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• What Is Action Research? | Definition & Examples

What Is Action Research? | Definition & Examples

Published on January 27, 2023 by Tegan George . Revised on January 12, 2024.

Table of contents

Types of action research, action research models, examples of action research, action research vs. traditional research, advantages and disadvantages of action research, other interesting articles, frequently asked questions about action research.

There are 2 common types of action research: participatory action research and practical action research.

• Participatory action research emphasizes that participants should be members of the community being studied, empowering those directly affected by outcomes of said research. In this method, participants are effectively co-researchers, with their lived experiences considered formative to the research process.
• Practical action research focuses more on how research is conducted and is designed to address and solve specific issues.

Both types of action research are more focused on increasing the capacity and ability of future practitioners than contributing to a theoretical body of knowledge.

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Action research is often reflected in 3 action research models: operational (sometimes called technical), collaboration, and critical reflection.

• Operational (or technical) action research is usually visualized like a spiral following a series of steps, such as “planning → acting → observing → reflecting.”
• Collaboration action research is more community-based, focused on building a network of similar individuals (e.g., college professors in a given geographic area) and compiling learnings from iterated feedback cycles.
• Critical reflection action research serves to contextualize systemic processes that are already ongoing (e.g., working retroactively to analyze existing school systems by questioning why certain practices were put into place and developed the way they did).

Action research is often used in fields like education because of its iterative and flexible style.

After the information was collected, the students were asked where they thought ramps or other accessibility measures would be best utilized, and the suggestions were sent to school administrators. Example: Practical action research Science teachers at your city’s high school have been witnessing a year-over-year decline in standardized test scores in chemistry. In seeking the source of this issue, they studied how concepts are taught in depth, focusing on the methods, tools, and approaches used by each teacher.

Action research differs sharply from other types of research in that it seeks to produce actionable processes over the course of the research rather than contributing to existing knowledge or drawing conclusions from datasets. In this way, action research is formative , not summative , and is conducted in an ongoing, iterative way.

As such, action research is different in purpose, context, and significance and is a good fit for those seeking to implement systemic change.

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Action research comes with advantages and disadvantages.

• Action research is highly adaptable , allowing researchers to mold their analysis to their individual needs and implement practical individual-level changes.
• Action research provides an immediate and actionable path forward for solving entrenched issues, rather than suggesting complicated, longer-term solutions rooted in complex data.
• Done correctly, action research can be very empowering , informing social change and allowing participants to effect that change in ways meaningful to their communities.

Disadvantages

• Due to their flexibility, action research studies are plagued by very limited generalizability  and are very difficult to replicate . They are often not considered theoretically rigorous due to the power the researcher holds in drawing conclusions.
• Action research can be complicated to structure in an ethical manner . Participants may feel pressured to participate or to participate in a certain way.
• Action research is at high risk for research biases such as selection bias , social desirability bias , or other types of cognitive biases .

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
• Inclusion and exclusion criteria

Research bias

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

Action research is conducted in order to solve a particular issue immediately, while case studies are often conducted over a longer period of time and focus more on observing and analyzing a particular ongoing phenomenon.

Action research is focused on solving a problem or informing individual and community-based knowledge in a way that impacts teaching, learning, and other related processes. It is less focused on contributing theoretical input, instead producing actionable input.

Action research is particularly popular with educators as a form of systematic inquiry because it prioritizes reflection and bridges the gap between theory and practice. Educators are able to simultaneously investigate an issue as they solve it, and the method is very iterative and flexible.

A cycle of inquiry is another name for action research . It is usually visualized in a spiral shape following a series of steps, such as “planning → acting → observing → reflecting.”

Sources in this article

We strongly encourage students to use sources in their work. You can cite our article (APA Style) or take a deep dive into the articles below.

George, T. (2024, January 12). What Is Action Research? | Definition & Examples. Scribbr. Retrieved April 11, 2024, from https://www.scribbr.com/methodology/action-research/

Cohen, L., Manion, L., & Morrison, K. (2017). Research methods in education (8th edition). Routledge.

Naughton, G. M. (2001).  Action research (1st edition). Routledge.

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Action Research vs. Case Study

What's the difference.

Action research and case study are both research methodologies used in social sciences to investigate and understand complex phenomena. However, they differ in their approach and purpose. Action research is a collaborative and participatory approach that involves researchers and practitioners working together to identify and solve practical problems in real-world settings. It aims to bring about positive change and improvement in the context being studied. On the other hand, case study is an in-depth and detailed examination of a particular individual, group, or situation. It focuses on understanding the unique characteristics and dynamics of the case being studied and often involves extensive data collection and analysis. While action research emphasizes practical application and problem-solving, case study emphasizes detailed exploration and understanding of a specific case.

Further Detail

Introduction.

Action research and case study are two widely used research methodologies in various fields. While both approaches aim to gain insights and understanding, they differ in their focus, design, and implementation. This article will explore the attributes of action research and case study, highlighting their similarities and differences.

Action Research

Action research is a participatory approach that involves collaboration between researchers and practitioners to address real-world problems. It emphasizes the active involvement of stakeholders in the research process, aiming to bring about practical change and improvement. Action research typically follows a cyclical process, consisting of planning, action, observation, and reflection.

One of the key attributes of action research is its focus on generating knowledge that is directly applicable to the context in which it is conducted. It aims to bridge the gap between theory and practice by actively involving practitioners in the research process. This participatory nature allows for a deeper understanding of the complexities and nuances of the problem being investigated.

Action research often involves multiple iterations, with each cycle building upon the insights gained from the previous one. This iterative approach allows for continuous learning and adaptation, enabling researchers to refine their interventions and strategies based on the feedback received. It also promotes a sense of ownership and empowerment among the participants, as they actively contribute to the research process.

Furthermore, action research is characterized by its emphasis on collaboration and co-learning. It encourages the exchange of ideas and knowledge between researchers and practitioners, fostering a sense of shared responsibility and collective action. This collaborative approach not only enhances the quality of the research but also increases the likelihood of successful implementation of the findings.

In summary, action research is a participatory and iterative approach that aims to generate practical knowledge through collaboration between researchers and practitioners. It focuses on addressing real-world problems and promoting positive change within specific contexts.

Case study, on the other hand, is an in-depth investigation of a particular phenomenon, event, or individual. It involves the detailed examination of a specific case or cases to gain a comprehensive understanding of the subject under study. Case studies can be conducted using various research methods, such as interviews, observations, and document analysis.

One of the key attributes of case study research is its ability to provide rich and detailed insights into complex phenomena. By focusing on a specific case, researchers can delve deep into the intricacies and unique aspects of the subject, uncovering valuable information that may not be easily captured through other research methods.

Case studies are often used to explore and understand real-life situations in their natural settings. They allow researchers to examine the context and dynamics surrounding the case, providing a holistic view of the phenomenon under investigation. This contextual understanding is crucial for gaining a comprehensive and nuanced understanding of the subject.

Furthermore, case studies are particularly useful when the boundaries between the phenomenon and its context are not clearly defined. They allow for the exploration of complex and multifaceted issues, enabling researchers to capture the interplay of various factors and variables. This holistic approach enhances the validity and reliability of the findings.

Moreover, case studies can be exploratory, descriptive, or explanatory in nature, depending on the research questions and objectives. They can be used to generate hypotheses, provide detailed descriptions, or test theoretical frameworks. This versatility makes case study research applicable in various fields, including psychology, sociology, business, and education.

In summary, case study research is an in-depth investigation of a specific phenomenon, providing rich and detailed insights into complex situations. It focuses on understanding the context and dynamics surrounding the case, allowing for a comprehensive exploration of multifaceted issues.

Similarities

While action research and case study differ in their focus and design, they also share some common attributes. Both approaches aim to gain insights and understanding, albeit through different means. They both involve the collection and analysis of data to inform decision-making and improve practice.

Furthermore, both action research and case study can be conducted in naturalistic settings, allowing for the examination of real-life situations. They both emphasize the importance of context and seek to understand the complexities and nuances of the phenomena under investigation.

Moreover, both methodologies can involve multiple data collection methods, such as interviews, observations, and document analysis. They both require careful planning and design to ensure the validity and reliability of the findings.

Additionally, both action research and case study can contribute to theory development. While action research focuses on generating practical knowledge, it can also inform and contribute to theoretical frameworks. Similarly, case studies can provide empirical evidence that can be used to refine and expand existing theories.

In summary, action research and case study share common attributes, including their aim to gain insights and understanding, their focus on real-life situations, their emphasis on context, their use of multiple data collection methods, and their potential contribution to theory development.

Action research and case study are two distinct research methodologies that offer unique approaches to gaining insights and understanding. Action research emphasizes collaboration, participation, and practical change, while case study focuses on in-depth investigation and contextual understanding. Despite their differences, both approaches contribute to knowledge generation and have the potential to inform theory and practice. Researchers should carefully consider the nature of their research questions and objectives to determine which approach is most suitable for their study.

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• Case Study | Definition, Examples & Methods

Case Study | Definition, Examples & Methods

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

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

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

Table of contents

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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Please note you do not have access to teaching notes, an action research case study: digital equity and educational inclusion during an emergent covid-19 divide.

Journal for Multicultural Education

ISSN : 2053-535X

Article publication date: 22 January 2021

Issue publication date: 4 June 2021

This paper aims to share responses from current literature, a small case study about perceptions and practices of the school of education faculty toward multicultural and educational issues concerning the rapid rise in online environments during coronavirus (COVID-19) experiences and just-in-time strategies for addressing digital equity and educational inclusion in K-16 online educational settings.

Design/methodology/approach

This is a conceptual paper that emerged from an action research case study. The study included four faculty in an urban school of education. The faculty participants were asked to provide examples of educational inclusion strategies used during transitioning their courses and advising to online environments in a Research I university. Faculty included one educational leadership, one sports management, one special education and one teacher education professor. Central issues explored practices related to language, technology access, curriculum design and technological competencies and assessment. A driving question was: How do institutions, schools or educators provide learning opportunities to support digital equity and inclusive education practice to maintain and strengthen relationships and core practices of multicultural education during a time of physical distancing during COVID-19? And what are the experiences, barriers, successes?

Research-based transformative knowledge, real situations and practical resources for considering inclusive education curriculum concepts were found that are connecting educators, teachers, learners and communities during this time of crisis.

Research limitations/implications

Methodological limitations that influenced the research design include conducting research in a totally virtual environment, small sample size, lack of diversity in curriculum content and one research site. The data collection was limited to written responses from the faculty participants. This action research study took place in a time frame limited by COVID-19 conditions during a four-month period.

Practical implications

In theory and practice, this new online movement suggests learners, teachers, educators and leaders are gaining experience and knowledge about resources and strategies for using new technologies, assessments and flexible curriculum as powerful tools for building language, curriculum and social-cultural communication bonds across generations and including special needs populations. Such new and emerging strategies could be used to bridge gaps in a time of distancing to support inclusive and equitable learning environments in education to minimize the effects of an emergent COVID-19 digital divide. Social learning culture as constructed, performed and captured in patterns of cooperation among faculties shows the world becoming more open and less restricted by borders. In conclusion, an emerging new conceptual framework is presented in Figure 2 to support action planning to bridge the digital equity access and learning gaps created by COVID-19.

Social implications

It is in times of strife and difficulty that problems and issues become exacerbated. While some educators easily adapted and took on the challenges of online learning, others needed time for learning and mourning (literally and figuratively). The issues of equity and access have become even more apparent as this paper takes inventory of intersections between multicultural education, special education, sports education and K-16 education overall. This is an excellent time to reflect on how education can address the cultural, economic and social barriers that impact student learning globally for all learners.

Originality/value

The brief collective case study reports educational experiences during a time of crisis that stimulates creative and innovative approaches to creating inclusive and equitable online learning environments to address diverse learning needs. The various and often contrasting educator responses from faculty facing digital and educational challenges present ideas that might be applicable in the global learning environment beyond the COVID-19 pandemic.

• Online learning
• New technologies
• Transformative knowledge

Acknowledgements

World Council on Curriculum and Instruction -WCCI (UNESCO-NGO) Newsletter, Winter 2020 Content cited by Toh Swee-Hin (S.H.Toh) President, WCCI. Professor Emeritus, University of Alberta. Laureate, UNESCO Prize for Peace Education (2000).

Pittman, J. , Severino, L. , DeCarlo-Tecce, M.J. and Kiosoglous, C. (2021), "An action research case study: digital equity and educational inclusion during an emergent COVID-19 divide", Journal for Multicultural Education , Vol. 15 No. 1, pp. 68-84. https://doi.org/10.1108/JME-09-2020-0099

Emerald Publishing Limited

Copyright © 2020, Emerald Publishing Limited

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Qualitative study design: Action research

• Qualitative study design
• Phenomenology
• Grounded theory
• Ethnography
• Narrative inquiry
• Action research
• Case Studies
• Field research
• Focus groups
• Observation
• Surveys & questionnaires
• Study Designs Home

Action research / Participatory Action Research

These methods focus on the emancipation, collaboration and empowerment of the participants. This methodology is appropriate for collaborative research with groups, especially marginalised groups, where there is more flexibility in how the research is conducted and considers feedback from the participants. 

Has three primary characteristics:  

Action oriented, participants are actively involved in the research.

involvement by participants in the research, collaborative process between participant and researcher - empowerment of participants. The participants have more of a say in what is being researched and how they want the research to be conducted.

cycle is iterative so that it is flexible and responsive to a changing situation.  

• Questionnaires
• Oral recordings
• Focus groups,
• Photovoice (use of images or video to capture the local environment / community and to share with others)
• Informal conversations 

Produces knowledge from marginalised people's point of view and can lead to more personalised interventions.  

Provides a voice for people to speak about their issues and the ability to improve their own lives. People take an active role in implementing any actions arising from the research. 

Transforms social reality by linking theory and practice.  

Limitations

Open ended questions are mainly used, and these can be misinterpreted by researcher – data needs to be cross-checked with other sources.

Data ownership between researcher and research participants needs to be negotiated and clearly stated from the beginning of the project.

Ethical considerations with privacy and confidentiality.

This method is not considered scientific as it is more fluid in its gathering of information and is considered an unconventional research method – thus it may not attract much funding.

Example questions

• What is the cultural significance of yarning amongst Aboriginal people?  

Macro Question:

• “What would it take to improve the stability of young people’s living situations?”  

Micro Questions:  

• “What can we do to better engage with accommodation service providers?”  
• “What can we do to improve the service knowledge of young people?”  
• “What can we do to measure stability outcomes for our clients?”  

(Department of Social Services)  

Example studies

• Miller, A., Massey, P. D., Judd, J., Kelly, J., Durrheim, D. N., Clough, A. R., . . . Saggers, S. (2015). Using a participatory action research framework to listen to Aboriginal and Torres Strait Islander people in Australia about pandemic influenza.  Rural and Remote Health , 15(3), 2923-2923.  
• Spinney, A. (2013). Safe from the Start? An Action Research Project on Early Intervention Materials for Children Affected by Domestic and Family Violence. Children & Society, 27(5), 397-405. doi:10.1111/j.1099-0860.2012.00454.x 
• Department of Social Services. (2019).  On PAR  - Using participatory action research to improve early intervention. 
• Liamputtong, P. (2013). Qualitative research methods (4th ed.). South Melbourne: Oxford  University Press. 
• Mills, J., & Birks, M. (2014). Qualitative Methodology: A Practical Guide. Retrieved from https://methods.sagepub.com/book/qualitative-methodology-a-practical-guide doi:10.4135/9781473920163 
• << Previous: Narrative inquiry
• Next: Case Studies >>
• Last Updated: Apr 8, 2024 11:12 AM
• URL: https://deakin.libguides.com/qualitative-study-designs

Home » Education » Difference Between Action Research and Case Study

Difference Between Action Research and Case Study

Main difference – action research vs case study.

