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Research Findings – Types Examples and Writing Guide

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Research Findings

Definition:

Research findings refer to the results obtained from a study or investigation conducted through a systematic and scientific approach. These findings are the outcomes of the data analysis, interpretation, and evaluation carried out during the research process.

Types of Research Findings

There are two main types of research findings:

Qualitative Findings

Qualitative research is an exploratory research method used to understand the complexities of human behavior and experiences. Qualitative findings are non-numerical and descriptive data that describe the meaning and interpretation of the data collected. Examples of qualitative findings include quotes from participants, themes that emerge from the data, and descriptions of experiences and phenomena.

Quantitative Findings

Quantitative research is a research method that uses numerical data and statistical analysis to measure and quantify a phenomenon or behavior. Quantitative findings include numerical data such as mean, median, and mode, as well as statistical analyses such as t-tests, ANOVA, and regression analysis. These findings are often presented in tables, graphs, or charts.

Both qualitative and quantitative findings are important in research and can provide different insights into a research question or problem. Combining both types of findings can provide a more comprehensive understanding of a phenomenon and improve the validity and reliability of research results.

Parts of Research Findings

Research findings typically consist of several parts, including:

• Introduction: This section provides an overview of the research topic and the purpose of the study.
• Literature Review: This section summarizes previous research studies and findings that are relevant to the current study.
• Methodology : This section describes the research design, methods, and procedures used in the study, including details on the sample, data collection, and data analysis.
• Results : This section presents the findings of the study, including statistical analyses and data visualizations.
• Discussion : This section interprets the results and explains what they mean in relation to the research question(s) and hypotheses. It may also compare and contrast the current findings with previous research studies and explore any implications or limitations of the study.
• Conclusion : This section provides a summary of the key findings and the main conclusions of the study.
• Recommendations: This section suggests areas for further research and potential applications or implications of the study’s findings.

How to Write Research Findings

Writing research findings requires careful planning and attention to detail. Here are some general steps to follow when writing research findings:

• Organize your findings: Before you begin writing, it’s essential to organize your findings logically. Consider creating an outline or a flowchart that outlines the main points you want to make and how they relate to one another.
• Use clear and concise language : When presenting your findings, be sure to use clear and concise language that is easy to understand. Avoid using jargon or technical terms unless they are necessary to convey your meaning.
• Use visual aids : Visual aids such as tables, charts, and graphs can be helpful in presenting your findings. Be sure to label and title your visual aids clearly, and make sure they are easy to read.
• Use headings and subheadings: Using headings and subheadings can help organize your findings and make them easier to read. Make sure your headings and subheadings are clear and descriptive.
• Interpret your findings : When presenting your findings, it’s important to provide some interpretation of what the results mean. This can include discussing how your findings relate to the existing literature, identifying any limitations of your study, and suggesting areas for future research.
• Be precise and accurate : When presenting your findings, be sure to use precise and accurate language. Avoid making generalizations or overstatements and be careful not to misrepresent your data.
• Edit and revise: Once you have written your research findings, be sure to edit and revise them carefully. Check for grammar and spelling errors, make sure your formatting is consistent, and ensure that your writing is clear and concise.

Research Findings Example

Following is a Research Findings Example sample for students:

Title: The Effects of Exercise on Mental Health

Sample : 500 participants, both men and women, between the ages of 18-45.

Methodology : Participants were divided into two groups. The first group engaged in 30 minutes of moderate intensity exercise five times a week for eight weeks. The second group did not exercise during the study period. Participants in both groups completed a questionnaire that assessed their mental health before and after the study period.

Findings : The group that engaged in regular exercise reported a significant improvement in mental health compared to the control group. Specifically, they reported lower levels of anxiety and depression, improved mood, and increased self-esteem.

Conclusion : Regular exercise can have a positive impact on mental health and may be an effective intervention for individuals experiencing symptoms of anxiety or depression.

Applications of Research Findings

Research findings can be applied in various fields to improve processes, products, services, and outcomes. Here are some examples:

• Healthcare : Research findings in medicine and healthcare can be applied to improve patient outcomes, reduce morbidity and mortality rates, and develop new treatments for various diseases.
• Education : Research findings in education can be used to develop effective teaching methods, improve learning outcomes, and design new educational programs.
• Technology : Research findings in technology can be applied to develop new products, improve existing products, and enhance user experiences.
• Business : Research findings in business can be applied to develop new strategies, improve operations, and increase profitability.
• Public Policy: Research findings can be used to inform public policy decisions on issues such as environmental protection, social welfare, and economic development.
• Social Sciences: Research findings in social sciences can be used to improve understanding of human behavior and social phenomena, inform public policy decisions, and develop interventions to address social issues.
• Agriculture: Research findings in agriculture can be applied to improve crop yields, develop new farming techniques, and enhance food security.
• Sports : Research findings in sports can be applied to improve athlete performance, reduce injuries, and develop new training programs.

When to use Research Findings

Research findings can be used in a variety of situations, depending on the context and the purpose. Here are some examples of when research findings may be useful:

• Decision-making : Research findings can be used to inform decisions in various fields, such as business, education, healthcare, and public policy. For example, a business may use market research findings to make decisions about new product development or marketing strategies.
• Problem-solving : Research findings can be used to solve problems or challenges in various fields, such as healthcare, engineering, and social sciences. For example, medical researchers may use findings from clinical trials to develop new treatments for diseases.
• Policy development : Research findings can be used to inform the development of policies in various fields, such as environmental protection, social welfare, and economic development. For example, policymakers may use research findings to develop policies aimed at reducing greenhouse gas emissions.
• Program evaluation: Research findings can be used to evaluate the effectiveness of programs or interventions in various fields, such as education, healthcare, and social services. For example, educational researchers may use findings from evaluations of educational programs to improve teaching and learning outcomes.
• Innovation: Research findings can be used to inspire or guide innovation in various fields, such as technology and engineering. For example, engineers may use research findings on materials science to develop new and innovative products.

Purpose of Research Findings

The purpose of research findings is to contribute to the knowledge and understanding of a particular topic or issue. Research findings are the result of a systematic and rigorous investigation of a research question or hypothesis, using appropriate research methods and techniques.

The main purposes of research findings are:

• To generate new knowledge : Research findings contribute to the body of knowledge on a particular topic, by adding new information, insights, and understanding to the existing knowledge base.
• To test hypotheses or theories : Research findings can be used to test hypotheses or theories that have been proposed in a particular field or discipline. This helps to determine the validity and reliability of the hypotheses or theories, and to refine or develop new ones.
• To inform practice: Research findings can be used to inform practice in various fields, such as healthcare, education, and business. By identifying best practices and evidence-based interventions, research findings can help practitioners to make informed decisions and improve outcomes.
• To identify gaps in knowledge: Research findings can help to identify gaps in knowledge and understanding of a particular topic, which can then be addressed by further research.
• To contribute to policy development: Research findings can be used to inform policy development in various fields, such as environmental protection, social welfare, and economic development. By providing evidence-based recommendations, research findings can help policymakers to develop effective policies that address societal challenges.

Characteristics of Research Findings

Research findings have several key characteristics that distinguish them from other types of information or knowledge. Here are some of the main characteristics of research findings:

• Objective : Research findings are based on a systematic and rigorous investigation of a research question or hypothesis, using appropriate research methods and techniques. As such, they are generally considered to be more objective and reliable than other types of information.
• Empirical : Research findings are based on empirical evidence, which means that they are derived from observations or measurements of the real world. This gives them a high degree of credibility and validity.
• Generalizable : Research findings are often intended to be generalizable to a larger population or context beyond the specific study. This means that the findings can be applied to other situations or populations with similar characteristics.
• Transparent : Research findings are typically reported in a transparent manner, with a clear description of the research methods and data analysis techniques used. This allows others to assess the credibility and reliability of the findings.
• Peer-reviewed: Research findings are often subject to a rigorous peer-review process, in which experts in the field review the research methods, data analysis, and conclusions of the study. This helps to ensure the validity and reliability of the findings.
• Reproducible : Research findings are often designed to be reproducible, meaning that other researchers can replicate the study using the same methods and obtain similar results. This helps to ensure the validity and reliability of the findings.

