Some lecturers come and tell you to start straight away from your diagnosis, and then they start treating you backward (FGD 6 Participant 3).

The students reported limited observation of their skills due a little emphasis placed by examiners on physical examination techniques, as well as not providing the students with the opportunity to propose treatment plans.

When we are doing these physical examinations on the ward no one is seeing you. You present your physical examination findings, but no one saw how you did it. You may think you are doing the right thing during the ward rotations, but actually your skills are bad (FGD 4 Participant 6).

They don’t give us time to propose management plans. The only time they ask for how you manage a patient is during the summative long case, yet during the ward rotation, they were not giving us the freedom to give our opinion on how we would manage the patient.(FGD 2Participant 6).

Supervision was reportedly dependent on the ward to which the student was allocated. Additionally, the participants believe that the large student-to-lecturer ratio negatively affects the opportunity to present.

My experience was different in years three and five. In year three, we had a specialist every day on the ward, but in year five, we would have a specialist every other day, sometimes even once a week. When I compare year five with year three, I think I was even a better doctor in year three than right now (FGD 1 Participant 1).

Clinical training is like nurturing somebody to behave or conduct themselves in a certain way. Therefore, if the numbers are large, the impacts per person decrease, and the quality decreases (KII 5).

Theme C: Case assessment and feedback

The study found that a student’s long case is assessed both during the case presentation on the ward and through the case write-up, with marks awarded accordingly.

They present to the supervisor and then also write it up, so at a later time you also mark the sheet where they have written up the cases; so they are assessed at presentation and write up (KII 2).

The mark awarded was reportedly a significant motivator for students to visit wards and clerk patients, but students also believe that the pressure to hunt for marks tends to override the goal of the formative assessment.

Your goal there is to learn, but most of us go with the goal of getting signatures; signature-based learning. The learning, you realize probably comes on later if you have the individual morale to go and learn (FGD 1 participant 1).

Feedback is an integral part of any formative assessment. While students receive feedback from lecturers, the participants were concerned about the absence of a formal channel for soliciting feedback from students.

Of course, teachers provide feedback to students because it is a normal part of teaching. However, it is not a common routine to solicit feedback about how teaching has gone. So maybe that is something that needs to be improved so that we know if we have been effective teachers (KII 3).

Whereas the feedback intrigues students to read more to compensate for their knowledge gap, they decried several encounters with demeaning, intimidating, insulting, demotivating, and embarrassing feedback from assessors.

Since we are given a specific target of case presentation we are supposed to make in my training , if I make the ten, I wouldn’t want to present again. Why would I receive other negative comments for nothing? They truly have a personality effect on the student, and students feel low self-esteem (FGD 1, Participant 4).

This study aimed to investigate the experiences of medical students and faculty regarding the use of the long case as a formative assessment method at a tertiary care teaching hospital in a low-resource setting. This qualitative research provides valuable insights into the current practices surrounding the long case as a formative assessment method in such a setting.

The study highlighted the patient bedside as the primary learning environment for medical students. Bedside teaching plays a crucial role in fostering the development of skills such as history-taking and physical examination, as well as modeling professional behaviors and directly observing learners [ 14 , 15 ]. However, the specialization of wards in tertiary hospitals means that students may not be exposed to certain conditions found in other wards. This lack of exposure can lead to issues of case specificity, which has been reported in various literature as a cause of low reliability and generalizability of the long case [ 16 , 17 ]. Participants in the study expressed feeling like pseudo-specialists based on their ward allocations. This is partly attributed to missing scheduled teachings and poor management of opportunities to clerk and present patients on other wards. Addressing these challenges is essential for enhancing the effectiveness of the long case as a formative assessment method in medical education.

Proper orientation at the beginning of a clerkship is crucial for clarifying the structure and organization, defining students’ roles, and providing insights into clinical supervisors’ perspectives [ 18 ]. However, the study revealed that orientation into the long case was unsatisfactory, resulting in time wastage and potentially hindering learning. Effective orientation requires dedicated time and should involve defining expectations and goals, as well as guiding students through the steps of history-taking and physical examination during the initial weeks of the rotation. Contrary to this ideal approach, the medical students reported being taken through systemic examinations when the clerkship was nearing its end, highlighting a significant gap in the orientation process. Proper orientation is very important since previous studies have also documented the positive impact of orientation on student performance [ 19 ]. Therefore, addressing the shortcomings in orientation practices identified in this study is essential for optimizing learning outcomes and ensuring that students are adequately prepared to engage in the long case.

There was reportedly a significant variation in the way students present their long cases, with some lecturers preferring only a case summary, while others expect a complete presentation or begin with a diagnosis. While this diversity in learning styles may expose students to both familiar and unfamiliar approaches, providing a balance of comfort and tension [ 20 ], it’s essential for students to first be exposed to familiar methods before transitioning to less familiar ones to expand their ability to use diverse learning styles. The variation observed in this context may be attributed to time constraints, as lecturers may aim to accommodate the large number of students within the available time. Additionally, a lack of standardized practices could also contribute to this variation. Therefore, there is a pressing need for standardized long-case practices to ensure a consistent experience for students and to meet the desired goals of the assessment. Standardizing the long case practice would not only provide a uniform experience for students but also enhance the reliability, validity, and perception of fairness of the assessment [ 9 , 21 ]. It would ensure that all students are evaluated using the same criteria, reducing potential biases and disparities in grading. Additionally, standardized practices facilitate better alignment with learning objectives and promote more effective feedback mechanisms [ 22 ].