Research is the careful study of a given field or problem in order to discover new facts or principles. Action research and case study are two types of research, which are mainly used in the field of social sciences and humanities. The main difference between action research and case study is their purpose; an action research study aims to solve an immediate problem whereas a case study aims to provide an in-depth analysis of a situation or case over a long period of time.

1. What is Action Research?      – Definition, Features, Purpose, Process

2. What is Case Study?      – Definition, Features, Purpose, Process

What is Action Research

Action research is a type of a research study that is initiated to solve an immediate problem. It may involve a variety of analytical, investigative and evaluative research methods designed to diagnose and solve problems. It has been defined as “a disciplined process of inquiry conducted by and for those taking the action. The primary reason for engaging in action research is to assist the “actor” in improving and/or refining his or her actions” (Sagor, 2000). This type of research is typically used in the field of education. Action research studies are generally conductors by educators, who also act as participants.

Here, an individual researcher or a group of researchers identify a problem, examine its causes and try to arrive at a solution to the problem. The action research process is as follows.

Action Research Process

• Identify a problem to research
• Clarify theories
• Identify research questions
• Collect data on the problem
• Organise, analyse, and interpret the data
• Create a plan to address the problem
• Implement the above-mentioned plan
• Evaluate the results of the actions taken

The above process will keep repeating. Action research is also known as cycle of inquiry or cycle of action since it follows a specific process that is repeated over time.

What is a Case Study

A case study is basically an in-depth examination of a particular event, situation or an individual. It is a type of research that is designed to explore and understand complex issues; however, it involves detailed contextual analysis of only a limited number of events or situations. It has been defined as “an empirical inquiry that investigates a contemporary phenomenon within its real-life context; when the boundaries between phenomenon and context are not clearly evident; and in which multiple sources of evidence are used.” (Yin, 1984)

Case studies are used in a variety of fields, but fields like sociology and education seem to use them the most. They can be used to probe into community-based problems such as illiteracy, unemployment, poverty, and drug addiction. 

Case studies involve both quantitative and qualitative data and allow the researchers to see beyond statistical results and understand human conditions. Furthermore, case studies can be classified into three categories, known as exploratory, descriptive and explanatory case studies.

However, case studies are also criticised since the study of a limited number of events or cases cannot easily establish generality or reliability of the findings. The process of a case study is generally as follows:

Case Study Process

• Identifying and defining the research questions
• Selecting the cases and deciding techniques for data collection and analysis
• Collecting data in the field
• Evaluating and analysing the data
• Preparing the report

Action Research : Action research is a type of a research study that is initiated to solve an immediate problem.

Case Study : Case study is an in-depth analysis of a particular event or case over a long period of time.                         

Action Research : Action research involves solving a problem.

Case Study : Case studies involve observing and analysing a situation.

Action Research : Action research studies are mainly used in the field of education.

Case Study : Case studies are used in many fields; they can be specially used with community problems such as unemployment, poverty, etc.

Action Research : Action research always involve providing a solution to a problem.

Case Study : Case studies do not provide a solution to a problem.

Participants

Action Research : Researchers can also act as participants of the research.

Case Study : Researchers generally don’t take part in the research study.

Zainal, Zaidah.  Case study as a research method . N.p.: n.p., 7 June 2007. PDF.

 Soy, Susan K. (1997).  The case study as a research method . Unpublished paper, University of Texas at Austin.

Sagor, Richard.  Guiding school improvement with action research . Ascd, 2000.

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Organizing Your Social Sciences Research Assignments

• Annotated Bibliography
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• Writing a Case Study
• About Informed Consent
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• Acknowledgments

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

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

How to Approach Writing a Case Study Research Paper

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

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

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

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

Structure and Writing Style

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

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

I.  Introduction

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

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

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

II.  Literature Review

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

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

III.  Method

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

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

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

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

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

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

IV.  Discussion

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

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

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

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

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

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

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

V.  Conclusion

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

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

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

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

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

Problems to Avoid

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

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

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

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

Writing Tip

At Least Five Misconceptions about Case Study Research

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

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

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

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

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The case study approach

Sarah crowe.

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

Kathrin Cresswell

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

Ann Robertson

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

Anthony Avery

Aziz sheikh.

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

Introduction

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

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

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

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

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

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

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

What is a case study?

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

Definitions of a case study

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

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

What are case studies used for?

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

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

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

How are case studies conducted?

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

Defining the case

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

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

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

Selecting the case(s)

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

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

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

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

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

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

Collecting the data

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

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

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

Analysing, interpreting and reporting case studies

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

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

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

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

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

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

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

Potential pitfalls and mitigating actions when undertaking case study research

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

Conclusions

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

Competing interests

The authors declare that they have no competing interests.

Authors' contributions

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

Pre-publication history

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

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

Acknowledgements

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

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Action research or case study?

When planning for a practice-based enquiry or small-scale study you will most often be confronted with the choice between an action research or case study approach. Strictly speaking, there are many approaches to enquiries, but for practical reasons the action research or case study approaches are amongst the most popular for teacher-researchers.

Your decision for one or the other approach must be well justified and to this end you must consult research methodology literature. However, in the following there will be a simplified exploration of the two approaches to get you started.

What is action research? Action research should be considered as a way of life in the classroom. As a reflective practitioner you will observe what happens in your class and then identify an issue or problem that you need to address. After consulting relevant literature you will then formulate a new approach or intervention, which you carry out in your classroom. Once you have worked with this intervention you will reflect and reconsider its effectiveness and impact and the cycle can start again. For a practice-based enquiry you may go through several cycles or through one cycle only. The advantage of the action research is that it naturally develops from your teaching practice and that it addresses real issues within your classroom. Typical critique of action researches would be that they are not rigorous or systematic enough.

What is case study? A case study is more difficult to understand because it can be a method as well as a methodology. Here we only look at case studies for their methodological function. If you want to learn more about a specific issue or you want to explore a particular problem or occurrence, then the case study is for you. The description of what makes a “case” differs in various research methodology publications, but generally speaking a “case” can refer to a group of people, a specific person or issue, a collective of ideas. The advantage of a case study is that you get to know the status quo in all its facets and so you gain a deep insight into your field of study. Common critique of the case study approach is that it is so specialised and specific to the context of the research that generalisability is lost. Sometimes it is also said that the mere description of a status quo is not practical for teachers because there are no changes. My argument would be that detailed knowlegde of what happens in your classroom or school can lead to recommendations for future practice. It is just that you do not enter a cyclical approach of evaluating and revisiting your suggested changes.

Action research or case study? Both approaches have their benefits and limitations within the realm of practice-based enquiries. The choice therefore depends on what it is that you want to find out. Are you planning to introduce a new teaching strategy or changes or interventions with some or all of your pupils? Or are you trying to explore a specific topic? The former would be a justification for action research, whereas the latter hints at a case study. You must be guided by your research focus, your research question or hypothesis and by the research methodology publications you consult.

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Difference between Case Study and Action research

1. Action Research : Action Research is a type of qualitative research. As the name suggests it is more action oriented in order to solve an immediate problem. Action research helps the researcher to improvise its current practices and is applied for researching into issues. It aims to learn through action leading to personal or professional development means focuses on improving and/or refining actions. This type research generally used in field of education to bridge the gap between educational theory and professional practice by improvising their current practices. This helps in observing the problem and identifying the cause and then addressing the issue so mainly it is more focused on immediate addressing to practical problems and in generating knowledge to produce change.

2. Case Study : Case study research refers to an in-depth examination of a particular event or individual or a group of individuals. It is more of a qualitative method of research where it understand complex issues by deeply observing and analyzing the event or situation by collecting and reporting the data related to the event or situation. Case study research is more towards description rather than immediate cause and effect finding. Case study is categorized into three ways i.e., exploratory, explanatory and descriptive based on research method. These studies involve both quantitative and qualitative data. This type of research can be used to address community-based problems like illiteracy, unemployment, poverty, and drug addiction.

Difference between Case study and Action Research :

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OPINION article

This article is part of the research topic.

Smart Sustainable Development: Exploring Innovative Solutions and Sustainable Practices for a Resilient Future

Action Learning for Change Management in Digital Transformation Provisionally Accepted

• 1 Frankfurt University of Applied Sciences, Germany

The final, formatted version of the article will be published soon.

Digital Transformation is not only a technology endeavour but affects the whole organisation, like a company or Non-Profit-Organisation (Tabrizi et al., 2019). Technologies like Artificial Intelligence, Data Science or Cloud Computing are relevant (Sebastian et al., 2017) but rather enable improvements (Pasqual et al., 2023;Vogelsang et al., 2019). Real benefits can only be achieved by a new business models or innovative products that will change the way how value is created in a company (Matt et al., 2015). As this also implies structural changes, succeeding in such a journey requires skills and competencies in conducting changes in an organisation.Education in courses on Digital Transformation at university aims to prepare students for conducting such changes within an organisation-both, from a technological but also from a management perspective. However, there are some challenges in teaching change management as the topic and the consequences of a change in a corporate environment are still quite abstract for students. While individual students managed personal changes in their life, challenges in a large organisation are hard to tell by just using words. Change projects and, therefore, a Digital Transformation for revolutionising the business model of a company, change the organisational structure, affect people and their careers and may cause uncertainty (Kotter, 2012).The paper presents a case study on applying Action Learning (AL) for simulating the situation during a change and how to facilitate a change. The objective therefore is to let students experience changes in organisations in order to develop a better understanding of the need for and how to deal with resistance from employees or stakeholders during a digital transformation. AL, an experienced-based learning method, is described as e.g. learning by doing, collaborating, sharing ideas, lifelong learning as well as reflecting on practice (Zuber-Skerrit, 2002, p. 114). It focusses on taking action on important issues or problems (Hauser et al., 2023, p. 117). In addition, it is "a framework for a group of people to learn and develop through open and trusting interaction" (Pedler et al., 2005in Hauser et al., 2023, p. 116). The basis of AL is the concept of question. By asking questions, AL becomes a social process in which a lot of people start to learn with and from each other, and a learning community comes into being (Revans, 1982, pp. 66, 69,70).As well as AL, sustainable education is a cultural shift in how education and learning is understood (Sterling, 2008, p. 65). If the method is applied in higher education, it changes the learning and teaching culture. While the main objective remains knowledge transfer, experience as well as soft skills become more important including planning and organising the own learning process. AL can be used as a method to encourage students to be more independent.An AL Project starts with a specific (real) problem without a (simple) solution at handlecturers accompany the learning. Addressing the problem that confronts participants necessitates a decisionmaking process within the group. In this project the primary objective is to make knowledge from the lecture permanently available in the students' minds and also to motivate them to learn more independently, reflect and think critically. The achievement of the objective is supposed to be determined during the oral exams at the end of the semester. The postgraduate course on Business Information Systems at the Frankfurt University of Applied Sciences (Germany) has a focus on Digital Transformation. A dedicated module on Strategic Process Management teaches methods and tools for optimising processes in the course of a transformationincluding change management. While teaching, it became clear that most students have never been subject to a significant corporate change, cannot assess the necessity for facilitating such a change and dealing with resistance from employees or stakeholders. The class was therefore running into danger to just learn words by heart (written in text books on change management) but will never understand how being part of such a change feels like. Hence, the teachers introduced one session using action learning to achieve sustainability in learning by experiencing change. The second author, who is the professor in charge, has no active role during the AL training session and is deliberately not in the room. As the examining and grading person the assumption is that it could hinder the training. The professor is therefore the Learning Process Facilitator (Robertson and Heckroodt, 2022, p. 81). The first author accompanies the process as participant and take on the role of observer. Two external facilitators guide the students through the training.This training has integrated work and learning which is the basis of AL (Maltiba andMarsick, 2008 in Cho andEgan, 2009, p. 441). The (learning) success was due to the systematic approach of this AL session as well due to the guidance of the trainers. Learning from experience does need structure otherwise it can be inefficient (Zuber-Skerrit, 2002, p. 115).A professional training company with experience in change management and personal development has been hired. Two trainers of this company prepared a curriculum on how to motivate a change and, at the same time, confronted the students with a tough situation. After the training, they had to break a wooden board with their bare hands. Being shocked by this perspective, students listened to the trainers while they talked about facilitation as well as motivation and explained everything based on breaking the board. The whole training took around five hours, and at the end, each participant broke the board with their bare hands. In the pursuit of insights, data was collected through a combination of student observations and discussions and reflective exchanges with the students. The master students were hesitant in the beginningthey were expecting a lecture and got a quite different setting: visible through a circle of chairs, flip chart instead of Power Point and two people in front who do not look familiar. The students were intimidated, unsure and initially quiet. Over the day, the students thawed out and participated. At first, they could not make the connection to their lecture. The trainers supported the students in building the bridge to change management in the work context. This guidance through the trainers was necessary. Students were encouraged to ask questions and think of examples from their professional contexts; if they did not have them, references to their personal lives or volunteer work should be made. By the end of the day, students were open, asking questions, exchanging knowledge and experience, loosened up, and having fun: As the students were also emotionally involved in the training (because of the challenge) they developed an empathic understanding on how employees feel when being subject to change. This is one of the intended results since Action Learning has a "dual mission": people development and business impact (Cho and Egan, 2009, p. 441). They were able to experience transformation and change.It was a functional decision not to include the examiner in the training, because the observer also noticed that the students were somewhat restrained and sometimes looked at her. The observer was only known to the students from greeting and she also had the feeling that this made some people feel inhibited. For this reason, the external trainers, who ensure confidentiality, were ideal. The participative observation could have influenced the students' later statements.This case study is only transferable to a limited extent, since it is very specific: it only includes postgraduate student from one degree programme who mainly have done their undergraduates at the same university. In addition, for German universities, it is a rather smaller study group (10-16 students). Another special feature is the special background of the external trainers: Business information specialists and instructors for Jiu-Jitsu which both influence the case study/training.At the end of the semester, the module was concluded with an oral exam. The second author had often experienced students here in the past who reproduced knowledge but had limited understanding of what it meant and had difficulty bringing examples. This year, things were different: the students were able to give a lively account of change management based on the training and were able to substantiate the contents of the lecture with practical examples. The primary objective, as stated previously, can be seen as achieved as almost all students were able to reflect on the challenges with changes. One student struggled explaining reasons for resistance against changes in a company in the oral exam and just repeated words from the lecture slides. In this case the professor switched back to the role as a learning companion and encouraged the student to reflect on how they felt while being confronted with the wooden board challenge. Now the technical knowledge was connected to the emotional side and struggles with changes were explained in a livelier way.Action Learning as an innovative teaching method not only have advantages but also disadvantages in higher education settings. The following disadvantages and how we have tried to mitigate them should be mentioned: Applying AL is time consuming, and it has to fit in the university's schedule. We met this challenge through early and transparent (semester) planning. For AL, they were scheduled for a whole day and the session took longer than the usual lecture and exercise slot in the timetable. To counter this, the lecture room showed by a different seating (seating circle), which suggested a different teaching method, it was the day with excess length, and the integration of external facilitators made it clear that today is not a normal lecture.The case study makes the authors quite optimistic that Action Learning could be integrated in the curriculum to gain more time for the implementation and to enable a sustainable learning effect. Notably, certain factors have emerged as influential in promoting success in our case: the necessity of implementing AL in smaller group settings, the acquisition of external facilitators, the proactive scheduling of additional time slots within the semester plan, and the clear, advance communication of these schedule adjustments to enable students to align their plans accordingly. Importantly, there was an active expression of interest from some students for more sessions of this nature. In future, we are also planning to try out shorter formats to test whether AL could also be implemented in a regular course, i.e. 90 minutes.

Keywords: Action Learning, Change Management, higher education, Teaching, digital transformation

Received: 21 Feb 2024; Accepted: 11 Apr 2024.