Advantages of Research Findings

Research findings have many advantages, which make them valuable sources of knowledge and information. Here are some of the main advantages of research findings:

• Evidence-based: Research findings are based on empirical evidence, which means that they are grounded in data and observations from the real world. This makes them a reliable and credible source of information.
• Inform decision-making: Research findings can be used to inform decision-making in various fields, such as healthcare, education, and business. By identifying best practices and evidence-based interventions, research findings can help practitioners and policymakers to make informed decisions and improve outcomes.
• Identify gaps in knowledge: Research findings can help to identify gaps in knowledge and understanding of a particular topic, which can then be addressed by further research. This contributes to the ongoing development of knowledge in various fields.
• Improve outcomes : Research findings can be used to develop and implement evidence-based practices and interventions, which have been shown to improve outcomes in various fields, such as healthcare, education, and social services.
• Foster innovation: Research findings can inspire or guide innovation in various fields, such as technology and engineering. By providing new information and understanding of a particular topic, research findings can stimulate new ideas and approaches to problem-solving.
• Enhance credibility: Research findings are generally considered to be more credible and reliable than other types of information, as they are based on rigorous research methods and are subject to peer-review processes.

Limitations of Research Findings

While research findings have many advantages, they also have some limitations. Here are some of the main limitations of research findings:

• Limited scope: Research findings are typically based on a particular study or set of studies, which may have a limited scope or focus. This means that they may not be applicable to other contexts or populations.
• Potential for bias : Research findings can be influenced by various sources of bias, such as researcher bias, selection bias, or measurement bias. This can affect the validity and reliability of the findings.
• Ethical considerations: Research findings can raise ethical considerations, particularly in studies involving human subjects. Researchers must ensure that their studies are conducted in an ethical and responsible manner, with appropriate measures to protect the welfare and privacy of participants.
• Time and resource constraints : Research studies can be time-consuming and require significant resources, which can limit the number and scope of studies that are conducted. This can lead to gaps in knowledge or a lack of research on certain topics.
• Complexity: Some research findings can be complex and difficult to interpret, particularly in fields such as science or medicine. This can make it challenging for practitioners and policymakers to apply the findings to their work.
• Lack of generalizability : While research findings are intended to be generalizable to larger populations or contexts, there may be factors that limit their generalizability. For example, cultural or environmental factors may influence how a particular intervention or treatment works in different populations or contexts.

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

Case Study | Definition, Examples & Methods

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

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

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

Table of contents

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

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

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

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

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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.

Cite this Scribbr article

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

McCombes, S. (2023, January 30). Case Study | Definition, Examples & Methods. Scribbr. Retrieved 2 April 2024, from https://www.scribbr.co.uk/research-methods/case-studies/

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Shona McCombes

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

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• Knowledge Base

Methodology

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

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

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

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

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

Table of contents

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

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

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

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

Prevent plagiarism. Run a free check.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Research bias

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

Cite this Scribbr article

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

McCombes, S. (2023, November 20). What Is a Case Study? | Definition, Examples & Methods. Scribbr. Retrieved April 3, 2024, from https://www.scribbr.com/methodology/case-study/

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Shona McCombes

Other students also liked, primary vs. secondary sources | difference & examples, what is a theoretical framework | guide to organizing, what is action research | definition & examples, what is your plagiarism score.

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

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

Research question

• Conceptual framework
• Conceptual vs. theoretical framework

Data collection

• Qualitative research methods
• Focus groups
• Observational research

What is a case study?

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

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

Case studies

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

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

Definition of a case study

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

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

Characteristics of case studies

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

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

The role of case studies in research

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

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

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

What is the purpose of a case study?

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

Why use case studies in qualitative research?

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

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

The explanatory, exploratory, and descriptive roles of case studies

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

The impact of case studies on knowledge development

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

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

Types of case studies

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

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

Exploratory case studies

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

Descriptive case studies

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

Explanatory case studies

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

Intrinsic, instrumental, and collective case studies

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

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

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

Critical information systems research

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

Health research

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

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

Asthma research studies

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

Other fields

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

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

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

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

Propositions

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

Units of analysis

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

Argumentation

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

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

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

Defining the research question

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

Selecting and defining the case

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

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

Developing a detailed case study protocol

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

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

Collecting data

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

Analyzing and interpreting data

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

Writing the case study report

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

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

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

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

Observations

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

Documents and artifacts

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

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

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

Ensuring the quality of data collection

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

Data analysis

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

Organizing the data

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

Categorizing and coding the data

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

Identifying patterns and themes

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

Interpreting the data

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

Verification of the data

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

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

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

Benefits include the following:

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

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

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

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

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What Is a Case Study?

Weighing the pros and cons of this method of research

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

Cara Lustik is a fact-checker and copywriter.

Verywell / Colleen Tighe

• Pros and Cons

What Types of Case Studies Are Out There?

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

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

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

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

At a Glance

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

What Are the Benefits and Limitations of Case Studies?

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

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

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

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

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

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

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

Case Study Examples

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

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

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

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

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

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

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

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

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

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

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

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

Section 1: A Case History

This section will have the following structure and content:

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

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

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

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

Section 2: Treatment Plan

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

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

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

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

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

Need More Tips?

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

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

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

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

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

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

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

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• Perspective
• Published: 22 November 2022

Single case studies are a powerful tool for developing, testing and extending theories

• Lyndsey Nickels   ORCID: orcid.org/0000-0002-0311-3524 1 , 2 ,
• Simon Fischer-Baum   ORCID: orcid.org/0000-0002-6067-0538 3 &
• Wendy Best   ORCID: orcid.org/0000-0001-8375-5916 4  

Nature Reviews Psychology volume  1 ,  pages 733–747 ( 2022 ) Cite this article

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• Neurological disorders

Psychology embraces a diverse range of methodologies. However, most rely on averaging group data to draw conclusions. In this Perspective, we argue that single case methodology is a valuable tool for developing and extending psychological theories. We stress the importance of single case and case series research, drawing on classic and contemporary cases in which cognitive and perceptual deficits provide insights into typical cognitive processes in domains such as memory, delusions, reading and face perception. We unpack the key features of single case methodology, describe its strengths, its value in adjudicating between theories, and outline its benefits for a better understanding of deficits and hence more appropriate interventions. The unique insights that single case studies have provided illustrate the value of in-depth investigation within an individual. Single case methodology has an important place in the psychologist’s toolkit and it should be valued as a primary research tool.

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Acknowledgements

The authors thank all of those pioneers of and advocates for single case study research who have mentored, inspired and encouraged us over the years, and the many other colleagues with whom we have discussed these issues.

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Nickels, L., Fischer-Baum, S. & Best, W. Single case studies are a powerful tool for developing, testing and extending theories. Nat Rev Psychol 1 , 733–747 (2022). https://doi.org/10.1038/s44159-022-00127-y

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Definition and Introduction

Case analysis is a problem-based teaching and learning method that involves critically analyzing complex scenarios within an organizational setting for the purpose of placing the student in a “real world” situation and applying reflection and critical thinking skills to contemplate appropriate solutions, decisions, or recommended courses of action. It is considered a more effective teaching technique than in-class role playing or simulation activities. The analytical process is often guided by questions provided by the instructor that ask students to contemplate relationships between the facts and critical incidents described in the case.

Cases generally include both descriptive and statistical elements and rely on students applying abductive reasoning to develop and argue for preferred or best outcomes [i.e., case scenarios rarely have a single correct or perfect answer based on the evidence provided]. Rather than emphasizing theories or concepts, case analysis assignments emphasize building a bridge of relevancy between abstract thinking and practical application and, by so doing, teaches the value of both within a specific area of professional practice.

Given this, the purpose of a case analysis paper is to present a structured and logically organized format for analyzing the case situation. It can be assigned to students individually or as a small group assignment and it may include an in-class presentation component. Case analysis is predominately taught in economics and business-related courses, but it is also a method of teaching and learning found in other applied social sciences disciplines, such as, social work, public relations, education, journalism, and public administration.