Related to the above, students reported limited observation of skills and little emphasis placed on them to learn physical examination techniques. This finding resonates with the research conducted by Abdalla and Shorbagi in 2018, where many students reported a lack of observation during history-taking and physical examination [ 23 ]. The importance of observation is underscored by the fact that students often avoid conducting physical examinations, as highlighted in Pavlakis & Laurent’s study among postgraduate trainees in 2001 [ 24 ]. This study sheds more light on the critical role of observation in forcing medical students to master clinical assessment and practical skills. The study also uncovered that students are rarely given the opportunity to propose management plans during case presentations, which hampers their confidence and learning of clinical decision-making. These findings likely stem from the large student-to-lecturer ratio and little attention given to these aspects of the long case during the planning of the assessment method. The result is students not receiving the necessary guidance and support to develop their clinical and decision-making skills. Therefore, addressing these issues by putting more emphasis on observation of student-patient interaction, management plan, and having a smaller student group is vital to ensure that medical students receive comprehensive training and are adequately prepared for their future roles as physicians.

The study found that the marks awarded for the long case serve as the primary motivator for students. This finding aligns with previous research indicating that the knowledge that each long case is part of assessment drives students to perform their duties diligently [ 2 , 25 ]. It underscores the crucial role that assessment plays in driving learning processes. However, the pressures to obtain marks and signatures reportedly hinder students’ engagement in learning. This could be attributed to instances where some lecturers relax on supervision or are absent, leaving students to struggle to find someone to assess them. Inadequate supervision by attending physicians has been identified in prior studies as one of the causes of insufficient clinical experience [ 26 ], something that need to be dealt with diligently. While the marks awarded are a motivating factor, it is essential to understand other underlying motivations of medical students to engage in the long case and their impact on the learning process.

Feedback is crucial for the long case to fulfill its role as an assessment for learning. The study participants reported that feedback is provided promptly as students present their cases. This immediate feedback is essential for identifying errors and learning appropriate skills to enhance subsequent performance. However, the feedback process appears to be unilateral, with students receiving feedback from lecturers but lacking a structured mechanism for providing feedback themselves. One reason for the lack of student feedback may be a perceived intimidating approach from lecturers which discourages students from offering their input. It is thus important to establish a conducive environment where students feel comfortable providing feedback without fear of negative repercussions. The study underscores the significance of feedback from students in improving the learning process. This aligns with the findings of Hattie and Timperley (2007), who emphasized that feedback received from learners contributes significantly to improvements in student learning [ 27 ]. Therefore, it is essential to implement strategies to encourage and facilitate bidirectional feedback between students and lecturers in the context of the long case assessment. This could involve creating formal channels for students to provide feedback anonymously or in a structured format, fostering open communication, and addressing any perceived barriers to feedback exchange [ 28 ]. By promoting a culture of feedback reciprocity, educators can enhance the effectiveness of the long case as an assessment tool.

Conclusions

In conclusion, the long case remains a cornerstone of formative assessment during clerkship in many medical schools, particularly in low-resource countries. However, its effectiveness is challenged by limitations such as case specificity in tertiary care hospitals, which can affect the assessment’s reliability and generalizability. The practice of awarding marks in formative assessment serves as a strong motivator for students but also creates tension, especially when there is inadequate contact with lecturers. This can lead to a focus on hunting for marks at the expense of genuine learning. Thus adequate supervision and feedback practices are vital for ensuring the success of the long case as an assessment for learning.

Furthermore, there is a need to foster standardized long case practice to ensure that scheduled learning activities are completed and that all students clerk and present patients with different conditions from various wards. This will promote accountability among both lecturers and students and ensure a consistent and uniform experience with the long case as an assessment for learning, regardless of the ward a student is assigned.

Data availability

The data supporting the study results of this article can be accessed from the Makerere University repository, titled “Perceptions of Medical Students and Lecturers of the Long Case Practices as Formative Assessment in Internal Medicine Clerkship at Makerere University,” available on DSpace. The identifier is http://hdl.handle.net/10570/13032 . Additionally, the raw data are securely stored with the researchers in Google Drive.

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This research was supported by the Fogarty International Centre of the National Institute of Health under award number 1R25TW011213. The content is solely the responsibility of the author and does not necessarily represent the official views of the National Institute of Health.

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JK contributed to the conception and design of the study, as well as the acquisition, analysis, and interpretation of the data. He also drafted the initial version of the work and approved the submitted version. He agrees to be personally accountable for his contribution and to ensure that any questions related to the accuracy or integrity of any part of the work, even those in which he was not personally involved, are appropriately investigated and resolved, with the resolution documented in the literature.IMG contributed to the analysis and interpretation of the data. He also made major corrections to the first draft of the manuscript and approved the submitted version. He agrees to be personally accountable for his contribution and to ensure that any questions related to the accuracy or integrity of any part of the work, even those in which he was not personally involved, are appropriately investigated and resolved, with the resolution documented in the literature.MA contributed to the analysis and interpretation of the data. He made major corrections to the first draft of the manuscript and approved the submitted version. He agrees to be personally accountable for his contribution and to ensure that any questions related to the accuracy or integrity of any part of the work, even those in which he was not personally involved, are appropriately investigated and resolved, with the resolution documented in the literature.SK made major corrections to the first draft and the final corrections for the submitted version of the work. She agrees to be personally accountable for her contribution and to ensure that any questions related to the accuracy or integrity of any part of the work, even those in which she was not personally involved, are appropriately investigated and resolved, with the resolution documented in the literature.

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Kumakech, J., Munabi, I.G., Mubuuke, A.G. et al. Experiences of medical students and faculty regarding the use of long case as a formative assessment method at a tertiary care teaching hospital in a low resource setting: a qualitative study. BMC Med Educ 24 , 621 (2024). https://doi.org/10.1186/s12909-024-05589-7

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DOI : https://doi.org/10.1186/s12909-024-05589-7

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