Copyright: © 2024 Ruhland and Jung. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) or licensor are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

* Correspondence: Mx. Anja Ruhland, Frankfurt University of Applied Sciences, Frankfurt, Germany

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• Open access
• Published: 09 April 2024

Creating culturally-informed protocols for a stunting intervention using a situated values-based approach ( WeValue InSitu ): a double case study in Indonesia and Senegal

• Annabel J. Chapman 1 ,
• Chike C. Ebido 2 , 3 ,
• Rahel Neh Tening 2 ,
• Yanyan Huang 2 ,
• Ndèye Marème Sougou 4 ,
• Risatianti Kolopaking 5 , 6 ,
• Amadou H. Diallo 7 ,
• Rita Anggorowati 6 , 8 ,
• Fatou B. Dial 9 ,
• Jessica Massonnié 10 , 11 ,
• Mahsa Firoozmand 1 ,
• Cheikh El Hadji Abdoulaye Niang 9 &
• Marie K. Harder 1 , 2  

BMC Public Health volume  24 , Article number:  987 ( 2024 ) Cite this article

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International development work involves external partners bringing expertise, resources, and management for local interventions in LMICs, but there is often a gap in understandings of relevant local shared values. There is a widespread need to better design interventions which accommodate relevant elements of local culture, as emphasised by recent discussions in global health research regarding neo-colonialism. One recent innovation is the concept of producing ‘cultural protocols’ to precede and guide community engagement or intervention design, but without suggestions for generating them. This study explores and demonstrates the potential of an approach taken from another field, named WeValue InSitu , to generate local culturally-informed protocols. WeValue InSitu engages stakeholder groups in meaning-making processes which ‘crystallize’ their envelope of local shared values, making them communicable to outsiders.

Our research context is understanding and reducing child stunting, including developing interventions, carried out at the Senegal and Indonesia sites of the UKRI GCRF Action Against Stunting Hub. Each national research team involves eight health disciplines from micro-nutrition to epigenetics, and extensive collection of samples and questionnaires. Local culturally-informed protocols would be generally valuable to pre-inform engagement and intervention designs. Here we explore generating them by immediately following the group WeValue InSitu crystallization process with specialised focus group discussions exploring: what local life practices potentially have significant influence on the environments affecting child stunting, and which cultural elements do they highlight as relevant. The discussions will be framed by the shared values, and reveal linkages to them. In this study, stakeholder groups like fathers, mothers, teachers, market traders, administrators, farmers and health workers were recruited, totalling 83 participants across 20 groups. Themes found relevant for a culturally-informed protocol for locally-acceptable food interventions included: specific gender roles; social hierarchies; health service access challenges; traditional beliefs around malnutrition; and attitudes to accepting outside help. The concept of a grounded culturally-informed protocol, and the use of WeValue InSitu to generate it, has thus been demonstrated here. Future work to scope out the advantages and limitations compared to deductive culture studies, and to using other formative research methods would now be useful.

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Although progress has been made towards the SDG of ‘Zero Hunger by 2025’, the global rates of malnutrition and stunting are still high [ 1 ]. Over the past 20 years, researchers have implemented interventions to reduce undernutrition, specifically focussing on the first 1000 days of life, from conception to 24 months [ 2 ]. However, due to both differing determinants between countries [ 3 , 4 ] as well as varying contextual factors, it is clear that no single fixed approach or combination of approaches can be relied on when implementing stunting interventions [ 5 , 6 , 7 ]. Furthermore, when external researchers design interventions for local areas in Low- and Middle-Income Countries (LMICs) they can often overlook relevant local cultural factors that consequently act as barriers to intervention uptake and reduce their effectiveness, such as geographical factors and the levels of migration in certain populations [ 8 , 9 ], or social norms or perceptions relating to accepting outside help, and power dynamics related to gender [ 10 , 11 , 12 ]. The inclusion of cultural level factors in behaviour change interventions has been proposed as a requirement for effective interventions [ 13 ]. However, despite the breadth of literature highlighting the negative impacts from failing to do this, the lack of integration or even regard of local culture remains a persistent problem in Global Health Research [ 14 ], possibly hindering progress towards the SDGs. Thus, there is a need for approaches to integrate local cultural elements into intervention design.

This lack of understanding of relevant local culture, social norms and shared values also has ethical implications. The field of Global Health Ethics was predominantly developed in the Global North, in High Income Countries (HICs), embedding values common in those countries such as the prominence of individual autonomy [ 15 , 16 ]. Researchers from HICs carrying out research in LMICs may wrongly assume that values held in the Global North are universal [ 14 ] and disregard some local values, such as those related to family and collective decision making, which are core to many communities in LMICs. It is therefore important for outside researchers to have an understanding of relevant local values, culture and social norms before conducting research in LMICs so as not to impose values that do not align with local culture and inadvertently cause harm or offence [ 16 , 17 ]. The importance of this is compounded by the colonial history that is often present in relationships between research communities in HICs and LMICs, and the fact that the majority of the funding and leading institutions are still located in the Global North [ 18 , 19 ]. Thus, conscious steps must be taken to avoid neo-colonialism in Global Health Research [ 20 ]. From a health-equity perspective, it is essential to ensure that those in vulnerable communities are not hindered from involvement in interventions to improve nutrition. Encouraging uptake by such communities could be provided if salient local shared values, norms and culture were taken into account [ 21 ].

In a recent paper, Memon et al., (2021) highlight the usefulness of first creating a cultural protocol that can precede and guide subsequent stages of community engagement or intervention design to ensure that salient local values are known to external researchers coming into the community [ 16 ]. We adopt the use of the concept of a cultural protocol, referring to locally-generated guidance about key values, norms, behaviours and customs relevant to working with the local community. However, we prefer the term, ‘culturally-informed protocol’ since this relates to only cultural elements deemed salient by the researchers, and locally, rather than any comprehensive notion of culture, nor extending beyond the research context.

Memon et al. (2021), point out links between the creation of such a protocol and existing codes of practice that have already been created for some cultures such as the Te Ara Tika, a Guideline for Māori Research Ethics [ 22 ]. Currently, research and interventions in Global Health can be informed by a stage of formative research involving one-to-one interviews, focus groups or direct observations, which can sometimes be ethnographic in nature such as within Focussed Ethnographic Studies or Rapid Assessment Procedures [ 23 , 24 , 25 ]. Although these methods can be effective to inform intervention designs, they have disadvantages like: can take long periods to complete [ 26 ], can be resource intensive [ 26 ] and can lack cultural acceptability [ 27 ]. These limitations may account for the frequent neglect of their use generally, highlighted by Aubel and Chibanda (2022) [ 14 ]. Additionally, none of these methods work towards making explicit local values, or towards the creation of a culturally-informed protocol. In brief, the literature suggests a need to develop alternative methods of Formative Research for understanding locally relevant cultural elements, that are less time-consuming and can generate data that is more easily translatable to intervention design. In addition, these approaches must be applicable in different cultures. Additionally, the protocols produced must be actionable and practical not only for guiding interactions between research teams but also for guiding the initial stages of intervention design.

The work presented here aims to address several of these needs. It includes an exploration of the usefulness of the WeValue InSitu ( WVIS ) approach because that has previously been shown, in environmental management domains, to offer a way to gather in-depth values-based perspectives from a target population [ 28 , 29 ] It was first created through action research, and co-designed to enable civil society organisations to better understand and measure the values-based aspects of their work [ 30 ]. The core WeValue InSitu process (detailed in Table 1 ) involves the crystallization of shared values, with a facilitator guiding a group of participants with shared experiences, through cycles of tacit meaning-making (using a stage of photo-elicitation and triggering) [ 31 ], until they can articulate more explicitly their shared values, in concise and precise statements. These statements are then linked together in a framework by the participants. In an example case in Nigeria, the results of the WVIS approach hinted at the creation of a culturally-informed protocol through an analysis of the shared values frameworks to find cultural themes for the creation of an indicator tool that was used to evaluate several development scenarios based on their social acceptability [ 29 ].

Furthermore, it has been found that if a group of WVIS participants take part in a specialised focus group discussion (FGD), named Perspectives EXploration (PEX:FGD) immediately afterward the main workshop, then they easily and articulately express their perspectives on the topics raised for discussion - and with allusions to the shared values they had crystallised just prior. In an example from Shanghai, the PEX:FGDs focussed on eliciting perspectives on climate change, which were shown to be closely linked with the cultural themes existing within the shared values frameworks produced immediately prior [ 32 ]. In that case, the PEX:FGDs allowed the cultural themes generated during the main WVIS workshop to be linked more closely to the research question. Those results suggested that the WVIS plus PEX:FGD approach could be used to create a specialised culturally-informed protocol for improved intervention design.

In the study presented here, the WVIS approach was explored for the purpose of creating culturally-informed protocols to inform the planning of interventions within two localities of the UKRI GCRF Action Against Stunting Hub [ 33 ]. The work was carried out in two parts. Firstly, the WVIS main workshop was used to elicit cultural themes within the target communities, indicating key elements to consider to ensure ethical engagement. Secondly, the PEX focus group discussions focussed on life practices related to stunting which we explored for the purpose of tailoring the culturally-informed protocols to the specific purpose of improving the design of an example intervention. The Action Against Stunting Hub works across three sites where stunting is highly prevalent but via different determinants: East Lombok in Indonesia (estimated 36% of under-fives stunted), Kaffrine in Senegal (estimated 16% of under-fives stunted) and Hyderabad in India (estimated 48% of under-fives stunted) [ 34 ]. We propose that, the information about local shared values in a given site could be used to inform the design of several interventions, but for our specific exploration the focus here is a proposed ‘egg intervention’, in which pregnant women would be provided with an egg three times per week as supplement to their diet. This study proposes that identifying shared values within a community, alongside information about local life practices, provides critical cultural information on the potential acceptability and uptake of this intervention which can be used to generate culturally-informed protocols consisting of recommendations for improved intervention design.

In this paper we aim to explore the use of the WVIS approach to create culturally-informed protocols to guide engagement and inform the design of localised egg interventions to alleviate stunting in East Lombok, Indonesia and Kaffrine, Senegal. We do this by analysing data about local shared values that are crystallized using the WeValue InSitu ( WVIS ) process to provide clear articulation of local values, followed by an analysis of life practices discussed during PEX:FGD to tailor the culturally-informed protocols for the specific intervention design.

Study setting

This research was exploratory rather than explanatory in nature. The emphasis was on demonstrating the usefulness of the WeValue InSitu ( WVIS ) approach to develop culturally-informed protocols of practical use in intervention design, in different cultural sites. This study was set within a broader shared-values workstream within the UKRI GCRF Action Against Stunting Hub project [ 33 ]. The Hub project, which was co-designed and co-researched by researchers from UK, Indonesia, Senegal and India, involves cohorts of 500 women and their babies in each site through pregnancy to 24 months old, using cross-disciplinary studies across gut health, nutrition, food systems, micro-nutrition, home environment, WASH, epigenetics and child development to develop a typology of stunting. Alongside these health studies are studies of the shared values of the communities, obtained via the WVIS approach described here, to understand the cultural contexts of that diverse health data. In this study the data from East Lombok, Indonesia and Kaffrine, Senegal were used: India’s data were not yet ready, and these two countries were deemed sufficient for this exploratory investigation.

The WVIS approach

The WVIS approach is a grounded scaffolding process which facilitates groups of people to make explicit their shared values in their own vocabulary and within their own frames (details in Fig. 1 and activities in Table 1 ). The first stage of the WVIS is Contextualisation, whereby the group identifies themselves and set the context of their shared experiences, for example, as ‘mothers in East Lombok, Indonesia’. Subsequently, there is a stage of Photo Elicitation, in which the group are first asked to consider what is important, meaningful or worthwhile to them about their context (e.g., ‘being mothers in East Lombok, Indonesia’) and then asked to choose photos from a localised set that they can use as props to help describe their answer to the group [ 29 ]. After this, a localised Trigger List is used. This Trigger List consists of 109 values statements that act as prompts for the group. Examples of these values statements are included below but all the statements begin with “it is important to me/us that…”. The group are asked to choose which statements within the trigger list resonate with them, and those are taken forward for group intersubjective discussion. After a topic of their shared values has been explored, the group begin to articulate and write down their own unique statements of them. These also all begin with “It is important to me/us that…”. After discussing all pressing topics, the group links the written statements on the table into a unique Framework, and one member provides a narrative to communicate it to ‘outsiders’. The WVIS provides a lens of each group’s local shared values, and it is through this lens that they view the topics in the focus group discussions which immediately follow, termed Perspectives EXplorations (PEX:FGDs).

Schematic of the macro-level activities carried out during the WeValue InSitu ( WVIS ) main workshop session

This results in very grounded perspectives being offered, of a different nature to those obtained in questionnaires or using external frameworks [ 31 ]. The specific PEX:FGD topics are chosen as pertinent to stunting contextual issues, including eating habits, food systems and environments, early educational environments, and perceptions of stunting. The local researchers ensured that all topics were handled sensitively, with none that could cause distress to the participants. The data for this study were collected over 2 weeks within December 2019–January 2020 in workshops in East Lombok, Indonesia, and 2 weeks within December 2020 in Kaffrine, Senegal.

The PEX:FGDs were kept open-ended so that participants could dictate the direction of the discussion, which allowed for topics that may not have been pre-considered by the facilitators to arise. Sessions were facilitated by local indigenous researchers, guided in process by researchers more experienced in the approach, and were carried out in the local languages, Bahasa in East Lombok, Indonesia and French or Wolof in Kaffrine, Senegal.

Development of localised WVIS materials

Important to the WVIS approach is the development of localised materials (Table 1 ). The main trigger list has been found applicable in globalised places where English is the first language, but otherwise the trigger lists are locally generated in the local language, incorporating local vocabulary and ways of thinking. To generate these, 5–8 specific interviews are taken with local community members, by indigenous university researchers, eliciting local phrases and ways of thinking. This is a necessary step because shared tacit values cannot be easily accessed without using local language. Examples of localised Trigger Statements produced this way are given below: (they all start with: “It is important to me/us that…”):

…there is solidarity and mutual aid between the people

…I can still be in communication with my children, even if far away

…husbands are responsible for the care of their wives and family

…the town council fulfils its responsibility to meet our needs

…people are not afraid of hard, and even manual work

Study participants

The group participants targeted for recruitment, were selected by local country Hub co-researchers to meet two sets of requirements. For suitability for the WVIS approach they should be between 3 and 12 in number; belong to naturally existing groups that have some history of shared experiences; are over 18 years old; do not include members holding significantly more power than others; and speak the same native language. For suitability in the PEX:FGD to offer life practices with relevance to the research topic of stunting, the groups were chosen to represent stakeholders with connections to the food or learning environment of children (which the Action Against Stunting Hub refer to as the Whole Child approach) [ 33 ]. The university researchers specialising in shared values from the UK, and Senegal and Indonesia respectively, discussed together which stakeholder groups might be appropriate to recruit. The local researchers made the final decisions. Each group was taken through both a WVIS workshop and the immediately-subsequent PEX:FGD.

Data collection and analysis

Standard data output from the WeValue session includes i) the jointly-negotiated bespoke Statements of shared values, linked together in their unique Framework, and ii) an oral recording of a descriptive Narrative of it, given by the group. These were digitized to produce a single presentation for each group as in Fig. 2 . It represents the synthesised culmination of the crystallisation process: a portrait of what was ‘important’ to each stakeholder group. Separately, statements from the group about the authenticity/ownership of the statements are collected.

An illustrative example of one digitized Shared Values Framework and accompanying Narrative from a teacher’s group in East Lombok, Indonesia. The “…” refers to each statement being preceded by “It is important to us that…”

When these Frameworks of ‘Statements of Shared Values’ are viewed across all the groups from one locality (Locality Shared Values Statements), they provide portraits of ‘what is important’ to people living there, often in intimate detail and language. They can be used to communicate to ‘outsiders’ what the general cultural shared values are. In this work the researchers thematically coded them using Charmaz constructionist grounded theory coding [ 35 ] to find broad Major Cultural Themes within each separate locality.