Ellet, William. The Case Study Handbook: A Student's Guide . Revised Edition. Boston, MA: Harvard Business School Publishing, 2018; Christoph Rasche and Achim Seisreiner. Guidelines for Business Case Analysis . University of Potsdam; Writing a Case Analysis . Writing Center, Baruch College; Volpe, Guglielmo. "Case Teaching in Economics: History, Practice and Evidence." Cogent Economics and Finance 3 (December 2015). doi:https://doi.org/10.1080/23322039.2015.1120977.

How to Approach Writing a Case Analysis Paper

The organization and structure of a case analysis paper can vary depending on the organizational setting, the situation, and how your professor wants you to approach the assignment. Nevertheless, preparing to write a case analysis paper involves several important steps. As Hawes notes, a case analysis assignment “...is useful in developing the ability to get to the heart of a problem, analyze it thoroughly, and to indicate the appropriate solution as well as how it should be implemented” [p.48]. This statement encapsulates how you should approach preparing to write a case analysis paper.

Before you begin to write your paper, consider the following analytical procedures:

• Review the case to get an overview of the situation . A case can be only a few pages in length, however, it is most often very lengthy and contains a significant amount of detailed background information and statistics, with multilayered descriptions of the scenario, the roles and behaviors of various stakeholder groups, and situational events. Therefore, a quick reading of the case will help you gain an overall sense of the situation and illuminate the types of issues and problems that you will need to address in your paper. If your professor has provided questions intended to help frame your analysis, use them to guide your initial reading of the case.
• Read the case thoroughly . After gaining a general overview of the case, carefully read the content again with the purpose of understanding key circumstances, events, and behaviors among stakeholder groups. Look for information or data that appears contradictory, extraneous, or misleading. At this point, you should be taking notes as you read because this will help you develop a general outline of your paper. The aim is to obtain a complete understanding of the situation so that you can begin contemplating tentative answers to any questions your professor has provided or, if they have not provided, developing answers to your own questions about the case scenario and its connection to the course readings,lectures, and class discussions.
• Determine key stakeholder groups, issues, and events and the relationships they all have to each other . As you analyze the content, pay particular attention to identifying individuals, groups, or organizations described in the case and identify evidence of any problems or issues of concern that impact the situation in a negative way. Other things to look for include identifying any assumptions being made by or about each stakeholder, potential biased explanations or actions, explicit demands or ultimatums , and the underlying concerns that motivate these behaviors among stakeholders. The goal at this stage is to develop a comprehensive understanding of the situational and behavioral dynamics of the case and the explicit and implicit consequences of each of these actions.
• Identify the core problems . The next step in most case analysis assignments is to discern what the core [i.e., most damaging, detrimental, injurious] problems are within the organizational setting and to determine their implications. The purpose at this stage of preparing to write your analysis paper is to distinguish between the symptoms of core problems and the core problems themselves and to decide which of these must be addressed immediately and which problems do not appear critical but may escalate over time. Identify evidence from the case to support your decisions by determining what information or data is essential to addressing the core problems and what information is not relevant or is misleading.
• Explore alternative solutions . As noted, case analysis scenarios rarely have only one correct answer. Therefore, it is important to keep in mind that the process of analyzing the case and diagnosing core problems, while based on evidence, is a subjective process open to various avenues of interpretation. This means that you must consider alternative solutions or courses of action by critically examining strengths and weaknesses, risk factors, and the differences between short and long-term solutions. For each possible solution or course of action, consider the consequences they may have related to their implementation and how these recommendations might lead to new problems. Also, consider thinking about your recommended solutions or courses of action in relation to issues of fairness, equity, and inclusion.
• Decide on a final set of recommendations . The last stage in preparing to write a case analysis paper is to assert an opinion or viewpoint about the recommendations needed to help resolve the core problems as you see them and to make a persuasive argument for supporting this point of view. Prepare a clear rationale for your recommendations based on examining each element of your analysis. Anticipate possible obstacles that could derail their implementation. Consider any counter-arguments that could be made concerning the validity of your recommended actions. Finally, describe a set of criteria and measurable indicators that could be applied to evaluating the effectiveness of your implementation plan.

Use these steps as the framework for writing your paper. Remember that the more detailed you are in taking notes as you critically examine each element of the case, the more information you will have to draw from when you begin to write. This will save you time.

NOTE : If the process of preparing to write a case analysis paper is assigned as a student group project, consider having each member of the group analyze a specific element of the case, including drafting answers to the corresponding questions used by your professor to frame the analysis. This will help make the analytical process more efficient and ensure that the distribution of work is equitable. This can also facilitate who is responsible for drafting each part of the final case analysis paper and, if applicable, the in-class presentation.

Framework for Case Analysis . College of Management. University of Massachusetts; Hawes, Jon M. "Teaching is Not Telling: The Case Method as a Form of Interactive Learning." Journal for Advancement of Marketing Education 5 (Winter 2004): 47-54; Rasche, Christoph and Achim Seisreiner. Guidelines for Business Case Analysis . University of Potsdam; Writing a Case Study Analysis . University of Arizona Global Campus Writing Center; Van Ness, Raymond K. A Guide to Case Analysis . School of Business. State University of New York, Albany; Writing a Case Analysis . Business School, University of New South Wales.

Structure and Writing Style

A case analysis paper should be detailed, concise, persuasive, clearly written, and professional in tone and in the use of language . As with other forms of college-level academic writing, declarative statements that convey information, provide a fact, or offer an explanation or any recommended courses of action should be based on evidence. If allowed by your professor, any external sources used to support your analysis, such as course readings, should be properly cited under a list of references. The organization and structure of case analysis papers can vary depending on your professor’s preferred format, but its structure generally follows the steps used for analyzing the case.

Introduction

The introduction should provide a succinct but thorough descriptive overview of the main facts, issues, and core problems of the case . The introduction should also include a brief summary of the most relevant details about the situation and organizational setting. This includes defining the theoretical framework or conceptual model on which any questions were used to frame your analysis.

Following the rules of most college-level research papers, the introduction should then inform the reader how the paper will be organized. This includes describing the major sections of the paper and the order in which they will be presented. Unless you are told to do so by your professor, you do not need to preview your final recommendations in the introduction. U nlike most college-level research papers , the introduction does not include a statement about the significance of your findings because a case analysis assignment does not involve contributing new knowledge about a research problem.

Background Analysis

Background analysis can vary depending on any guiding questions provided by your professor and the underlying concept or theory that the case is based upon. In general, however, this section of your paper should focus on:

• Providing an overarching analysis of problems identified from the case scenario, including identifying events that stakeholders find challenging or troublesome,
• Identifying assumptions made by each stakeholder and any apparent biases they may exhibit,
• Describing any demands or claims made by or forced upon key stakeholders, and
• Highlighting any issues of concern or complaints expressed by stakeholders in response to those demands or claims.

These aspects of the case are often in the form of behavioral responses expressed by individuals or groups within the organizational setting. However, note that problems in a case situation can also be reflected in data [or the lack thereof] and in the decision-making, operational, cultural, or institutional structure of the organization. Additionally, demands or claims can be either internal and external to the organization [e.g., a case analysis involving a president considering arms sales to Saudi Arabia could include managing internal demands from White House advisors as well as demands from members of Congress].

Throughout this section, present all relevant evidence from the case that supports your analysis. Do not simply claim there is a problem, an assumption, a demand, or a concern; tell the reader what part of the case informed how you identified these background elements.

Identification of Problems

In most case analysis assignments, there are problems, and then there are problems . Each problem can reflect a multitude of underlying symptoms that are detrimental to the interests of the organization. The purpose of identifying problems is to teach students how to differentiate between problems that vary in severity, impact, and relative importance. Given this, problems can be described in three general forms: those that must be addressed immediately, those that should be addressed but the impact is not severe, and those that do not require immediate attention and can be set aside for the time being.

All of the problems you identify from the case should be identified in this section of your paper, with a description based on evidence explaining the problem variances. If the assignment asks you to conduct research to further support your assessment of the problems, include this in your explanation. Remember to cite those sources in a list of references. Use specific evidence from the case and apply appropriate concepts, theories, and models discussed in class or in relevant course readings to highlight and explain the key problems [or problem] that you believe must be solved immediately and describe the underlying symptoms and why they are so critical.

Alternative Solutions

This section is where you provide specific, realistic, and evidence-based solutions to the problems you have identified and make recommendations about how to alleviate the underlying symptomatic conditions impacting the organizational setting. For each solution, you must explain why it was chosen and provide clear evidence to support your reasoning. This can include, for example, course readings and class discussions as well as research resources, such as, books, journal articles, research reports, or government documents. In some cases, your professor may encourage you to include personal, anecdotal experiences as evidence to support why you chose a particular solution or set of solutions. Using anecdotal evidence helps promote reflective thinking about the process of determining what qualifies as a core problem and relevant solution .

Throughout this part of the paper, keep in mind the entire array of problems that must be addressed and describe in detail the solutions that might be implemented to resolve these problems.

Recommended Courses of Action

In some case analysis assignments, your professor may ask you to combine the alternative solutions section with your recommended courses of action. However, it is important to know the difference between the two. A solution refers to the answer to a problem. A course of action refers to a procedure or deliberate sequence of activities adopted to proactively confront a situation, often in the context of accomplishing a goal. In this context, proposed courses of action are based on your analysis of alternative solutions. Your description and justification for pursuing each course of action should represent the overall plan for implementing your recommendations.

For each course of action, you need to explain the rationale for your recommendation in a way that confronts challenges, explains risks, and anticipates any counter-arguments from stakeholders. Do this by considering the strengths and weaknesses of each course of action framed in relation to how the action is expected to resolve the core problems presented, the possible ways the action may affect remaining problems, and how the recommended action will be perceived by each stakeholder.

In addition, you should describe the criteria needed to measure how well the implementation of these actions is working and explain which individuals or groups are responsible for ensuring your recommendations are successful. In addition, always consider the law of unintended consequences. Outline difficulties that may arise in implementing each course of action and describe how implementing the proposed courses of action [either individually or collectively] may lead to new problems [both large and small].

Throughout this section, you must consider the costs and benefits of recommending your courses of action in relation to uncertainties or missing information and the negative consequences of success.

The conclusion should be brief and introspective. Unlike a research paper, the conclusion in a case analysis paper does not include a summary of key findings and their significance, a statement about how the study contributed to existing knowledge, or indicate opportunities for future research.

Begin by synthesizing the core problems presented in the case and the relevance of your recommended solutions. This can include an explanation of what you have learned about the case in the context of your answers to the questions provided by your professor. The conclusion is also where you link what you learned from analyzing the case with the course readings or class discussions. This can further demonstrate your understanding of the relationships between the practical case situation and the theoretical and abstract content of assigned readings and other course content.

Problems to Avoid

The literature on case analysis assignments often includes examples of difficulties students have with applying methods of critical analysis and effectively reporting the results of their assessment of the situation. A common reason cited by scholars is that the application of this type of teaching and learning method is limited to applied fields of social and behavioral sciences and, as a result, writing a case analysis paper can be unfamiliar to most students entering college.

After you have drafted your paper, proofread the narrative flow and revise any of these common errors:

• Unnecessary detail in the background section . The background section should highlight the essential elements of the case based on your analysis. Focus on summarizing the facts and highlighting the key factors that become relevant in the other sections of the paper by eliminating any unnecessary information.
• Analysis relies too much on opinion . Your analysis is interpretive, but the narrative must be connected clearly to evidence from the case and any models and theories discussed in class or in course readings. Any positions or arguments you make should be supported by evidence.
• Analysis does not focus on the most important elements of the case . Your paper should provide a thorough overview of the case. However, the analysis should focus on providing evidence about what you identify are the key events, stakeholders, issues, and problems. Emphasize what you identify as the most critical aspects of the case to be developed throughout your analysis. Be thorough but succinct.
• Writing is too descriptive . A paper with too much descriptive information detracts from your analysis of the complexities of the case situation. Questions about what happened, where, when, and by whom should only be included as essential information leading to your examination of questions related to why, how, and for what purpose.
• Inadequate definition of a core problem and associated symptoms . A common error found in case analysis papers is recommending a solution or course of action without adequately defining or demonstrating that you understand the problem. Make sure you have clearly described the problem and its impact and scope within the organizational setting. Ensure that you have adequately described the root causes w hen describing the symptoms of the problem.
• Recommendations lack specificity . Identify any use of vague statements and indeterminate terminology, such as, “A particular experience” or “a large increase to the budget.” These statements cannot be measured and, as a result, there is no way to evaluate their successful implementation. Provide specific data and use direct language in describing recommended actions.
• Unrealistic, exaggerated, or unattainable recommendations . Review your recommendations to ensure that they are based on the situational facts of the case. Your recommended solutions and courses of action must be based on realistic assumptions and fit within the constraints of the situation. Also note that the case scenario has already happened, therefore, any speculation or arguments about what could have occurred if the circumstances were different should be revised or eliminated.

Bee, Lian Song et al. "Business Students' Perspectives on Case Method Coaching for Problem-Based Learning: Impacts on Student Engagement and Learning Performance in Higher Education." Education & Training 64 (2022): 416-432; The Case Analysis . Fred Meijer Center for Writing and Michigan Authors. Grand Valley State University; Georgallis, Panikos and Kayleigh Bruijn. "Sustainability Teaching using Case-Based Debates." Journal of International Education in Business 15 (2022): 147-163; Hawes, Jon M. "Teaching is Not Telling: The Case Method as a Form of Interactive Learning." Journal for Advancement of Marketing Education 5 (Winter 2004): 47-54; Georgallis, Panikos, and Kayleigh Bruijn. "Sustainability Teaching Using Case-based Debates." Journal of International Education in Business 15 (2022): 147-163; .Dean,  Kathy Lund and Charles J. Fornaciari. "How to Create and Use Experiential Case-Based Exercises in a Management Classroom." Journal of Management Education 26 (October 2002): 586-603; Klebba, Joanne M. and Janet G. Hamilton. "Structured Case Analysis: Developing Critical Thinking Skills in a Marketing Case Course." Journal of Marketing Education 29 (August 2007): 132-137, 139; Klein, Norman. "The Case Discussion Method Revisited: Some Questions about Student Skills." Exchange: The Organizational Behavior Teaching Journal 6 (November 1981): 30-32; Mukherjee, Arup. "Effective Use of In-Class Mini Case Analysis for Discovery Learning in an Undergraduate MIS Course." The Journal of Computer Information Systems 40 (Spring 2000): 15-23; Pessoa, Silviaet al. "Scaffolding the Case Analysis in an Organizational Behavior Course: Making Analytical Language Explicit." Journal of Management Education 46 (2022): 226-251: Ramsey, V. J. and L. D. Dodge. "Case Analysis: A Structured Approach." Exchange: The Organizational Behavior Teaching Journal 6 (November 1981): 27-29; Schweitzer, Karen. "How to Write and Format a Business Case Study." ThoughtCo. https://www.thoughtco.com/how-to-write-and-format-a-business-case-study-466324 (accessed December 5, 2022); Reddy, C. D. "Teaching Research Methodology: Everything's a Case." Electronic Journal of Business Research Methods 18 (December 2020): 178-188; Volpe, Guglielmo. "Case Teaching in Economics: History, Practice and Evidence." Cogent Economics and Finance 3 (December 2015). doi:https://doi.org/10.1080/23322039.2015.1120977.

Writing Tip

Ca se Study and Case Analysis Are Not the Same!

Confusion often exists between what it means to write a paper that uses a case study research design and writing a paper that analyzes a case; they are two different types of approaches to learning in the social and behavioral sciences. Professors as well as educational researchers contribute to this confusion because they often use the term "case study" when describing the subject of analysis for a case analysis paper. But you are not studying a case for the purpose of generating a comprehensive, multi-faceted understanding of a research problem. R ather, you are critically analyzing a specific scenario to argue logically for recommended solutions and courses of action that lead to optimal outcomes applicable to professional practice.