The second area of data collection was in the post- WVIS event: the PEX:FGD for each group. A translator/interpreter provided a running commentary during these discussions, which was audio recorded and then transcribed. The specific topics raised for each group to discuss varied depending on their local expertise. This required completely separate workstreams of coding of the dataset with respect to each topic. This was carried out independently by two researchers: one from UK (using NVivo software (Release 1.3.1)) and one from the local country, who resolved any small differences. All the transcripts were then collated and inductively, interpretively analysed to draw out insights that should be relayed back to the Action Against Stunting Hub teams as contextual material.

The extracts of discussion which were identified as relevant within a particular Hub theme (e.g. hygiene) were then meta-ethnographically synthesised [ 36 ] into ‘Hub Theme Statements’ on each topic, which became the core data for later communication and interrogation by other researchers within the Action Against Stunting Hub. These statements are interpretations of participants’ intended meanings, and links from each of them to data quotes were maintained, enabling future interpretations to refer to them for consistency checks between received and intended meaning.

In this investigation, those Hub Theme Statements (derived from PEX:FGD transcripts) were then deductively coded with respect to any topics with potential implications of the egg intervention. Literature regarding barriers and facilitators to nutrition interventions indicated the following topics could be relevant: attitudes to accepting help; community interactions; cooking and eating habits; traditional beliefs about malnutrition; sharing; social hierarchies [ 12 , 37 , 38 ] to which we added anything related to pregnancy or eggs. This analysis produced our Egg Intervention Themes from the data.

The Major Cultural Themes and Egg Intervention Themes were then used to create a set of culture-based recommendations and intervention specific recommendations respectively for each locality. These recommendations were then combined to form specialized culturally-informed protocols for the egg intervention in each locality: East Lombok, Indonesia and Kaffrine, Senegal. The process is displayed schematically in Fig.  3 .

Schematic representation of the method of production of the culturally-informed protocol for each locality

The preparation of the localised WVIS materials at each site took 6 hours of interview field work, and 40 person hours for analysis. The 10 workshops and data summaries were concluded within 10 workdays by two people (80 person hours). The analysis of the PEX:FGD data took a further 80 person hours. Thus, the total research time was approximately 200 person hours.

The stakeholder group types are summarised in Table 2 . The data is presented in three parts. Firstly, the Major Cultural Themes found in East Lombok, Indonesia and in Kaffrine, Senegal are described – the ones most heavily emphasised by participants. Then, the Egg Intervention Themes and finally, the combined set of Recommendations to comprise a culturally-informed protocol for intervention design for each location. Quotations are labelled INDO or SEN for East Lombok, Indonesia and Kaffrine, Senegal, respectively.

Major cultural themes from frameworks and narratives

These were derived from the Locality Shared Values Statements produced in the WVIS .

East Lombok, Indonesia

Religious values.

Islamic values were crucially important for participants from East Lombok, Indonesia and to their way of life. Through living by the Quran, participating in Islamic community practices, and teaching Islamic values to their children, participants felt they develop their spirituality and guarantee a better afterlife for themselves and their children. Participants stated the Quran tells them to breastfeed their children for 2 years, so they do. Despite no explicit religious official curriculum in Kindergarten, the teachers stated that it was important to incorporate religious teaching.

“East Lombok people always uphold the religious values of all aspects of social life.”

“It is important for me to still teach religious values even though they are not clearly stated in the curriculum.” – Workshop 1 INDO (teachers).

“In Quran for instance, we are told to breastfeed our kids for 2 years. We can even learn about that ” – Workshop 3 INDO (mothers).

Related to this was the importance of teaching manners to children and preventing them from saying harsh words. Teachers stated that it was important to create a happy environment for the children and to ensure that they are polite and well-behaved. Similarly, mothers emphasised the need to teach their children good religious values to ensure they will be polite and helpful to their elders.

“Children don’t speak harsh words.”

“My children can help me like what I did to my parents”.

– Workshop 8 INDO (mothers).

Togetherness within families and the community

The Locality Shared Values Frameworks stressed the importance of togetherness, both within family and community. Comments mentioned it being important that people rely heavily on their family and come together in times of need to support each other and provide motivation. This was also important more broadly, in that people in society should support each other, and that children grow up to contribute to society. This was also reflected in comments around roles within the family. Despite women being primary care givers, and men working to finance the family, participants stated that they follow a process of consultation to make decisions, and when facing hardships.

“that we have the sense of kinship throughout our society”.

“We have togetherness as mothers”.

“For the family side, whatever happens we need to be able to be united as a whole family. We need to have the [sense of] forgiveness for the sake of the children” – Workshop 2 INDO (mothers).

Attitudes about extra-marital pregnancy

In East Lombok, Indonesia, it was essential to both mothers and fathers that pregnancy happened within a marriage, this was to ensure that the honour of the family was upheld and that the lineage of the child was clear. The potential danger to health that early pregnancies can cause was also acknowledged.

“If they don’t listen to parents’ advice, there will be the possibility of pre-marital pregnancy happening, which will affect the family [so much].

The affect is going to be ruining the good name, honour and family dignity. When the children [are] born outside [of] marriage, she or he will have many difficulties like getting a birth certificate [and] having a hard time when registering to school or family” - Workshop 4 INDO (mothers).

“ To make sure that our children avoid getting married at a very young age and moreover [avoid] having free sex so that they will not get pregnant before the marriage” - Workshop 9 INDO (fathers).

Kaffrine, Senegal

The Major Cultural Themes which emerged from the Kaffrine data are described below. As these are grounded themes, they are different than those seen in East Lombok, Indonesia.

Access to healthcare

A recurring theme amongst the groups in Kaffrine were aspirations of affordable and easy-to-access healthcare. Community health workers stated the importance of encouraging women to give birth in hospitals and spoke of the importance of preventing early pregnancy which result from early marriages. Giving birth in hospitals was also a concern for Public Office Administrators who highlighted that this leads to subsequent issues with registering children for school. Mothers and fathers stated the importance of being able to afford health insurance and access healthcare so that they could take care of themselves.

“That the women give birth in the hospital” – Workshop 11 SEN (CHWS).

“To have affordable health insurance ” – Workshop 10 SEN (mothers).

“To have access to health care ” – Workshop 3 SEN (fathers).

“It is important that women give birth in the hospital in order to be able to have a certificate that allows us to establish the civil status” – Workshop 9 SEN (administrators).

Additionally, Community health workers spoke of their aspiration to have enough supplements to provide to their community so as to avoid frustration at the lack of supply, and mothers spoke of their desire to be provided with supplements.

“To have dietary supplements in large quantities to give them to all those who need them, so as not to create frustration” – Workshop 11 SEN (CHWS).

Another aspect of access to healthcare, was mistrust between fathers and community health workers. Community health workers explained that sometimes men can blame them when things go wrong in a pregnancy or consider their ideas to be too progressive. Thus, to these community health workers the quality of endurance was very important.

“Endurance (Sometimes men can accuse us of influencing their wives when they have difficulties in conceiving)” – Workshop 5 SEN (CHWs).

Another recurring theme was the importance of having secure employment and a means to support themselves; that there were also jobs available for young people, and that women had opportunities to make money to help support the family. This included preventing early marriages so girls could stay in school. Having jobs was stated as essential for survival and important to enable being useful to the community and society.

“To have more means of survival (subsistence) to be able to feed our families”.

“To have a regular and permanent job”.

“We assure a good training and education for our children so that they will become useful to us and the community”.

“ Our women should have access to activities that will support us and lessen our burden” – Workshop 3 SEN (fathers).

It was considered very important to have a religious education and respect for religious elders. Moreover, living by, and teaching, religious values such as being hard working, humble and offering mutual aid to others, was significant for people in Kaffrine.

“Have an education in the Islamic Culture (Education that aligns with the culture of Islam)”.

“Respect toward religious leaders” – Workshop 3 SEN (fathers).

“ To organize religious discussions to develop our knowledge about Islam ” - Workshop 10 SEN (mothers).

“ Have belief and be prayerful and give good counselling to people ” - Workshop 4 SEN (grandmothers).

Egg intervention themes from each country from perspectives EXplorations focus group discussion data

Below are results of analyses of comments made during the PEX:FGDs in East Lombok, Indonesia and Kaffrine, Senegal. The following codes were used deductively: attitudes to accepting outside help, traditional gender roles, food sharing, traditional beliefs, social hierarchies and understanding of stunting and Other. These topics were spoken about during open discussion and were not the subject of direct questions. For example, topics relating to traditional gender roles came up in East Lombok, during conversations around the daily routine. Thus, in order to more accurately reflect the intended meaning of the participants, these were labelled food practices, under the “Other” theme. If any of the themes were not present in the discussion, they are not shown below.

Attitudes to accepting outside help

Few mentions were made that focussed on participants attitudes to accepting outside help, but participants were sure that they would not make changes to their menus based on the advice of outside experts. Additionally, teachers mentioned that they are used to accepting help from local organisations that could to help them to identify under-developed children.

“ We don’t believe that [the outsiders are] going to change our eating habits or our various menus ” – Workshop 3 INDO (Mothers).

Traditional gender roles

In East Lombok, mothers spoke about how their husbands go to work and then provide them with daily money to buy the food for the day. However, this was discussed in relation to why food is bought daily and is thus discussed below in the topics Other – Food practices.

Food sharing

In East Lombok, Indonesia, in times when they have extra food, they share it with neighbours, in the hope that when they face times of hardship, their neighbours will share with them. Within the household, they mentioned sharing food from their plate with infants and encouraging children to share. Some mothers mentioned the importance of weekly meetings with other mothers to share food and sharing food during celebrations.

“ Sometimes we share our food with our family. So, when we cook extra food, we will probably send over the food to our neighbour, to our families. So, sometimes, with the hope that when we don’t have anything to eat, our neighbour will pay for it and will [share with] us.” – Workshop 3 INDO (Mothers).

“Even they serve food for the kids who come along to the house. So, they teach the kids to share with their friends. They provide some food. So, whenever they play [at their] house, they will [eat] the same.” – Workshop 2 INDO (Mothers).

Understanding of stunting

The teachers in East Lombok were aware of child stunting through Children’s Development Cards provided by local healthcare organizations. They stated that they recognise children with nutrition problems as having no patience period, no expression, no energy for activities and less desire to socialise and play with other children. The teachers said that stunted children do not develop the same as other children and are not as independent as children who are the proper height and weight for their development. They also stated that they recognise stunted children by their posture, pale faces and bloated stomachs. They explained how they usually use the same teaching methods for stunting children, but will sometimes allow them to do some activities, like singing, later, once the other children are leaving.

“ They have no patience period, don’t have any energy to do any of the activities. No expression, only sitting down and not mingling around with the kids. They are different way to learn. They are much slower than the other kids .” – Workshop 1 INDO (teachers).

“ When they are passive in singing, they will do it later when everyone else is leaving, they just do it [by] themselves ” – Workshop 1 INDO (teachers).

Specific views on eggs

In East Lombok, Indonesia, there were no superstitions or traditional beliefs around the consumption of eggs. When asked specifically on their views of eggs, and if they would like to be provided with eggs, women in East Lombok said that they would be happy to accept eggs. They also mentioned that eggs were a food they commonly eat, feed to children and use for convenience. Eggs were considered healthy and were common in their house.

“ We choose eggs instead. If we don’t have time, we just probably do some omelettes or sunny side up. So, it happens, actually when we get up late, we don’t have much time to be able to escort our kids to the school, then we fry the eggs or cook the instant noodles. And it happens to all mothers. So, if my kids are being cranky, that’s what happens, I’m not going to cook proper meals so, probably just eggs and instant noodles.” – Workshop 3 INDO (Mothers).

Other important topics – food practices

Some detailed themes about food practices were heard in East Lombok, Indonesia. The women were responsible for buying and preparing the food, which they purchased daily mainly due to the cost (their husbands were paid daily and so provided them with a daily allowance) and lack of storage facilities. They also bought from mobile vendors who came to the street, because they could buy very small amounts and get occasional credit. The mother decided the menu for the family and cooked once per day in the morning: the family then took from this dish throughout the day. Mothers always washed their fruits and vegetables and tried to include protein in their meals when funds allowed: either meat, eggs, tofu or tempeh.

“ One meal a day. They [the mothers] cook one time and they [the children] can eat it all day long. Yes, they can take it all day long. They find that they like [to take the food], because they tend to feel hungry.” – Workshop 6 INDO (Mothers).

“ They shop every day because they don’t have any storage in their house and the other factor is because the husband has a daily wage. They don’t have monthly wage. In the morning, the husband gives the ladies the money and the ladies go to the shop for the food. ” – Workshop 4 INDO (Mothers).

In Kaffrine, the following themes emerged relating to an egg intervention: they were different in content and emphasis to Lombok and contained uniquely local cultural emphases.

Mothers were welcoming of eggs as a supplement to improve their health during pregnancy and acknowledged the importance of good nutrition during pregnancy. However, they also mentioned that their husbands can sometimes be resistant to accepting outside help and provided an example of a vaccination programme in which fathers were hesitant to participate. However, participants stated that the Government should be the source of assistance to them (but currently was not perceived to be so).

“But if these eggs are brought by external bodies, we will hesitate to take it. For example, concerning vaccination some fathers hesitate to vaccinate their children even if they are locals who are doing it. So, educating the fathers to accept this is really a challenge” – Workshop 11 SEN (CHWs).

Some traditional gender roles were found to be strong. The participants emphasised that men are considered the head of the household, as expected in Islam, with the mother as primary caregiver for children. This is reflected in the comments from participants regarding the importance of Islam and living their religious values. The men thus made the family decisions and would need to be informed and agree to any family participation in any intervention – regardless of the education level of the mother. The paternal grandmother also played a very important role in the family and may also make decisions for the family in the place of the father. Community Health Workers emphasised that educating paternal grandmothers was essential to improve access to healthcare for women.

“There are people who are not flexible with their wives and need to be informed. Sometimes the mother-in-law can decide the place of the husband. But still, the husband’s [permission] is still necessary.” – Workshop 1 SEN (CHWs).

“[We recommend] communication with mothers-in-law and the community. Raise awareness through information, emphasizing the well-being of women and children.” – Workshop 1 SEN (CHWs).

“The [grand]mothers take care of the children so that the daughters in-law will take care of them in return So it’s very bad for a daughter in law not to take care of her mother in-law. Society does not like people who distance themselves from children.” – Workshop 4 SEN (grandmothers).

Social hierarchies

In addition to hierarchies relating to gender/position in the family such as grandmothers have decision making power, there was some mention of social hierarchies in Kaffrine, Senegal. For example, during times of food stress it was said that political groups distribute food and elected officials who choose the neighbourhoods in which the food will be distributed. Neighbourhood leaders then decide to whom the food is distributed, meaning there is a feeling that some people are being left out.

“ It’s political groups that come to distribute food or for political purposes…organizations that often come to distribute food aid, but in general it is always subject to a selection on the part of elected officials, in particular the neighbourhood leaders, who select the people they like and who leave the others ” – Workshop 11 SEN (CHWs).

Participants explained that during mealtimes, the family will share food from one large plate from which the father will eat first as a sign of respect and courtesy. Sometimes, children would also eat in their neighbour’s house to encourage them to eat.

“ Yes, it happens that we use that strategy so that children can eat. Note that children like to imitate so that’s why we [send them to the neighbour’s house]” – Workshop 11 SEN (CHWs)”.

Traditional beliefs about malnutrition

In Kaffrine, Senegal, some participants spoke of traditional beliefs relating to malnutrition, which are believed by fewer people these days. For example, uncovered food might attract bad spirits, and any person who eats it will become ill. There were a number of food taboos spoken of which were thought to have negative consequences for the baby, for example watermelon and grilled meat which were though to lead to birth complications and bleeding. Furthermore, cold water was thought to negatively impact the baby. Groups spoke of a tradition known as “bathie” in which traditional healers wash stunted children with smoke.