To avoid any confusion, here are twelve characteristics that delineate the differences between writing a paper using the case study research method and writing a case analysis paper:

• Case study is a method of in-depth research and rigorous inquiry ; case analysis is a reliable method of teaching and learning . A case study is a modality of research that investigates a phenomenon for the purpose of creating new knowledge, solving a problem, or testing a hypothesis using empirical evidence derived from the case being studied. Often, the results are used to generalize about a larger population or within a wider context. The writing adheres to the traditional standards of a scholarly research study. A case analysis is a pedagogical tool used to teach students how to reflect and think critically about a practical, real-life problem in an organizational setting.
• The researcher is responsible for identifying the case to study; a case analysis is assigned by your professor . As the researcher, you choose the case study to investigate in support of obtaining new knowledge and understanding about the research problem. The case in a case analysis assignment is almost always provided, and sometimes written, by your professor and either given to every student in class to analyze individually or to a small group of students, or students select a case to analyze from a predetermined list.
• A case study is indeterminate and boundless; a case analysis is predetermined and confined . A case study can be almost anything [see item 9 below] as long as it relates directly to examining the research problem. This relationship is the only limit to what a researcher can choose as the subject of their case study. The content of a case analysis is determined by your professor and its parameters are well-defined and limited to elucidating insights of practical value applied to practice.
• Case study is fact-based and describes actual events or situations; case analysis can be entirely fictional or adapted from an actual situation . The entire content of a case study must be grounded in reality to be a valid subject of investigation in an empirical research study. A case analysis only needs to set the stage for critically examining a situation in practice and, therefore, can be entirely fictional or adapted, all or in-part, from an actual situation.
• Research using a case study method must adhere to principles of intellectual honesty and academic integrity; a case analysis scenario can include misleading or false information . A case study paper must report research objectively and factually to ensure that any findings are understood to be logically correct and trustworthy. A case analysis scenario may include misleading or false information intended to deliberately distract from the central issues of the case. The purpose is to teach students how to sort through conflicting or useless information in order to come up with the preferred solution. Any use of misleading or false information in academic research is considered unethical.
• Case study is linked to a research problem; case analysis is linked to a practical situation or scenario . In the social sciences, the subject of an investigation is most often framed as a problem that must be researched in order to generate new knowledge leading to a solution. Case analysis narratives are grounded in real life scenarios for the purpose of examining the realities of decision-making behavior and processes within organizational settings. A case analysis assignments include a problem or set of problems to be analyzed. However, the goal is centered around the act of identifying and evaluating courses of action leading to best possible outcomes.
• The purpose of a case study is to create new knowledge through research; the purpose of a case analysis is to teach new understanding . Case studies are a choice of methodological design intended to create new knowledge about resolving a research problem. A case analysis is a mode of teaching and learning intended to create new understanding and an awareness of uncertainty applied to practice through acts of critical thinking and reflection.
• A case study seeks to identify the best possible solution to a research problem; case analysis can have an indeterminate set of solutions or outcomes . Your role in studying a case is to discover the most logical, evidence-based ways to address a research problem. A case analysis assignment rarely has a single correct answer because one of the goals is to force students to confront the real life dynamics of uncertainly, ambiguity, and missing or conflicting information within professional practice. Under these conditions, a perfect outcome or solution almost never exists.
• Case study is unbounded and relies on gathering external information; case analysis is a self-contained subject of analysis . The scope of a case study chosen as a method of research is bounded. However, the researcher is free to gather whatever information and data is necessary to investigate its relevance to understanding the research problem. For a case analysis assignment, your professor will often ask you to examine solutions or recommended courses of action based solely on facts and information from the case.
• Case study can be a person, place, object, issue, event, condition, or phenomenon; a case analysis is a carefully constructed synopsis of events, situations, and behaviors . The research problem dictates the type of case being studied and, therefore, the design can encompass almost anything tangible as long as it fulfills the objective of generating new knowledge and understanding. A case analysis is in the form of a narrative containing descriptions of facts, situations, processes, rules, and behaviors within a particular setting and under a specific set of circumstances.
• Case study can represent an open-ended subject of inquiry; a case analysis is a narrative about something that has happened in the past . A case study is not restricted by time and can encompass an event or issue with no temporal limit or end. For example, the current war in Ukraine can be used as a case study of how medical personnel help civilians during a large military conflict, even though circumstances around this event are still evolving. A case analysis can be used to elicit critical thinking about current or future situations in practice, but the case itself is a narrative about something finite and that has taken place in the past.
• Multiple case studies can be used in a research study; case analysis involves examining a single scenario . Case study research can use two or more cases to examine a problem, often for the purpose of conducting a comparative investigation intended to discover hidden relationships, document emerging trends, or determine variations among different examples. A case analysis assignment typically describes a stand-alone, self-contained situation and any comparisons among cases are conducted during in-class discussions and/or student presentations.

The Case Analysis . Fred Meijer Center for Writing and Michigan Authors. Grand Valley State University; Mills, Albert J. , Gabrielle Durepos, and Eiden Wiebe, editors. Encyclopedia of Case Study Research . Thousand Oaks, CA: SAGE Publications, 2010; Ramsey, V. J. and L. D. Dodge. "Case Analysis: A Structured Approach." Exchange: The Organizational Behavior Teaching Journal 6 (November 1981): 27-29; Yin, Robert K. Case Study Research and Applications: Design and Methods . 6th edition. Thousand Oaks, CA: Sage, 2017; Crowe, Sarah et al. “The Case Study Approach.” BMC Medical Research Methodology 11 (2011):  doi: 10.1186/1471-2288-11-100; Yin, Robert K. Case Study Research: Design and Methods . 4th edition. Thousand Oaks, CA: Sage Publishing; 1994.

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• Clinical Journal of Oncology Nursing
• Number 4 / August 2020

Fear of Cancer Progression: Findings From Case Studies and a Nurse-Led Intervention

Anne M. Reb

Tami Borneman

Marissa A. Cangin

Background: Fear of cancer recurrence or progression (FOP) is a significant concern for cancer survivors. With the advent of new targeted therapies and immunotherapy, many patients with advanced cancer are living longer while dealing with uncertainty and fears related to cancer progression. Although some level of FOP is normal and adaptive, high levels adversely affect quality of life and healthcare costs.

Objectives: This article describes a nurse-led intervention for managing FOP in two patients with advanced gynecologic cancer. The intervention teaches skills for managing worry, challenging unhelpful beliefs, and modifying unhelpful coping behaviors.

Methods: Preliminary findings from the two case studies are presented, including a comparison of post-treatment FOP scores to baseline scores.

Findings: The participants reported feeling more focused, less overwhelmed, and more in control of their worries. Both participants achieved statistically reliable improvements in FOP scores.

Jump to a section

Fear of cancer recurrence or progression (FOP) is the fear, worry, or concern about cancer returning or progressing (Lebel et al., 2016). Among cancer survivors, FOP is a prevalent unmet need associated with high levels of distress, anxiety, and depression (Sharpe et al., 2018; Thewes et al., 2014). About 49% of cancer survivors and as many as 70% of patients with advanced cancer experience moderate to high FOP (Butow et al., 2018), including intrusive thoughts, unhelpful coping behaviors, and difficulty making future plans (Lebel et al., 2016). Healthcare providers lack training in managing FOP (Butow et al., 2018). Providers may be unaware of FOP because patients may hesitate sharing their worries, particularly when family members are present (Economou & Reb, 2017). Nurses are well placed to discuss FOP with their patients (Dawson et al., 2016). This article describes a nurse-led intervention to manage FOP. Preliminary findings from two case studies are presented, including the change in FOP score from baseline to postintervention.

FOP is a common reaction following an advanced cancer diagnosis (Ozga et al., 2015). Although some FOP is normal and even adaptive, some patients retain high FOP levels across time (Simard et al., 2013). Risk factors for clinically significant FOP include being newly diagnosed, being of a younger age, having cancer- or treatment-related side effects, and experiencing anxiety (Simard et al., 2013). FOP is problematic when poorly managed; high levels adversely affect quality of life (Lengacher et al., 2016; Tauber et al., 2019) and increase healthcare costs (Lebel et al., 2013). Patient behaviors include being hypervigilant about minor symptoms, requesting unnecessary tests, and constantly browsing the Internet for cancer-related information (Butow et al., 2018), which reinforces worry-driven behavior (Heathcote et al., 2018).

FOP may be an even greater concern in patients with advanced cancer (Lutgendorf et al., 2017; Mehnert et al., 2013). Targeted therapies and immunotherapies have increased patient survival. Treatment for extended durations and frequent monitoring contributes to FOP vulnerability (Thewes et al., 2017). Screening for FOP is not routinely done; however, screening for general distress is more common. FOP can be assessed by validated questionnaires with cutoff scores identifying those with dysfunctional FOP levels. Butow et al. (2018) suggest screening for FOP in clinical practice. According to a systematic review (Thewes et al., 2012), two measures are recommended: the Fear of Cancer Recurrence Inventory–Severity subscale (Simard & Savard, 2009) and the FOP Short Form (SF) questionnaire (Mehnert et al., 2006).

Nurses are well positioned to ask patients about FOP and about coping strategies they are using to manage their fears. One approach is to normalize FOP by asking if the patient feels that their worries are excessive, overwhelming, or interfering with their life (Butow et al., 2018).

Overview of Interventions

Two meta-analyses confirmed the overall efficacy of FOP interventions (Hall et al., 2018; Tauber et al., 2019). In a review of mind-body interventions by Hall et al. (2018), FOP trials were categorized as mindfulness-based (n = 3), cognitive-behavioral therapy (CBT) (n = 4), communication skills (n = 2), and a gratitude intervention (n = 1). At postintervention, small to medium effects were found (Hedges’ g = 0.36, p < 0.001). In Tauber et al. (2019), some studies used traditional CBT, in which the content of beliefs about FOP are challenged. Other studies used more contemporary CBT, where the process of worry and rumination are targeted, not thought content. Tauber et al. (2019) found that contemporary CBTs were more efficacious than traditional CBTs for FOP. However, several gaps in the studies were highlighted, including a focus on breast cancer and patients with early-stage disease. Most interventionists were psychologists. A report by Brebach et al. (2016) found that nurse-led FOP interventions have been effective, with uptake rates higher than non-nursing interventions. Training nurses to provide psychoeducational interventions is an efficient and cost-effective way to increase access to these services (McCarthy et al., 2018).

This article describes a nurse-led FOP intervention and preliminary findings from two patients with advanced gynecologic cancer. The Day-by-Day (DBD) intervention is adapted from Conquer Fear, an intervention found more efficacious than relaxation training in a large randomized trial of patients with early-stage cancer (Butow et al., 2017). Conquer Fear is based on a model that worry about cancer is normal, but some people have beliefs that worry is dangerous (i.e., the stress will bring the cancer back) or helpful (i.e., a recurrence will be identified more quickly). In addition, patients may become hypervigilant to physical sensations, which increases worry about recurrence (Sharpe et al., 2017). This FOP preoccupation makes it hard for people to engage in other life goals (Fardell et al., 2016). Using a case study approach, this article describes the intervention components and results.

Intervention Development

Adaptations to Conquer Fear were made to reflect the increased risk of recurrence among women with advanced gynecologic cancer and to shorten individual sessions to accommodate patients with advanced cancer. In addition, case studies, surveillance guidelines, and resources were revised to be relevant to advanced cancer; threat monitoring behaviors were revised to reflect unhelpful coping strategies exhibited by the patients; and more emphasis was placed on values-based goal setting.

Nurse Training Intervention

The study team, consisting of two advanced practice nurses (APNs) (interventionists), the principal investigator (PI), a psychologist, and a senior research coordinator (a certified health education specialist), participated in a two-day training workshop led by Louise Sharpe, PhD, one of the Conquer Fear developers. The intervention components were explained, and the goals and content of each session and key skills for managing FOP were reviewed. Role-play was used to practice these skills.

Patient Sample

Using a convenience sample, two patients with stage III or IV gynecologic cancer were recruited from the outpatient medical oncology clinic at a free-standing comprehensive cancer center in southern California. Patients were eligible if they were at least three months after initial diagnosis and had a score of 34 or greater on the FOP-SF (Mehnert et al., 2006) or 24 or greater on the Impact of Event Scale–Revised (Sundin & Horowitz, 2002). The Impact of Event Scale–Revised measures cancer-related distress. Items are categorized into three subscales: intrusion, avoidance, and hyperarousal. Scores range from 0 to 88, and a score of 24 or greater indicates significant distress (Sundin & Horowitz, 2002).

FOP was measured using the FOP-SF, with 12 items selected from the original 43-item questionnaire (FOP-Q) (Herschbach et al., 2005). Items are scored from 1 (never) to 5 (very often). Total scores ranged from 12 to 60; a cutoff score of 34 or greater indicates dysfunctional levels of FOP (Herschbach et al., 2010). The FOP-SF was comprehensively validated in a large sample of patients with breast cancer (Hinz et al., 2015; Mehnert et al., 2006).

To determine if a meaningful change occurred between baseline and postintervention FOP scores, the Reliable Change Index (RCI) was calculated (Jacobson et al., 1984). The RCI indicates whether the patient has made a reliable symptom change over the course of treatment (Ferguson et al., 2002). To calculate the RCI, the difference in raw scores from baseline to postintervention is divided by the standard error of the differences between scores. A score greater than 1.96 shows a reliable change (Jacobson & Truax, 1991).

Case Study 1

Gail is a 50-year-old woman with recurrent BRCA1-positive stage IV ovarian cancer. A single mother with two grown children, Gail has a strong faith and social support system. Following the card-sort exercise (Ciarrochi & Bailey, 2009), Gail identifies healthy eating and independence as non-negotiable values. The APN helps Gail identify specific goals, including diet maintenance, walking more, and furthering her education. Gail states that she is constantly preoccupied with thoughts of recurrence. She frequently calls her nurse about her tumor marker results and experiences anxiety whenever scans are due. She frequently examines her breasts and scans her body for new pains that might represent a cancer recurrence. Gail experiences both positive and negative beliefs about worry, believing that being alert to and investigating new symptoms keeps her safe. Alternatively, she states that this worry will make her sick. Although Gail keeps busy to try to avoid cancer thoughts, she states that she experiences intrusive thoughts, making it difficult for her to concentrate. Although Gail initially remained preoccupied with recurrence, with ATT practice, she states that she feels less self-focused and more relaxed. The APN reviews detached mindfulness exercises. Gail states that the cloud metaphor was most helpful. Gail uses a journal to record her worries to reference during her worry time. She states that journaling helps her feel more in control over her worries, allowing her to attend to more meaningful events at other times. Gail also reviews previous responses to triggers and creates a new plan for managing unhelpful coping behaviors. The detached mindfulness and ATT skills helped her notice worrying thoughts but not get caught up in them. She calls less frequently and has cut back on the frequency of body scanning. Gail said she feels inspired by her progress and motivated to continue skills practice.

Analysis: Gail endorsed positive and negative beliefs about worry, distress around follow-up scans, and threat-monitoring behaviors, including frequent tumor marker inquiries and breast self-examinations. Her self-focused attention and intrusive thoughts interfered with her concentration. With skills practice, Gail reports less intrusive thoughts and threat-monitoring behaviors. She states that she feels calmer and more in control over her thoughts and worries.