“ There are traditional practices called (Bathie) which are practiced by traditional healers. Parents are flexible about the practice of Bathie ” – Workshop 1 SEN (CHWs).

Causes of malnutrition and stunting were thought to be a lack of a balanced diet, lack of vitamin A, disease, intestinal worms, poor hygiene, socio-cultural issues such as non-compliance with food taboos, non-compliance with exclusive breastfeeding and close pregnancies. Malnutrition was also thought by some to be hereditary. Numerous signs of malnutrition were well known amongst the groups in Kaffrine. For example, signs of malnutrition were thought to be a big bloated belly, diarrhoea, oedema of the feet, anaemia, small limbs and hair loss as well as other symptoms such as red hair and a pale complexion. Despite this, malnutrition was thought to be hard to identify in Kaffrine as not all children will visit health centres, but mothers do try to take their babies heights and weights monthly. The groups were aware of the effect of poverty on the likelihood of stunting as impoverished parents cannot afford food. Furthermore, the groups mentioned that there is some stigma towards stunted children, and they can face mockery from other children although most local people feel pity and compassion towards them. Malnourished children are referred to as Khiibon or Lonpogne in the local language of Wolof.

“ It is poverty that is at the root of malnutrition, because parents do not have enough money [and] will have difficulty feeding their families well, so it is the situation of poverty that is the first explanatory factor of malnutrition here in Kaffrine” – Workshop 9 SEN (administrators).

“It can happen that some children are the victim of jokes for example of mockery from children of their same age, but not from adults and older ” – Workshop 9 SEN (administrators).

Pregnancy beliefs

In Kaffrine, Senegal, there were concerns around close pregnancies, and pregnancies in women who were too young, and for home births. Within the communities there was a stigma around close pregnancies, which prevented them from attending antenatal appointments. Similarly, there were superstitions around revealing early pregnancies, which again delayed attendance at health centres.

Groups acknowledged the role of good nutrition, and mentioned some forbidden foods such as salty foods, watermelon and grilled meat (which sometimes related back to a traditional belief that negative impacts would be felt in the pregnancy such as birth complications and bleeding). Similarly, drinking cold water was thought to negatively affect the baby. Beneficial foods mentioned included vegetables and meat, during pregnancy.

“ Often when a woman has close pregnancies, she can be ashamed, and this particularly delays the time of consultation” – Workshop 5 SEN (CHWs).

“Yes, there are things that are prohibited for pregnant women like salty foods” – Workshop 11 SEN (CHWs).

In Kaffrine, Senegal, some participants spoke of a traditional belief that if a pregnant woman consumes eggs then her baby might be overweight, or have problems learning how to talk. Despite this, mothers in Kaffrine said that they would be happy to accept eggs as a supplement, although if supplements are provided that require preparation (such as powdered supplements), they would be less likely to accept them.

“These restrictions are traditional, and more women no longer believe that eggs will cause a problem to the child. But if these eggs are brought by external bodies, we will hesitate to take it.” – Workshop 11 SEN (CHWs).

“They don’t eat eggs before the child starts speaking (the child only eats eggs when he starts talking). This is because it’s very heavy and can cause bloating and may also lead to intestinal problems.” – Workshop 4 SEN (grandmothers).

Other important topics – access to health services

For the participants in Kaffrine, Senegal, accessing health services was problematic, particularly for pre- and post-natal appointments, which faced frequent delays. Some women had access due to poor roads and chose to give birth at home. Access issues were further compounded by poverty and social factors, as procedures in hospitals can be costly, and women with close pregnancies (soon after an earlier one) can feel shame from society and hide their pregnancy.

“Women really have problems of lack of finances. There are social services in the hospital; but those services rarely attend to women without finances. Even when a child dies at birth they will require money to do the necessary procedure ” – Workshop 11 SEN (CHWs).

Creation of the culturally-informed protocols

Recommendations that comprise a culturally-informed protocol for intervention design in each locality are given in Table 3 .

The Major Cultural Themes, and specific Egg Intervention Themes drawn out from only 9–11 carefully planned group sessions in each country provided a rich set of recommendations towards a culturally-informed protocol for the localised design of a proposed Egg Intervention for both East Lombok, Indonesia and Kaffrine, Senegal. A culturally-informed protocol designed in this way comprises cultural insights which are worthy of consideration in local intervention design and should guide future stages of engagement and provide a platform from which good rapport and trust can be built between researchers and the community [ 16 ]. For example, in Kaffrine, Senegal, the early involvement of husbands and grandmothers is crucial, which reflects values around shared decision making within families that are noted to be more prevalent in LMICs, in contrast to individualistic values in HICs [ 16 , 39 ]. Similarly, due to strong religious values in both East Lombok, Indonesia and Kaffrine, Senegal, partnerships with Islamic leaders is likely to improve engagement. Past studies show the crucial role that religious leaders can play in determining social acceptability of interventions, particularly around taboo topics such as birth spacing [ 40 ].

The WVIS plus PEX:FGD method demonstrated here produced both broad cultural themes from shared values, which were in a concise and easy-to-understand format which could be readily communicated with the wider Action Against Stunting Hub, as well as life practices relevant to stunting in Kaffrine, Senegal and in East Lombok, Indonesia. Discussions of shared values during the WVIS main workshop provided useful cultural background within each community. PEX:FGD discussion uncovered numerous cultural factors within local life practices that could influence on the Egg Intervention engagement and acceptability. Combining themes from the WVIS workshop and PEX:FGDs allowed for specific recommendations to be made towards a culturally-informed protocol for the design of an Egg Intervention that included both broad cultural themes and specific Intervention insights (Table 3 ). For example, in Kaffrine, Senegal, to know that the husband’s authoritative family decision-making for health care (specific) is rooted in Islamic foundations (wider cultural) points to an Intervention Recommendation within the protocol, involving consultations with Islamic Leaders to lead community awareness targeting fathers. Similarly, in East Lombok, Indonesia the (specific) behaviour of breastfeeding for 2 years was underpinned by (wider cultural) shared values of living in Islam. This understanding of local values could prevent the imposition of culturally misaligned values, which Bernal and Adames (2017) caution against [ 17 ].

There are a number of interesting overlaps between values seen in the WVIS Frameworks and Narratives and the categories of Schwartz (1992) and The World Values Survey (2023) [ 41 , 42 ]. For example, in both Kaffrine, Senegal and East Lombok, Indonesia, strong religious values were found, and the groups spoke of the importance of practicing their religion with daily habits. This would align with traditional and conservation values [ 41 , 43 ]. Furthermore, in Kaffrine, Senegal participants often mentioned the importance of mutual aid within the community, and similar values of togetherness and respect in the community were found in East Lombok, Indonesia. These would seem to align with traditional, survival and conservation values [ 41 , 43 ]. However, the values mentioned by the groups in the WVIS workshops are far more specific, and it is possible that through asking what is most worthwhile, valuable and meaningful about their context, the participants are able to prioritise which aspects of their values are most salient to their daily lives. Grounded shared values such as these are generally neglected in Global Health Research, and values predominant in the Global North are often assumed to be universal [ 14 ]. Thus, by excluding the use of a predefined external framework, we minimized the risk of imposing our own ideas of values in the community, and increased the relevance, significance and local validity of the elicited information [ 28 ].

Participatory methods of engagement are an essential step in conducting Global Health Research but there is currently a paucity of specific guidance for implementing participatory methods in vulnerable communities [ 16 , 44 ]. In addition, there is acknowledgement in the literature that it is necessary to come into communities in LMICs without assumptions about their held values, and to use bottom-up participatory approaches to better understand local values [ 14 , 16 ]. The WVIS plus PEX:FGD methodology highlighted here exemplifies a method that is replicable in multiple country contexts [ 28 , 32 ] and can be used to crystallize local In Situ Shared Values which can be easily communicated to external researchers. Coupled with the specialised FGD (PEX:FGD), values-based perceptions of specific topics (in this case stunting) can be elicited leading to the creation of specific Culture-based recommendations. This therefore takes steps to answer the call by Memon and colleagues (2021) for the creation of cultural protocols ahead of conducting research in order to foster ethical research relationships [ 16 ]. We believe that the potential usefulness of the WVIS approach to guide engagement and inform intervention design is effectively demonstrated in this study and WVIS offers a method of making explicit local values in a novel and valuable way.

However, we acknowledge that our approach has several limitations. It has relied heavily on the local university researchers to debate and decide which participant stakeholder groups should be chosen, and although they did this in the context of the Whole Child approach, it would have been advantageous to have involved cultural researchers with a deeper understanding of cultural structures, to ensure sufficient opportunities for key cultural elements to emerge. This would have in particular strengthened the intervention design derived from the PEX:FGD data. For example, we retrospectively realised that our study could have been improved if grandmothers had been engaged in East Lombok. Understanding this limitation leads to suggestion for further work: to specifically investigate the overlap of this approach with disciplinary studies of culture, where social interactions and structures are taken into account via formal frameworks.

There are more minor limitations to note. For example, the WVIS approach can only be led by a trained and experienced facilitator: not all researchers can do this. A training programme is currently under development that could be made more widely available through online videos and a Handbook. Secondly, although the groups recruited do not need to be representative of the local population, the number recruited should be increased until theoretical saturation is achieved of the themes which emerge, which was not carried out in this study as we focussed on demonstrating the feasibility of the tool. Thirdly, there is a limit to the number of topics that can be explored in the PEX:FGDs within the timeframe of one focus group (depending on the stamina of the participants), and so if a wider range of topics need formative research, then more workshops are needed. Lastly, this work took place in a large, highly collaborative project involving expert researchers from local countries as well as international experts in WVIS : other teams may not have these resources. However, local researchers who train in WVIS could lead on their own (and in this Hub project such training was available).

The need for better understanding, acknowledgement and integration of local culture and shared values is increasing as the field of Global Health Research develops. This study demonstrates that the WVIS plus PEX:FGD shared values approach provides an efficient approach to contextualise and localise interventions, through eliciting and making communicable shared values and local life practices which can be used towards the formation of a culturally-informed protocols. Were this method to be used for intervention design in future, it is possible that more focus should be given to existing social structures and support systems and a greater variety of stakeholders should be engaged. This study thus contributes to the literature on methods to culturally adapt interventions. This could have significant implications for improving the uptake of nutrition interventions to reduce malnutrition through improved social acceptability, which could help progression towards the goal of Zero Hunger set within the SDGs. The transferability and generalisability of the WVIS plus PEX:FGD approach should now be investigated further in more diverse cultures and for providing formative research information for a wider range of research themes. Future studies could also focus on establishing its scaling and pragmatic usefulness as a route to conceptualising mechanisms of social acceptability, for example a mechanism may be that in communities with strong traditional religious values, social hierarchies involving religious leaders and fathers exist and their buy-in to the intervention is crucial to its social acceptability. Studies could also focus on the comparison or combination of WVIS plus PEX:FGD with other qualitative methods used for intervention design and implementation.

Availability of data and materials

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request [email protected], Orcid number 0000–0002–1811-4597. These include deidentified Frameworks of Shared Values and Accompanying Narrative from each Group; deidentified Hub Insight Statements of relevant themes.

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Acknowledgements

We thank the Hub PI, Claire Heffernan, for feedback on a late draft of the manuscript.

The Action Against Stunting Hub is funded by the Medical Research Council through the UK Research and Innovation (UKRI) Global Challenges Research Fund (GCRF), Grant No.: MR/S01313X/1.

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Annabel J. Chapman, Mahsa Firoozmand & Marie K. Harder

Department of Environmental Science and Engineering, Fudan University, Shanghai, People’s Republic of China

Chike C. Ebido, Rahel Neh Tening, Yanyan Huang & Marie K. Harder

Department of Zoology and Environmental Biology, University of Nigeria, Nsukka, Nigeria

Chike C. Ebido

Preventive Medicine and Public Health, Université Cheikh Anta Diop (UCAD), Dakar, Senegal

Ndèye Marème Sougou

Faculty of Psychology, Universitas Islam Negeri Syarif Hidayatullah, Jakarta, Indonesia

Risatianti Kolopaking

Southeast Asian Ministers of Education Organization Regional Centre for Food and Nutrition (SEAMEO RECFON) Universitas Indonesia, Jakarta, Indonesia

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International Research Laboratory (IRL 3189) Environnement santé et sociétés/CNRS/UCAD, Dakar, Senegal

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Contributions

MKH formulated the initial research question and study design. AJC developed the specific research question. Data collection in Senegal involved CCE, NMS, AHD, FBD, RNT, CEHAN and JM. Data collection in Indonesia involved RA, RK, YH and MKH. Cultural interpretation in Senegal Involved AHD, FBD, NMS, RNT and JM. Analysis involved AJC and MF. AJC and MKH wrote the paper.

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Correspondence to Marie K. Harder .

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Chapman, A.J., Ebido, C.C., Tening, R.N. et al. Creating culturally-informed protocols for a stunting intervention using a situated values-based approach ( WeValue InSitu ): a double case study in Indonesia and Senegal. BMC Public Health 24 , 987 (2024). https://doi.org/10.1186/s12889-024-18485-y

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DOI : https://doi.org/10.1186/s12889-024-18485-y

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ROCHESTER, Minn. — A Mayo Clinic study shows stem cells derived from patients' own fat are safe and may improve sensation and movement after traumatic spinal cord injuries . The findings from the phase 1 clinical trial appear in Nature Communications . The results of this early research offer insights on the potential of cell therapy for people living with spinal cord injuries and paralysis for whom options to improve function are extremely limited.

In the study of 10 adults, the research team noted seven participants demonstrated improvements based on the American Spinal Injury Association (ASIA) Impairment Scale. Improvements included increased sensation when tested with pinprick and light touch, increased strength in muscle motor groups, and recovery of voluntary anal contraction, which aids in bowel function. The scale has five levels, ranging from complete loss of function to normal function. The seven participants who improved each moved up at least one level on the ASIA scale. Three patients in the study had no response, meaning they did not improve but did not get worse.

"This study documents the safety and potential benefit of stem cells and regenerative medicine," says Mohamad Bydon, M.D. , a Mayo Clinic neurosurgeon and first author of the study. "Spinal cord injury is a complex condition. Future research may show whether stem cells in combination with other therapies could be part of a new paradigm of treatment to improve outcomes for patients."

No serious adverse events were reported after stem cell treatment. The most commonly reported side effects were headache and musculoskeletal pain that resolved with over-the-counter treatment.

In addition to evaluating safety, this phase 1 clinical trial had a secondary outcome of assessing changes in motor and sensory function. The authors note that motor and sensory results are to be interpreted with caution given limits of phase 1 trials. Additional research is underway among a larger group of participants to further assess risks and benefits.

The full data on the 10 patients follows a 2019 case report that highlighted the experience of the first study participant who demonstrated significant improvement in motor and sensory function.

Watch: Dr. Mohamad Bydon discusses improvements in research study

Journalists: Broadcast-quality sound bites are available in the downloads at the end of the post. Please courtesy: "Mayo Clinic News Network." Name super/CG: Mohamad Bydon, M.D./Neurosurgery/Mayo Clinic.

Stem cells' mechanism of action not fully understood

In the multidisciplinary clinical trial, participants had spinal cord injuries from motor vehicle accidents, falls and other causes. Six had neck injuries; four had back injuries. Participants ranged in age from 18 to 65.

Participants' stem cells were collected by taking a small amount of fat from a 1- to 2-inch incision in the abdomen or thigh. Over four weeks, the cells were expanded in the laboratory to 100 million cells and then injected into the patients' lumbar spine in the lower back. Over two years, each study participant was evaluated at Mayo Clinic 10 times.