Case Study 2

Debra is a 65-year-old woman with stage III uterine cancer diagnosed two years prior. She completed neoadjuvant radiation therapy and chemotherapy, followed by surgery. Her husband recently died from colorectal cancer. Debra reveals she is most afraid of being alone and is depressed and lonely since her husband’s death. In the past, she had been active in her church but now finds it stressful. The APN discussed the impact of Debra’s grief and recent loss as contributing to her fears. Using the card-sort exercise, Debra states that her top values were her faith, having close relationships and feeling supported, and being there for her family. The nurse encourages Debra to set small but attainable goals consistent with her values and explores ways in which she might seek support. Debra agrees to set a monthly social activity goal, such as attending a book club and volunteering at church. Focusing on these goals helps Debra deal with her grief and fears.

Debra states that she has intrusive thoughts about the possibility of cancer progression. She is particularly fearful at night, which affects her sleep. Triggers for intrusive thoughts include concerns about her family and follow-up scans. Debra endorses negative beliefs about worry, expressing that she could make herself sick if she continues to worry. Although she said she tries to avoid these thoughts, she finds it difficult to control her worries. Although the ATT was challenging initially, with practice it helped Debra to focus her thinking. Debra reports that the cloud metaphor helped her to let go of worrying thoughts. Debra would go to her worry room around 4 pm to think about her concerns. Postponing worries helps her feel less overwhelmed and more in control of her thoughts. Both ATT and detached mindfulness skills help Debra break the worry cycle. Although she states that she has some residual fears at night, her sleep has become more restful. To manage triggers, Debra plans to use ATT to reinforce focused thinking as well as detached mindfulness and worry postponement to manage intrusive thoughts.

Analysis: Debra’s grief over the loss of her husband contributed to increased FOP. She endorsed mainly negative beliefs about worry. Although she tried to avoid negative thoughts, worry overwhelmed her. Debra did not exhibit threat monitoring behaviors, reassured by her close medical surveillance. However, her self-focused attention and intrusive thoughts interfered with her concentration and sleep. With skills practice, Debra learned to manage intrusive thoughts. Postintervention, she stated she felt calmer, more focused, and her sleep improved.

At baseline, Debra had a clinically significant FOP level, as measured by the FOP-SF (Mehnert et al., 2006). The post-treatment FOP-SF score was compared with a baseline score using the RCI procedure (Jacobson & Truax, 1991). Her FOP-SF score was significantly reduced, indicating that she had made a statistically reliable improvement (RCI = 3.45, p < 0.05). In addition, at 12 weeks follow-up, she was in the normal FOP-SF score range.

FOP is a prevalent unmet need in patients with advanced cancer (Ozga et al., 2015; Sharpe et al., 2017). The findings from the case studies support the benefits of a nurse-led intervention to help patients manage FOP. The DBD intervention helps patients reflect on their most important values and targets unhelpful beliefs about worry and related coping behaviors. When confronted with a life-threatening illness, patients may lose sight of what gives their life meaning, spending time on less important activities. Helping patients reflect on their primary values provides direction and meaning in life (Fashler et al., 2018). Patients with FOP are often burdened with worry, which may underlie unhelpful coping behaviors. Some patients may avoid cancer reminders, increasing FOP (Fardell et al., 2016). Although frequent self-examination or requests for additional surveillance tests may provide temporary reassurance, these behaviors ultimately increase FOP (Butow et al., 2018). The DBD intervention teaches patients skills to manage intrusive thoughts and worries that they can use in their daily lives. The skills practice promotes focused attention, flexibility in response to worry, and thought detachment.

Nurses and other healthcare providers may not recognize FOP in patients or may be reluctant to discuss it (Curran et al., 2017; Thewes et al., 2014). These patients may be known to the clinical team because they call frequently with minor complaints or seek unnecessary tests for reassurance. Many providers are uncertain how to manage FOP (Thewes et al., 2014). Rather than ordering unnecessary tests, providers who carefully listen to the patient’s concerns and discuss the evidence-based rationale for surveillance decisions communicate understanding and confidence (Butow et al., 2018).

Lessons Learned

Based on the case studies describing the patients’ experience receiving the DBD intervention, patients requested more flexibility related to intervention sessions and practicing skills. One patient preferred phone delivery, whereas the other preferred in-person sessions. One patient found it difficult to access a computer to listen to the ATT flash drive during the day and suggested having a smartphone app. Although the patients found the card-sort exercise very helpful, they reported difficulty narrowing down their top values. The APNs learned to explain the goal of the value cards up front and ask patients to choose their top 10 non-negotiable values.

Implications for Nursing

This article describes a nurse-led intervention for managing FOP in patients with advanced gynecologic cancer. If patients are experiencing FOP, a nurse can encourage patients to express their fears. Nurses can assess how FOP affects the patient’s daily life, considering prior losses or trauma that may heighten FOP. By incorporating intervention techniques, nurses can help patients identify triggers, teach practical skills for managing triggers and worries, and challenge beliefs that contribute to unhelpful coping behaviors. The card-sort exercise can help patients identify their most important values and set goals aligned with those values. Teaching patients about recurrence symptoms, follow-up care, and healthy lifestyles equips them with ways to take control of their health.

FOP is a significant concern for patients with advanced cancer. This article highlights a nurse-led intervention for managing FOP. The case studies illustrate the intervention components, which teach skills for managing worry and help patients modify unhelpful coping behaviors. Skills include attention training, detached mindfulness, and worry postponement. After the intervention, patients reported feeling more focused and in control of their worries. Both achieved reliable improvements in FOP-SF scores.

About the Author(s)

Anne M. Reb, PhD, NP, is an assistant professor in the Beckman Research Institute, Tami Borneman, RN, MSN, CNS, FPCN, is a senior research specialist, and Denice Economou, RN, PhD, CHPN, is a senior research specialist, all in the Division of Nursing Research and Education, Marissa A. Cangin, PsyD, is an assistant clinical professor and licensed psychologist in the Department of Supportive Care Medicine, and Sunita K. Patel, PhD, is an associate professor in the Departments of Population Sciences and Supportive Care Medicine, all at City of Hope National Medical Center in Duarte, CA; and Louise Sharpe, PhD, is a professor of clinical psychology in the School of Psychology at the University of Sydney in New South Wales, Australia. The authors gratefully acknowledge the patients who generously contributed their time and supported this study. The authors also thank Nancy Guerrero-Llamas, MPH, CHES, for assistance with data management and adapting the intervention manual and patient workbook; Maribel Tejada, BS, for assistance with data management and technical support; and Betty Ferrell, PhD, and Judith Baggs, PhD, for review and comments on the manuscript. The authors take full responsibility for this content. This project is supported by the Palliative Care Research Cooperative Group funded by National Institute of Nursing Research (U2CNR014637). The article has been reviewed by independent peer reviewers to ensure that it is objective and free from bias. Reb can be reached at [email protected] , with copy to [email protected] . (Submitted July 2019. Accepted February 13, 2020.)

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• Open access
• Published: 02 April 2024

Adopting, implementing and assimilating coproduced health and social care innovations involving structurally vulnerable populations: findings from a longitudinal, multiple case study design in Canada, Scotland and Sweden

• Gillian Mulvale   ORCID: orcid.org/0000-0003-0546-6910 1 ,
• Jenn Green 1 ,
• Glenn Robert 2 , 5 ,
• Michael Larkin 3 ,
• Nicoline Vackerberg 4 , 5 ,
• Sofia Kjellström 5 ,
• Puspita Hossain 6 ,
• Sandra Moll 7 ,
• Esther Lim 8 , 9 &
• Shioma-Lei Craythorne 3  

Health Research Policy and Systems volume  22 , Article number:  42 ( 2024 ) Cite this article

Metrics details

Innovations in coproduction are shaping public service reform in diverse contexts around the world. Although many innovations are local, others have expanded and evolved over time. We know very little, however, about the process of implementation and evolution of coproduction. The purpose of this study was to explore the adoption, implementation and assimilation of three approaches to the coproduction of public services with structurally vulnerable groups.