Although it is understood that stem cells move toward areas of inflammation — in this case the location of the spinal cord injury — the cells' mechanism of interacting with the spinal cord is not fully understood, Dr. Bydon says. As part of the study, researchers analyzed changes in participants' MRIs and cerebrospinal fluid as well as in responses to pain, pressure and other sensation. The investigators are looking for clues to identify injury processes at a cellular level and avenues for potential regeneration and healing.

The spinal cord has limited ability to repair its cells or make new ones. Patients typically experience most of their recovery in the first six to 12 months after injuries occur. Improvement generally stops 12 to 24 months after injury. In the study, one patient with a cervical spine injury of the neck received stem cells 22 months after injury and improved one level on the ASIA scale after treatment.

Two of three patients with complete injuries of the thoracic spine — meaning they had no feeling or movement below their injury between the base of the neck and mid-back — moved up two ASIA levels after treatment. Each regained some sensation and some control of movement below the level of injury. Based on researchers' understanding of traumatic thoracic spinal cord injury, only 5% of people with a complete injury would be expected to regain any feeling or movement.

"In spinal cord injury, even a mild improvement can make a significant difference in that patient's quality of life," Dr. Bydon says.

Research continues into stem cells for spinal cord injuries

Stem cells are used mainly in research in the U.S., and fat-derived stem cell treatment for spinal cord injury is considered experimental by the Food and Drug Administration.

Between 250,000 and 500,000 people worldwide suffer a spinal cord injury each year, according to the  World Health Organization .

An important next step is assessing the effectiveness of stem cell therapies and subsets of patients who would most benefit, Dr. Bydon says. Research is continuing with a larger, controlled trial that randomly assigns patients to receive either the stem cell treatment or a placebo without stem cells.

"For years, treatment of spinal cord injury has been limited to supportive care, more specifically stabilization surgery and physical therapy," Dr. Bydon says. "Many historical textbooks state that this condition does not improve. In recent years, we have seen findings from the medical and scientific community that challenge prior assumptions. This research is a step forward toward the ultimate goal of improving treatments for patients."

Dr. Bydon is the Charles B. and Ann L. Johnson Professor of Neurosurgery. This research was made possible with support from Leonard A. Lauder, C and A Johnson Family Foundation, The Park Foundation, Sanger Family Foundation, Eileen R.B. and Steve D. Scheel, Schultz Family Foundation, and other generous Mayo Clinic benefactors. The research is funded in part by a Mayo Clinic Transform the Practice grant.

Review the study for a complete list of authors and funding.

About Mayo Clinic Mayo Clinic is a nonprofit organization committed to innovation in clinical practice, education and research, and providing compassion, expertise and answers to everyone who needs healing. Visit the  Mayo Clinic News Network  for additional Mayo Clinic news.

Media contact:

• Susan Barber Lindquist, Mayo Clinic Communications, [email protected]
• Personal journey shapes unique perspective Mayo Clinic scientists pioneer immunotherapy technique for autoimmune diseases

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Laggards go beyond catching up to become niche champions: a longitudinal case study in China

• Published: 11 April 2024

Cite this article

• Xinmin Peng 1 ,
• Abby Jingzi Zhou   ORCID: orcid.org/0000-0002-1052-5842 2 ,
• Xiaomeng Liu 2 &
• Dianguang Liu 1  

Using a longitudinal case study on Cixing, which is a leading Chinese player in the flat knitting machine industry, this paper explores the process in which laggard firms catch up and exceed catching up to become niche champions in China. We propose a theoretical framework that illustrates the significance of contexts and response strategies for niche champions at different stages, focusing on the market and technology perspectives. In particular, the context is formed by the market ladder and technology modularization, requiring laggard firms to adopt appropriate market development and technology learning strategies in order to respond to the environment and achieve growth. During the catch-up stage, these companies should employ a market leveraging strategy and a technology deconstruction strategy to match the incumbents in the context of a pyramidal market ladder with low technology modularization. In the beyond-catch-up stage, as incumbents, they should adopt a market repositioning strategy and a technology reconstruction strategy to evolve into niche champions in the context of an upgraded market ladder with high technology modularization. Our research contributes to the literature on catch-up and niche champions by elucidating the process, contexts, and strategies of laggards in catching up and becoming niche champions in the global market. Practical insights are also offered to firms and policy makers in emerging economies.

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The whole-garment technology represents a revolutionary approach of producing knitted wear as it can generate a complete garment in one piece without cutting or sewing. This technology involves a complex technical system that includes various scientific principles, engineering applications, and product development, requiring long-term accumulation.

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This study was financially supported by the National Natural Science Foundation of China (NSFC 72202111; 72172068; 71772097) and the Ministry of Education in China (22YJC630084).

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Peng, X., Zhou, A.J., Liu, X. et al. Laggards go beyond catching up to become niche champions: a longitudinal case study in China. Asia Pac J Manag (2024). https://doi.org/10.1007/s10490-024-09961-5

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Duke Health researchers publish study on hormone modification to enable lactation in transgender women

Duke researchers published a study on using hormone-modification technology to enable transgender women to lactate. 

The report , titled “Novel Lactation Induction Protocol for a Transgender Woman Wishing to Breastfeed: A Case Report,” was published on March 27 in the National Library of Medicine. It is the fifth report ever published on lactation for a transgender woman, but is the only one that used metoclopramide for lactation induction. 

Research was conducted by second-year medical student Esme Trahair, clinical pharmacist Sarah Kokosa, researcher Andy Weinhold, researcher Heather Parnell, Associate Professor of Medicine Carly Kelley and Andrea Dotson, assistant professor in family medicine and community health. 

The subject of the study, a 50-year-old anonymous transgender woman, began to receive gender-affirming hormone therapy in 2018 and sought to breastfeed her grandchild in 2022. 

According to the report, the woman’s “primary motivation for inducing lactation was to experience the bond from breastfeeding that she had not been able to experience with her own five children.” 

Within four weeks of beginning a modified hormone regimen, which included 10 mg of metoclopramide three times daily, the patient was able to lactate.

The woman reported producing breast milk over a period of two weeks, during which she breastfed her four-month-old granddaughter multiple times. 

Since breastfeeding the infant, the patient reported an emotional bond with her grandchild and female gender affirmation, as noted by her reports that breastfeeding “felt very different from formula feeding her other children; she stated she has a special bond with this baby for which she is grateful.”

The patient did not experience any side effects from the therapy. She said she wished she had known about this option earlier on, and hopes other transgender women can similarly realize their breastfeeding goals.

The report concluded by emphasizing the need for further research on lactation protocols for transgender individuals and a greater understanding of the priorities of transgender patients who wish to lactate.

The Chronicle requested an interview with an author of the study, who forwarded the request to the Duke Health News Office. The office did not respond for comment.

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The tyranny of time.

Taking charge: Manufacturers support growth with active workforce strategies

As the industry grows, manufacturers are actively investing in attracting and retaining employees, drawing on innovation and an ecosystem approach to help improve the worker experience., john coykendall.

US Industrial Products & Construction leader

United States

John is a vice chair, Deloitte LLP, and the leader of the US Industrial Products & Construction practice. John has more than 25 years of consulting experience focusing on global companies with highly-engineered products in the A&D, Industrial Products and Automotive industries.

John advises senior executives on driving impactful and sustained performance improvement, through both top-line growth and margin improvement initiatives. He has led large-scale transformation efforts to help businesses with strategic cost transformation and operations/supply chain initiatives.

John has an undergraduate degree from Lafayette College in Business & Economics and Government & Law and an MBA from Duke University.

Kate Hardin

Executive director

Kate Hardin, Executive Director of Deloitte’s Research Center for Energy and Industrials, has worked in the energy industry for 25 years. She currently leads Deloitte’s research on the impact of the energy transition on the energy and industrial manufacturing sectors. Before that, Kate led IHSMarkit’s integrated coverage of transportation decarbonization and the implications for automotive and energy companies.

Kate has served as an expert in residence at Yale’s Center for Business and Environment, and she is also a member of the Council on Foreign Relations. Kate has an MBA from the Yale School of Management and a MA in Russian studies from Yale University.

John Morehouse

Research leader, Industrial products manufacturing

John Morehouse is the research lead for Industrial Products Manufacturing in the Deloitte Research Center for Energy & Industrials. He has more than 25 years of experience in manufacturing-related roles in industry, academia, and government.

Victor Reyes

Managing Director

Victor is a managing director in Deloitte’s Human Capital practice, focused on helping organizations reimagine their people strategies and HR capabilities to deliver business results, enhance talent experience, and anticipate and embrace future workforce challenges. He serves as Deloitte’s Human Capital consulting leader for the Industrial Products & Construction sector. In his more than 23 years as a management consultant, he has designed and implemented programs that include talent strategy, acquisition, and development; HR technology strategy and deployment; global shared services and outsourcing; mergers, acquisitions and divestitures; and workforce analytics. Victor has served clients in the Americas, Europe, and Southeast Asia, and has worked in multiple industries, including energy, aerospace, financial services, telecom, healthcare, consumer products, retail, and real estate. He holds an MBA from Harvard Business School and a BA in Government from Harvard College, and is a certified Senior Professional in Human Resources (SPHR) and SHRM Senior Certified Professional (SHRM-SCP). For over 15 years, he has led pro bono consulting projects for non-profits across the country. He and his wife live in Washington, DC.

Gardner Carrick

Chief program officer, The Manufacturing Institute

Gardner Carrick is the chief program officer for The Manufacturing Institute, the nonprofit affiliate of the National Association of Manufacturers (NAM). Carrick leads the Institute’s efforts to create a world class workforce for the US Manufacturing sector. He oversees all of the MI’s program activities, including the Institute’s FAME education program, Heroes MAKE America program, Women MAKE America team, and workforce initiatives.

Strong growth in US manufacturing, even as talent challenges persist

The US manufacturing industry is experiencing strong growth. Manufacturing employment has surpassed pre-pandemic levels and stands close to 13 million as of January 2024. 1 The number of manufacturing establishments in the United States grew by more than 11% between the first quarter of 2019 and the second quarter of 2023, approaching 393,000 by the end of the period. 2 Construction spending in manufacturing—that is, dollars invested to build new or expand existing manufacturing facilities—has nearly tripled since June 2020 and was up 37% year over year in January 2024 when it reached a record high of US$225 billion (figure 1). Even as average lead times have declined since the pandemic, 3 the desire to de-risk supply chains and establish facilities closer to US customers has continued to drive investment from domestic and foreign manufacturers. 4

Legislation and policy have also played a role. Deloitte analysis of government data as of September 2023 indicates that nearly 300 new clean technology and semiconductor and electronics manufacturing facilities have been announced and are planned for completion by 2031, 5 spurred in part by the Infrastructure Investment and Jobs Act (IIJA), the Inflation Reduction Act (IRA), and the Creating Helpful Incentives to Produce Semiconductors (CHIPS) Act. These projects represent over US$430 billion invested and include announcements of more than 234,000 new manufacturing jobs to be created. 6 The US Department of Defense launched its National Defense Industrial Strategy in January 2024 to guide investment and support the development of a modern and innovative defense industrial ecosystem. The overarching goals are to improve supply chain resiliency, enhance acquisition flexibility, develop the requisite workforce, and elevate the technological preparedness of the defense industrial base over the next three to five years. 7 These combined efforts seem to signal a positive outlook for the manufacturing sector, with potential implications for innovation, supply base expansion, job creation, and overall industry resilience in the United States.

Table of contents

• Strong growth in US manufacturing
• Changing workforce expectations
• Creating a leading workforce experience
• Attracting and upskilling talent
• The road ahead

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Or copy link, about the 2024 deloitte and the manufacturing institute talent study.

In December 2023, Deloitte and The Manufacturing Institute embarked on their sixth manufacturing talent study in more than two decades (hereafter referred to as the “study”). The study involved an online survey of more than 200 US manufacturers, interviews with more than 10 senior executives from manufacturing organizations of all sizes and across all sectors, and an extensive collation of secondary data on labor supply and demand.

• Supported by Deloitte’s economics team, the study conducted proprietary analysis on labor supply and demand data to explore the potential impact of unfilled jobs on the nation’s economy.
• The study also includes extensive analysis of data comprising manufacturing job descriptions and analysis of growth trends.
• Research included a targeted analysis of over 80 manufacturing companies’ annual reports and investor presentations.

Workforce issues remain a leading concern for manufacturers: A skills gap and an applicant gap

Alongside this potential growth, the 2024 Deloitte and The Manufacturing Institute Talent Study  identified another trend: There is not just a skills gap, but notably a gap in applicants for open positions in manufacturing. Three important themes, in particular, stood out in the study:

• Industry growth is driving the need for more workers of every type—from entry-level associates to skilled production workers to engineers.
• Skill requirements are evolving and are spread between technical manufacturing skills, digital skills, and soft skills.
• There is a shortage of potential candidates applying for positions—whether skilled or unskilled—and manufacturers need to retain the valuable talent they have.

Attracting and retaining talent is the primary business challenge indicated by over 65% of respondents in the National Association of Manufacturers’ (NAM) outlook survey for the first quarter of 2024. 8 Workforce challenges have also been the top concern for manufacturers surveyed by NAM since the fourth quarter of 2017, with the exception of the pandemic. 9 This timing coincides with the first instance when total job openings in the United States exceeded the number of unemployed Americans. 10 This phenomenon is partly due to longer-term economic factors, such as the declining population growth rate and the decreasing labor force participation rate, which has trended lower on demographic factors, including increased retirements. 11 In addition, even though December 2023 quit-rate data suggests some improvement as they approach pre-pandemic levels, employee turnover rates remain elevated, 12 posing a challenge for manufacturers. This could be partly attributable to the increased caretaking responsibilities many Americans of working age are facing since the pandemic, 13 and also to the higher numbers of millennials and Generation Z workers joining the workforce, 14 who bring a different set of expectations. 15

Even with some recent cooling, the labor market remains tight, and the resulting applicant gap may continue. This could impact the ability of manufacturers to fully capitalize on this recent growth in public and private investment. The net need for new employees in manufacturing could be around 3.8 million between 2024 and 2033. And, around half of these open jobs (1.9 million) could remain unfilled if manufacturers are not able to address the skills gap and the applicant gap 16   (figure 2).

Evolving skill requirements complicate the search for talent

This potential growth in the manufacturing sector appears to be creating demand for more employees across the board, even amid a historically tight labor market. 17 Moreover, the growth in construction jobs fostered by policy incentives may intensify competition for welders, electricians, and other trades, which could exacerbate the imbalance in labor supply and demand in manufacturing. Further complicating the picture is the evolving landscape of skill requirements and the rearchitecting of roles that is likely to be required as manufacturers continue their journey toward the smart factory and Industry 4.0.   

Evolving skill sets in manufacturing

The World Economic Forum’s 2023 Future of Jobs report highlights that 40% of the current skill requirements in advanced manufacturing will evolve over the next five years. 18 Manufacturers are prioritizing the development of these top three skills over the next five years: leadership skills, digital skills, and soft skills. 19

To better understand the growing breadth of evolving skills that manufacturers are seeking, we analyzed the past five years of job posting data. 20 The research found a 75% increase in demand for simulation and simulation software skills, sought mostly for technology-enabled production or testing roles (figure 3). Customer service and client support skills showed significant upticks in demand as well, and this trend is likely to continue as manufacturers increase digital interactions with customers and expand their aftermarket services. The growing focus on employee relations skills has likely resulted from manufacturers’ efforts to develop a worker-friendly environment and a dedication to hiring from more diverse talent pools. 21 Manufacturing-specific skills, including those related to advanced processes like 3D printing, as well as cloud-based enterprise resource planning (ERP) solutions, have also experienced gains. The growth in demand for soft skills like critical thinking, problem-solving, and creativity tend to underpin many of the other skills that have shown the greatest gains, like customer service, simulation, and manufacturing processes.

Digital skills are important according to surveyed manufacturers, but soft skills are a necessary complement

One out of two respondents in our study indicated that it is “important” or “very important” for employees to have a high level of digital proficiency. Another 40% see it as “good to have,” primarily for engineers and engineering technicians, operations personnel, and maintenance technicians. Manufacturers are integrating technologies such as computer numerical control, programmable logic controllers, sensors, advanced robotics, 3D printing, and others with artificial intelligence across functions. 22 This integration underscores the importance of having a digitally savvy workforce with skills such as machine learning, cybersecurity, data management, and data analysis. Meanwhile, network security and the ability to work with modern ERP systems and interconnected machines are increasingly becoming important. 23 Additionally, smart factory solutions are on the rise, requiring digital skills to design, implement, and operate.

The increased adoption of digital tools and technologies tends to bring soft skills such as adaptability, problem-solving, critical and cross-functional thinking, initiative and leadership to the fore. For example, critical-thinking skills are important to evaluate the outputs from AI tools, including generative AI, and to process data mined from interconnected machines. However, digital and soft skills alone are generally not enough—for employees to successfully apply these skills, it tends to be important to have a strong foundation in the fundamentals of manufacturing, especially in highly specialized sectors such as fabricated metal product manufacturing, and aerospace and defense. For example, to learn how to effectively operate welding robots, it can be helpful—and often necessary—for a worker to have welding experience in a manufacturing environment.

More manufacturing workers are likely to be needed for higher-skill roles

According to occupation data from the US Bureau of Labor Statistics (BLS), some of the fastest growing manufacturing occupations projected until 2032 24 tend to be well-aligned with the skills in highest demand over the last five years. As operations and products become more complex and manufacturers look to integrate the information collected from their smart connected devices, equipment, and systems, highly skilled roles could grow the fastest between 2022 and 2032. 25

Industrial machinery maintenance technicians comprised over 270,000 employees in manufacturing in 2022 and these roles could grow as much as 16% by 2032. 26 Mechanical and industrial engineers combined to make nearly 370,000 employees in the sector and these occupations are each likely to expand by almost 11% over the same period. 27 Together, software and web developers, computer and information systems managers, and computer and information analysts constituted close to 243,000 manufacturing employees in 2022, and combined, they  could increase by nearly 13% by 2032. 28 Although statisticians and data scientists currently make up a small portion of manufacturing employment (7,500), these roles may grow by close to 30% by 2032. 29

Traditional production roles are likely to also continue to be important. According to BLS data, production-related occupations currently employ the largest number of people in the sector, and BLS also projects this to be the case in 2032. 30 However, the fastest growing production roles are likely to be those that require higher-level skill sets, such as semiconductor-processing technicians, machinists, first-line supervisors, welders, and electronics and electromechanical assemblers. 31 Gains are also likely for material-moving occupations such as laborers and material movers and industrial truck and tractor operators. 32

Educational trends suggest a gap

Graduation data from the National Center for Education Statistics suggests that traditional training methods may not be able to keep up. While the number of bachelor’s degrees awarded in all fields of study from 2011 to 2022 has increased, the number of associate degrees—which tend to prepare graduates for high-skill trades—has remained stagnant (figure 4). The number of certificates awarded, which can offer foundational training for skilled trades, has experienced a moderate increase over the same period, and a significant jump from 2021 to 2022, even surpassing the number of associate degrees awarded.   

For degree programs most relevant to manufacturing, there has been a substantial increase in graduates from programs such as computer and information sciences and engineering (figure 5) that typically require a bachelor’s degree. There has also been growth in mechanic and repair technologies degrees, as well as precision production, fueled in large part, it appears, by substantial post-pandemic upticks from 2021 to 2022. However, growth has been slow in the remaining programs that prepare graduates for higher skilled roles like engineering technologists and skilled transportation and material moving positions. Our analysis also found that the average growth in certificates awarded was more than four times the growth in associate degrees for manufacturing-related programs over 2011 to 2022.

While this trend could help to grow a talent pool with the foundational knowledge companies can continue to build upon once workers are hired, it also suggests there may be a need to produce more highly skilled graduates with associate degrees. In general, if the number of people entering and graduating from degree programs that prepare them for high-skill manufacturing trades does not accelerate, the talent gap could widen.

Some manufacturers are taking an active role—and the lead—in addressing talent challenges

The key question becomes: Given the talent challenges, how can manufacturers build the workforce needed to seize the growth opportunity at hand? Our study found that there is a shift underway in the sector and, in general, companies are currently taking a more active approach to addressing both the skills gap and the applicant gap. Manufacturers seem to be focusing on investing in partnerships—and the worker pipeline and the work environment—to help create the workforce they need with the requisite skill sets and improve employee retention. Our study found that the following three approaches, when used in combination, are helping some manufacturers in overcoming the talent challenges they face:  

• Understanding changing workforce expectations
• Applying a “customer focus” to workforce challenges to create a leading worker experience
• Taking an ecosystem approach to attract and upskill talent

Changing workforce expectations affect hiring and retention

As more baby boomers and Generation X workers move closer to or into retirement, the workforce may be made up more of millennials and Generation Z workers, who can have a different set of expectations when it comes to work culture and the working environment itself. In one recent survey, those respondents were found to be more prone to job switching, which can impact attraction and retention. 33 Generally, surveyed executives from our study reported that higher levels of flexibility, including remote-work options, seem to be among the most impactful strategies to attract and retain employees (figure 6), which can also be challenging with fixed work schedules and traditional in-person production team settings often seen in manufacturing. 34

“The average tenure in our organization is reducing. So, we need to understand that even if we get a capable hire for two years, how do we then accelerate the capable hire’s onboarding and distribution of knowledge across the larger organization and develop others quickly with the expectation that they’re not going to stay with us for more than two years.”

—Interview with industry executive 35

Providing the flexibility that workers want

Nearly half (47%) of respondents in our study indicated that flexible work arrangements (for example, flexible shifts, shift swapping, split shifts) is the strategy that their company has found to be most impactful for retaining employees (figure 6). Flexible work was second only to competitive employee benefit programs. 

A predicament to solve

The hours spent on caretaking have increased for full-time workers since the pandemic; this includes child care but also care for parents and spouses. 36 According to BLS data, the average number of employees who missed work in the United States in 2023 due to child care stood at 47,000—42% above the pre-pandemic 2019 average of 33,000. 37 In a recent study by The Manufacturing Institute, 49.2% of women and 8.0% of men indicated that lack of child care support was their most significant labor-force challenge. 38 Yet in a previous Deloitte and The Manufacturing Institute study, only 8% of surveyed manufacturing leaders said that their company offered new or additional day care options. 39

Some companies have piloted or implemented child care programs and have observed significant benefits. An executive from a distribution and logistics service provider told us that a pilot child care program run by an external organization was established adjacent to a warehouse and it was utilized by close to 80% of employees, who paid for the care. The executive reported a fourfold improvement in the turnover of this facility. 40

An executive from an electric products manufacturer shared that the company developed a two-day per week part-time position that offers tuition assistance and pay without benefits that initially targeted university students. 41 The executive added that once the program was off the ground, “to our surprise, there were a lot of stay-at-home parents that wanted that—they came out of the woodwork to have a two-day workweek.” They now have close to 400 employees in the successful program with good attendance and retention rates.

Some manufacturers are partnering with innovative temp agencies to provide the workforce and skills they need while providing workers the flexibility that they are looking for. Leveraging digital tools and apps, some temp agencies can provide part-time workers, including the semi-retired, college students, and caregivers, the opportunity to sign up for work slots and overtime, while providing the flexibility to cancel or swap shifts, with vacated spots being backfilled with another worker, with the help of AI tools. 42

Taking a bigger role in skills development to attract and retain employees

The applicant gap seems to be prompting more employers to focus on training as a means to attract and retain employees. According to Deloitte’s Workforce Experience research , employees who feel they can acquire necessary skills that are important for the future are 2.7 times less likely to leave their organization in the next 12 months. 43 Changing skill requirements have prompted some companies to employ a “skills-based” approach that focuses on employees’ abilities and competencies rather than their job titles or formal qualifications, better aligning workers with work that fits their skills and capabilities (figure 7).

Manufacturers seem to recognize the value of upskilling and are using a variety of strategies to train employees, irrespective of role or function, to create an agile workforce. Internal training academies or programs were highlighted as instrumental in helping employees adapt to new technologies and processes.

“STEM has been defined for years as science, technology, engineering, and mathematics. But STEM to us is soft skills, technical or technology skills, engagement, and motivation. Those are the skills we need. The rest of it can be taught all day long.”

—Interview with industry executive 44

Many companies are also leveraging e-learning platforms to facilitate flexible and self-paced learning opportunities and are sponsoring industry workshops, conferences, and seminars to help ensure employees are apprised of industry trends and leading practices. Some employers are conducting regular skills assessments of employees to track progress and refine training programs to meet evolving needs.

Mentoring, knowledge transfer, and rotational programs for new hires are gaining traction among manufacturers and are intended to enrich employees’ experiences while helping to ensure well-rounded skill development. Such programs can encourage employees to gain experience across departments, which helps enable a versatile workforce.

Providing additional support that employees seek

There is growing recognition that many job seekers need support services to help them meet the requirements of a full-time job, and these can range from help with the daily commute to finding affordable housing close to their job. 45 Reliable transportation to complete a daily commute can be a challenge for some employees, especially in rural areas with limited or no public transit. 46 An executive from an electric products manufacturing company mentioned that “[reliable] transportation was the number one reason people were leaving our roles.” 47 The company partnered with a transportation service provider to offer subsidized rides to employees to and from work. 48 An automotive manufacturer in a rural area is collaborating with other companies and city and county government to investigate the local obstacles to transportation and devise pilot programs to improve transportation in the area. 49

Finding affordable housing is also a challenge for some employees, especially given that the median home price in the United States increased by 37% between January 2019 and November 2023 and the average rental price in US cities rose by 26% over the same period. 50 Our interviews emphasized some manufacturers are working with a state or local government to investigate and develop affordable workforce housing options and opportunities. 51

Applying customer focus to create a leading workforce experience

Creating and improving products and processes is the core of what manufacturers do. They use a variety of strategies and frameworks to accomplish these objectives, such as “define, measure, analyze, improve, and control” (DMAIC) 52 and Design Thinking. 53 This focus on what the customer needs could be applied to creating innovative workforce solutions, especially when the optimal worker experience is a guiding principle. One executive emphasized that empowering talent organizations to be innovative is important, as “challenging them to be entrepreneurs and find new disruptive ways of doing things can bring great ideas.”

Another executive said, “We want our customers to be first. We want our employees to be first. We want to meet them where they are, which means we adjust how we do things.” According to a study on the American workplace, employees in the manufacturing industry seem to be less engaged when compared to other industries. 54 Actively disengaged employees are almost twice as likely to seek new jobs than engaged employees. 55

Creating a sense of purpose

According to The Deloitte Global 2022 Gen Z and Millennial survey , nearly 40% of millennials and Gen Zs have turned down a job because it didn’t match their values. On the other hand, respondents who are happy with their company’s impact on society and the environment are more likely to stay with the company for over five years. 56 Executive interviews indicated that providing a sense of purpose, emphasizing the importance of culture, and establishing clear leadership can provide motivation and help drive performance. 

“People who have been here for a long time and new hires are seeking a sense of belonging and being part of something bigger. It’s not a mantra that we just talk about with a certain level of employees—it’s deep throughout the organization, and when they come to work, they know what they are coming to work for, and they sign up to that purpose.”

—Interview with industry executive 57

In particular, multiple executives highlighted that centering at least part of their mission statement on green products and projects and their benefit to the planet has helped them to attract and retain talent. An executive from a household electronics manufacturer expressed it this way: “This population cares about the planet and they want companies who are responsible in the way they manage their company. Sustainability is a very key part of what we do in our business—it’s important to our associates and it’s important to our customers.” 58

Promoting a work environment focused on health, safety, and comfort

Several executives that we interviewed indicated that creating a comfortable working environment was important not only for attracting new talent but could also make the difference between keeping or losing employees to a competitor. As one executive summed it up, “We have to provide ways for people to feel safe and comfortable when they come to work. It's really important that employees feel like their companies care about them—that they see them—and that they believe that their employees’ health and well-being are important.” And the needed improvements can be as intuitive as better lighting in the parking lot or improving the cafeteria.

One executive indicated that before acquiring and completely renovating a 50-year-old manufacturing facility, their company surveyed employees to determine what was most important to them in a working environment. Improved lighting, including natural light, and air quality were at the top of workers’ lists, and the renovated smart factory design was based on the feedback received. 59

Technology can help engage and empower workers—and make their jobs better, safer, and easier

Technology plays an important role in shaping the future of workforce development. It can act as a magnet in both attracting and retaining skilled individuals. As gleaned from our interviews, high-tech manufacturing environments seem to appeal to the workforce. Manufacturers that have built smart factories to enhance performance are also noting higher retention in these high-tech facilities. 60

Deloitte Global’s Millennials and Gen Z Study highlights that more than one-third of surveyed millennials and Gen Zs believe that AI and other technologies can augment jobs or various job functions over the next decade. 61 In another recent study, over half of the surveyed workforce believe it is important for manufacturers to focus on the consistent availability of technology to attract more people, whereas only 31% of manufacturing executives agreed to prioritize technology to attract employees. 62

Enhanced employee engagement can be achieved by integrating technology into manufacturing processes. Digital tools including AI, generative AI, and automation can be used to augment mental and physical human capabilities to optimize production, make jobs easier, and provide autonomy by giving operators new channels to report production issues, which can enable efficient triage and rapid problem resolution. The integration of technology has also helped to revolutionize upskilling in the industry. Most companies we interviewed are exploring the potential of augmented or virtual reality (AR or VR) for comprehensive training, potentially allowing workers to acquire new skills using these tools. An executive mentioned that VR has reduced training time for welders at the company by 50% to 60%. The flexibility in technology-facilitated trainings can enable individuals to upskill at their convenience, helping to foster a more dynamic and efficient learning environment.

Taking an ecosystem approach to attract and upskill talent 

The smart manufacturing ecosystem.

A previous Deloitte report highlighted the possible value of using an ecosystem approach to accelerate smart manufacturing , specifically in improving innovation by enabling better collaboration among partners who share the common goal of developing and implementing smart factory solutions (figure 8). 63

In its general form, a business ecosystem involves organizations coming together, or partnering, to solve shared problems and meet shared objectives. 64 Collaboration, co-innovation, and co-evolution are at the heart of what drives an ecosystem. 65 (An example of a smart factory ecosystem is described in the sidebar titled “The smart manufacturing ecosystem.”)

A talent ecosystem is anchored by regional organizations that can contribute to helping companies attract, upskill, and even retain the workers that they need. It includes traditional organizations that develop talent, such as K-12 institutions, technical colleges, and universities, as well as a wide range of partners beyond education. Similar to the production ecosystem approach to accelerate smart manufacturing practices, a talent ecosystem can help improve innovation in talent strategies by enabling better collaboration among partners who share the common goal of developing and implementing workforce solutions. Figure 9 highlights some of the potential participants and capabilities manufacturers can forge by implementing a talent ecosystem.

The talent ecosystem in action

Many companies have had to move beyond traditional talent approaches and innovate to improve their talent strategies. As one executive says, “We’ve had to break a lot of paradigms and change our mindset to adapt.” But manufacturers are no strangers to breaking paradigms: The industry is the leading sector in the United States for innovation, accounting for 53% of all private-sector research and development. 66 Increasingly, manufacturers seem to be leveraging this innovation foundation to implement an ecosystem approach and improve worker experience. (An example of a talent ecosystem in action is described in the sidebar titled “Cultivating the future smart factory workforce with an ecosystem approach.”)

Our study corroborates that most manufacturers are establishing ecosystems to help expand their talent pool and develop the requisite skills. Ninety-four percent of surveyed manufacturers indicated that they are forming at least one partnership to improve job attraction and retention. 67 On average, our study respondents are partnering with four or more organizations to form an ecosystem (figure 10). So, what partnerships are some manufacturers forging and how are they leveraging these to help overcome talent hurdles?

Cultivating the future smart factory workforce with an ecosystem approach

Wichita State University emphasizes applied learning experiences across all majors, including industry-driven and technology-transfer projects, to help students gain practical skills and knowledge that help prepare them for professional settings, including smart factory environments. The university fosters an ecosystem that prioritizes and streamlines collaboration with industry partners, which supports regional innovation and helps to build a well-prepared workforce for advanced manufacturing and other sectors. 68

Partnerships to build awareness of manufacturing careers and opportunities 

Manufacturers across the nation open their doors on National Manufacturing Day to provide plant tours to the local community, including students, parents, teachers, and guidance counselors from K-12 schools. 69 A past Deloitte study has indicated tours of advanced manufacturing facilities for students can be an effective strategy for increasing interest in manufacturing jobs. 70 Several manufacturing executives indicated that company representatives regularly visit local K-12 schools to talk about the company, careers offered, and the high-tech environment in manufacturing facilities to inspire students to consider manufacturing careers. 71 Several companies have also donated manufacturing equipment to schools to spark interest and support skills development. 72

In partnership with an engineering and construction firm and a welding equipment manufacturer, the American Welding Society offers nationwide grants to high school programs that do not currently have welding programs. 73 The grant provides a kit with a welding machine and other equipment to give students the opportunity to experience welding—many for the first time—and possibly inspire them to consider a career in the field. In another example, a flooring manufacturer implemented a work-based learning program in partnership with local high schools, which provides flexible and paid work experiences in several departments, as well as opportunities to advance into an apprenticeship program. 74 The company reported that, in 2023, it achieved 100% retention of graduating seniors and hired over 50 students from the program. 75

Partnerships to build, leverage, and support training programs

Some manufacturers are finding innovative ways to form partnerships to work with local technical colleges—as well as organizations throughout the talent ecosystem—to build the workforce that they need. Employer-led consortia to create programs that suit shared workforce development needs seem to have become more commonplace. Some consortia are even led by local workforce, government, or economic development agencies to build a workforce with the requisite skills to support a specific manufacturing sector in a region. 76

Many states have implemented manufacturing career pathways from the National Career Clusters® Framework 77 to create programs that meet state needs, and an updated framework design is expected in fall 2024. 78 Strong workforce training programs can be important for attracting new businesses and keeping existing companies within a state. 79 In Georgia’s QuickStart program, the Technical College System of Georgia partners with manufacturers to establish new facilities or expand in the state to develop and deliver customized training programs to create a skilled workforce ready to begin production. 80 Since its inception, QuickStart has trained over 1 million workers and companies often cite it as an important factor for choosing to set up new facilities or expand in Georgia. 81 The Virginia Talent Accelerator Program, a partnership between the Virginia Economic Development Partnership and the Virginia Community College System, offers recruitment and training services to greenfield or expanding facilities in the state of Virginia. 82 The Greater Wichita Partnership worked with Deloitte to develop an action plan to help the region build a workforce for the future. The plan emphasizes the need for collaboration among industry, education, and community stakeholders to drive inclusion, expand the talent pool, invest in skill development, and support innovation. Together, they can provide access to upskilling opportunities focused on high priority skills such as communication, computer literacy, and project management. 83

Some manufacturers are partnering with community organizations. For example, a large automotive manufacturer partnered with Goodwill to administer credentialled training programs in local communities focused on developing digital skills, including IT support, and even training auto technicians. 84 Other companies have partnered with Goodwill to take advantage of the trained talent pool that they offer through the Talent Source program, 85 or the manufacturing services that they offer, including producing and packaging automotive components, and even manufacturing uniforms for the US military. 86

Apprenticeships and programs for work study also appear to be on the rise. The number of apprentices in advanced manufacturing occupations increased to 59,500 in fiscal 2023, which is nearly triple the total in fiscal year 2021. 87 Nearly half (47%) of survey respondents in the 2022 Deloitte and The Manufacturing Institute Perceptions study indicated that apprenticeships, work studies, or internships at manufacturing companies would be the most effective way to increase interest in manufacturing as a career choice. 88 The Manufacturing Institute’s FAME program is one example that has helped to bolster the pipeline for maintenance technicians (see sidebar titled “FAME: Developing regional pools of maintenance technicians”). The Inflation Reduction Act offers tax credits to companies who hire employees from registered apprenticeship programs, which may increase the demand for apprenticeship programs and help expand training opportunities. 89

FAME: Developing regional pools of maintenance technicians

One example of an innovative program to build regional pools of maintenance technicians—which are in high demand in advanced manufacturing environments—is the FAME program, which was started by an automotive manufacturer and transferred to The Manufacturing Institute to boost its national reach. 90 Students attend classes at a local community college two days a week and work three days for a local sponsoring manufacturer. 91 They are paid a competitive wage and engage in hands-on training and classroom education to develop technical and professional skills related to manufacturing. Graduates earn an associate degree and are certified as an Advanced Manufacturing Technician. The automotive manufacturer worked closely with its initial community college partners to tailor the program to meet its needs. 92 Today, the program has grown to nearly 40 employer-led chapters in 14 states, and it has produced over 1,800 graduates since 2012 who have benefitted from a 90% placement rate. 93

Partnerships that look beyond the traditional talent pipeline

Manufacturers have focused efforts on increasing the size of their talent pool and created a more diverse and inclusive workforce by partnering with a variety of organizations to engage groups that may have unique barriers to entering or re-entering the workforce.

Individuals that were formerly incarcerated who seek a “second chance”

Several manufacturers have established a sense of purpose, given back to their local community, and even improved retention rates by providing work opportunities to applicants that were formerly incarcerated, who are reentering the workforce. A packaging manufacturer reported that almost 70% of its nearly 200-person workforce comprised second-chance individuals—and the company’s attrition rate is 25 percentage points lower than the sector average. 94 In a recent study, 82% of managers reported that second-chance individuals may add even more value to their companies than those not part of the program. 95 Through the Workforce Opportunity Tax Credit, companies can also receive up to US$2,400 per employee. 96 However, people that were formerly incarcerated may face unique challenges related to transportation, housing, and job flexibility. Partnerships with local organizations can be essential for providing this support in cases where manufacturers don’t have the expertise or resources in house (see sidebar titled “Resources supporting job-seekers that were formerly incarcerated”).

Resources supporting job seekers that were formerly incarcerated

The Manufacturing Institute recently released its “Second Chance Hiring Toolkit for Local Communities,” which leverages data from successful second chance programs across the United States. The toolkit recommends identifying a local hub organization to form partnerships between employers and community-based reentry organizations to build regional programs. 97 An example of a partnership model is the Beacon of Hope Business Alliance in Cincinnati, Ohio, which is operated by Cincinnati Works, a nonprofit organization whose mission is to provide workforce training and support services that people living in poverty need to become economically self-sufficient. 98 The goal of the alliance is to support job seekers that were formerly incarcerated, as they seek meaningful employment. 99 It is an ecosystem of partners that includes employers, community-based organizations that provide workforce training and support, a local government reentry and rehabilitation office, a nonprofit legal organization, and faith-based organizations.

Refugees and immigrants

Some companies have partnered with local organizations and resettlement groups to access a diverse talent pool of refugees and immigrant populations. A furniture manufacturer began hiring refugees nearly four decades ago and today they make up nearly half of the company’s workforce. 100 Not only does it help to fill a need for workers, but it can also provide a sense of purpose as the company and workforce help community members. An executive from a large manufacturing company stated that new partnerships were needed to implement a similar program, but the benefits have been well worth it. 101 While a majority of companies that have implemented refugee hiring programs report higher retention rates and lower turnover, there are unique challenges to overcome, including language and cultural barriers. 102

“In the past, we said you had to be fluent in English, and we were missing out on a very hardworking, committed workforce. We teamed up with our local community partners and have been able to access a diverse group of refugees and immigrants from Afghans to Cubans, to other Spanish-speaking populations. It’s been tremendously successful—the retention rate is significantly better than other populations—it’s 76%. We are also developing an app so that they have access to translation available at their fingertips.”

—Interview with industry executive 103

According to the study, nearly one-third of surveyed manufacturers are partnering with organizations that support veterans. Their military experience often instills technical, leadership, and communication skills that are important for success in a manufacturing environment. 104 But transitioning into a civilian workplace is not without its challenges. 105 It can be difficult for veterans to communicate how the skills, traits, and work habits developed in the military align with those listed on job requisitions. Partner organizations that support veterans, and programs like The Manufacturing Institute’s Heroes MAKE America, 106 can help manufacturers make these connections, provide veterans with access to manufacturing-specific training and certification, and help companies establish a pool of veteran candidates. 107

Workplace accommodations

Some people have unique abilities that can make them a good fit for certain manufacturing roles—including skilled production jobs like computer numerical control machine operators—that are generally difficult for manufacturers to fill. 108 There may be individuals with remarkable intellectual and visual abilities, as well as a high propensity to learn, who may also be neurodiverse and require additional accommodations in the workplace. 109 An automotive aftermarket parts supplier and a large heavy equipment manufacturer have formed innovative partnerships with organizations in their communities, which specialize in working with and training people with disabilities for the workforce. 110 These partnerships have led to the partner organization providing contract manufacturing services, as well as direct hiring of employees by the manufacturer. Moreover, individuals with physical limitations may be able to pursue additional employment opportunities with the advancement of digital technologies and robotics, as their qualifications and certifications could still enable them to engage in remote control monitoring of robotics, for example. The potential pool of talent is significant. Over 33 million working-age Americans were identified as having a disability in 2023—only 7.5 million are currently employed, and only 9.1% are employed in manufacturing. 111

A dedicated focus on the talent development team

It can take dedicated effort, and perhaps additional resources, including staff members with additional experience and skill sets, for talent organizations to take an ecosystem approach and focus on the many aspects of worker experience. An individual or group within the company should be responsible for getting out into the community and building relationships with the full spectrum of organizations within the ecosystem. Professionals with an economic development, business development, or sales background may be particularly well-suited for this role. On the other hand, experience performing research and analysis may be most helpful for benchmarking and comparing existing innovative talent programs. Partnering closely with plant managers, front-line supervisors, and other production leaders to offer training and support when implementing new and innovative talent programs may be necessary. Finally, new positions may be needed to support the needs of applicant groups.

Final thoughts: The road ahead 

Manufacturers are taking an active role and applying an innovative mindset to address talent challenges that face the industry. The approaches will likely continue to be needed as manufacturers compete for workers in the current labor market. To help address the skills gap and the applicant gap, companies should consider leveraging an ecosystem approach to attract more workers to the industry and provide them with the skills they need. However, the manufacturing industry is poised for growth in the next decade and the challenge is not just finding and upskilling the people needed to take on the approximately 3.8 million projected possible new jobs, but also retaining them. Workers’ experiences can not only shape their professional journey but can also foster an inclusive and collaborative workplace that can help increase employee retention.

The executives’ participation in this article is solely for educational purposes based on their knowledge of the subject and the views expressed by them are solely their own. This article should not be deemed or construed to be for the purpose of soliciting business for any of the companies mentioned, nor does Deloitte advocate or endorse the services or products provided by these companies.

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Acknowledgments

The authors would like to thank Kruttika Dwivedi and Anuradha Joshi for their key contributions to this report, including research, analysis, and writing. 

They would also like to thank Luke Monck ,  Misha Nikulin ,  Simona Savitt , and  Lindsey Berckman,  the members of the 2024 Talent Study Deloitte Advisory Board.

The authors would like to thank Carolyn Lee ,   who served as the advisor from The Manufacturing Institute.

The authors would like to thank Zack Pu ,  Asi Klein , Trey Howard ,   and Ram Iyer  for their subject-matter inputs.

The authors would like to acknowledge the support of Clayton Wilkerson for orchestrating resources related to the report; Narasimham Mulakaluri and Akshay Jadhav for their data expertise; Daniel Bachman for his subject-matter inputs; Heather Ashton Manolian for managing Deloitte’s relationship with The Manufacturing Institute and providing subject-matter inputs; Kimberly Prauda and Neelu Rajput who drove the marketing strategy and related assets to bring the story to life; Alyssa Weir for her leadership in public relations; and Rithu Thomas and Preetha Devan from the Deloitte Insights team who supported the report’s publication.

Cover image by: Rahul B

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Scaling Community-Owned Real Estate for Affordable Housing

About This Investment 

Affordable, stable housing helps create the physical, economic, and social conditions a community needs to help its members thrive. Often, when external entities and investors control real estate development, the core needs of residents are sidelined in favor of profit. In contrast, when communities themselves own land through structures like community land trusts (CLTs), residents’ voices can guide housing policy and investment decisions, preventing gentrification and displacement and ensuring that community needs are being met. Despite their effectiveness in preserving long-term affordability for communities with low incomes, CLTs remain underfunded by the mainstream financial and philanthropic sectors.  

The Robert Wood Johnson Foundation (RWJF) seeks to address this funding gap with a $5 million investment to the National Housing Trust Community Development Fund (NHT). In partnership with Grounded Solutions Network (GSN), NHT looks to strengthen CLTs by increasing their capacity for property acquisition, introducing financial management loans for housing operations, and promoting long-term affordable housing development. 

Why It Was Needed

Having ownership and control over one’s place of residence contributes significantly to a household’s ability to generate wealth, build financial security, and improve physical and mental wellbeing. When residents have a share in the benefits of neighborhood development efforts, they gain empowerment and a stronger sense of belonging, enhancing community resilience.  

However, maintaining long-term affordability is challenging due to the nature of the real estate market. Traditional investors and developers often see housing merely as a financial asset with profitability as the goal, driving up costs. In contrast, community members see home as more than a financial commodity–it is a place where people learn, grow, and build their lives. Community ownership helps put control of housing back into the hands of the people who live in it, supporting price stability and long-term affordability.

How It Works

CLTs are a model of community-driven ownership, in which a nonprofit managed by residents, community members, and mission-aligned partners stewards housing. After acquiring a property, a CLT offers homes for purchase or rent at reduced prices, with the land staying under community ownership. Homeowners can buy properties at reduced rates and typically have long-term, renewable land leases with the CLT. These agreements ensure that if a home is sold, it remains affordable for future residents with low incomes.  

About the Borrower

The National Housing Trust Community Development Fund (NHT), a community development financial institution (CDFI) with a 20-year track record. NHT has deployed more than $50 million in loans, preserved more than 13,000 affordable units, and leveraged more than $1 billion in capital by providing quality, affordable loan products in 28 states and the District of Columbia. It uses a holistic approach to underwriting, including technical assistance, that has allowed its portfolio to combat the affordable housing crisis.  

Grounded Solutions Network (GSN), formed in 2016 through the merger of the National Community Land Trust Network and Cornerstone Partnership, is the leading national expert on community land trusts and shared-equity ownership models. It has a network of over 200 nonprofit, public, private, and philanthropic members in 40 states. 

In the Spotlight

North East Housing Initiative (NEHI), a community land trust formed in 2014 to support permanently affordable housing in northeast Baltimore, received an enterprise loan from NHT in 2023 following a line-of-credit loan in 2022. Since then, NEHI added 20 properties to its portfolio, transforming vacant properties into permanently affordable homes to help build a community that is sustainable, inclusive, and diverse.

“The National Housing Trust’s enterprise loan has been immensely helpful to our liquidity, allowing us to plan further ahead to scale future acquisitions. Being able to respond at market speed allows us to respond at the rate that our community needs us.” —Garrick Good, President/CEO, NEHI

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