We conducted a 4 year longitudinal multiple case study (2019–2023) of three coproduced public service innovations involving vulnerable populations: ESTHER in Jönköping Region, Sweden involving people with multiple complex needs (Case 1); Making Recovery Real in Dundee, Scotland with people who have serious mental illness (Case 2); and Learning Centres in Manitoba, Canada (Case 3), also involving people with serious mental illness. Data sources included 14 interviews with strategic decision-makers and a document analysis to understand the history and contextual factors relating to each case. Three frameworks informed the case study protocol, semi-structured interview guides, data extraction, deductive coding and analysis: the Consolidated Framework for Implementation Research, the Diffusion of Innovation model and Lozeau’s Compatibility Gaps to understand assimilation.

The adoption of coproduction involving structurally vulnerable populations was a notable evolution of existing improvement efforts in Cases 1 and 3, while impetus by an external change agency, existing collaborative efforts among community organizations, and the opportunity to inform a new municipal mental health policy sparked adoption in Case 2. In all cases, coproduced innovation centred around a central philosophy that valued lived experience on an equal basis with professional knowledge in coproduction processes. This philosophical orientation offered flexibility and adaptability to local contexts, thereby facilitating implementation when compared with more defined programming. According to the informants, efforts to avoid co-optation risks were successful, resulting in the assimilation of new mindsets and coproduction processes, with examples of how this had led to transformative change.

Conclusions

In exploring innovations in coproduction with structurally vulnerable groups, our findings suggest several additional considerations when applying existing theoretical frameworks. These include the philosophical nature of the innovation, the need to study the evolution of the innovation itself as it emerges over time, greater attention to partnered processes as disruptors to existing power structures and an emphasis on driving transformational change in organizational cultures.

Peer Review reports

Growing recognition by governments internationally of the need to involve the perspectives of people using public services when designing, delivering and improving those services has been described as a Participatory Zeitgeist reflecting the “spirit of our time” [ 1 , 2 (p247)]. Researchers and designers have developed various approaches drawn from different disciplines and using different labels (for example, codesign, cocreation, coproduction) that align with principles in the citizen engagement literature [ 3 ]. These approaches recognize that service users have experiences and assets and can contribute to service design and delivery along with professional expertise, rather than simply being passive recipients of services designed and delivered by others [ 3 , 4 ]. While these approaches can be used with anyone, they have been increasingly applied to promote the inclusion of structurally vulnerable populations in the design and delivery of innovative health and social care services that seek to support them.

While coproduction has the potential to reform inequitable structures and social processes, excluding vulnerable groups or involving them in a tokenistic manner may unintentionally reinforce existing power imbalances [ 4 , 5 ]. For example, gaps have been noted between the rhetoric of service user involvement in international mental health policy and the readiness to adopt such policies in practice [ 6 ]. Challenges have also been noted in incorporating the voices of individuals with complex needs in improving care coordination across health and social services [ 7 ].

Despite increasing attention to coproduction in the literature and practice, knowledge gaps exist with respect to the implementation of coproduction involving vulnerable populations in different contexts [ 8 , 9 , 10 ]. An international symposium of coproduction researchers and people with lived experience held in Birmingham, England in 2017 identified the need for research to understand how exemplary coproduction innovations involving structurally vulnerable groups originated and their assimilation into routine practice [ 11 ]. To our knowledge, established implementation science models have yet to be applied to coproduction, where service users and service providers are cocreating innovations during the process of implementation [ 12 ].

In this paper, we present findings from a longitudinal case study exploring the factors and processes that influence the adoption, implementation and assimilation of three diverse coproduced public service innovations involving structurally vulnerable groups. We explored the perspectives of strategic leaders involved in advancing coproduction processes involving vulnerable groups. Our analysis proceeds through the lens of existing frameworks from the literature to discuss the outer context (economic, social, political, geographical), inner context (organizational and community considerations), individual factors, innovation features and process considerations [ 13 ].

Conceptual foundations: coproduction, structural vulnerability and implementation processes

Coproduction: Coproduction has been defined as “… involvement of public service users in the design, management, delivery and/or evaluation of public services” [ 4 ]. A core feature of coproduction approaches is that they are applied in a flexible manner, dynamically and innovatively responding to local needs and context [ 14 ].

Structural vulnerability: We adopt the term structurally vulnerable populations to recognize that vulnerability is not inherent in these populations but rather in the social, economic and political systems in which they are embedded [ 15 , 16 ]. Examples include individuals who may require multiple health and/or other public services, including people with complex and intersecting health needs (for example, heart failure and dementia) along with poverty, homelessness and/or being members of newcomer or racialized groups. Structural barriers (for example, lack of trust, language, cultural, scheduling, financial) and power relations may prevent them from engaging in coproduction.

Adoption, implementation and assimilation: We draw on and combine elements from three theoretical frameworks to guide this research. The first is the Diffusion Of Innovation (DOI) model [ 17 ], which identifies how political, social, economic, cultural, and organizational factors and processes affect fidelity and adoption during the diffusion of service innovation. The second is the Consolidated Framework for Implementation Research (CFIR) [ 18 , 19 ], which demonstrates the importance of contextual factors at multiple levels (external context, internal context, innovation features, processes and individual characteristics) in shaping the implementation of service improvements. The third is Lozeau et al.’s (2002) compatibility gaps [ 20 ], which characterize different forms of assimilation of innovations into routine practice [ 20 , 21 ]. Based on these frameworks, we define innovation as a novel set of behaviours, routines and ways of working that are directed at improving health outcomes, administrative efficiency, cost effectiveness or users’ experiences, and that are implemented by planned and coordinated action [ 20 ]. We define adoption as the incremental considerations and progressive individual and collective decision-making from pre-contemplation through exploration by which organizations ultimately decide to adopt the innovation (programme/model/process). Implementation describes the formal strategies to promote the integration of innovations into existing practices. Assimilation is the informal process by which, over time, innovations become part of routine ways of doing things. Assimilation can be characterized as (a) transformation when there is high fidelity to the model and the organization adjusts its functioning to fit the assumptions of the model; (b) customization when the model is adapted to the context and the organization adjusts its practices; (c) loose coupling whereby the innovation is adopted only superficially, while the functioning of the organization remains largely unaffected; or (d) co-optation whereby the innovation becomes captured and distorted to reinforce existing organizational roles and power structures [ 21 ].

Study aim and design

We adopt a longitudinal multiple case study approach to understand the dynamic nature by which three coproduced innovations intended to address the needs of vulnerable populations were adopted, implemented and assimilated [ 22 ]. Case study research is well suited to studying contemporary phenomena in their real-life contexts, and theory is often adopted to focus the analysis, allowing the theory to be augmented or revised based on emerging findings [ 22 ]. To meet the criteria of being a ‘case’, an innovation had to be underpinned by a coproduction model involving structurally vulnerable populations in the design, management, delivery and/or evaluation of a public service that has advanced through these phases. Concepts from the CFIR, DOI and assimilation frameworks described above informed the case study protocol, semi-structured interview questions, data extraction and coding.

Case selection

The three cases were selected through the networks of the investigators to illustrate how coproduction involving vulnerable populations can be advanced in different contexts: the region of Jönköping, Sweden striving for better patient outcomes and experiences by tailoring care to the needs of people with multiple complex needs (Case 1 – ESTHER); the city of Dundee, Scotland aiming to advance the recovery of people with mental illness through greater collaboration with those with lived experience and among service organizations (Case 2 – Making Recovery Real [MRR]); and a rural and an urban branch of a national community mental health organization in a Canadian province that adapted the English Recovery College model of coproduced educational programming to support the recovery of people with serious mental illness (Case 3 – Canadian Mental Health Association [CMHA] Manitoba and Winnipeg and CMHA Central branches’ Learning Centres in Manitoba, Canada) (see Tables  1 , 2 and 3 ).

The study team were familiar with each of these cases and were confident in having good access to them over time. Additionally, their different national contexts offered the opportunity to consider macro-level factors. While each of these countries’ health and social care systems are largely publicly funded, funding is the responsibility of different levels of government (municipal, provincial and/or national) and services are administered and delivered primarily by local governments and/or designated authorities (see Table  4 ).

Data sources and collection

Data sources include relevant academic and grey literature identified through electronic searches and/or recommended or shared by local gatekeepers and key informants to inform the background case context for the individual case analyses, and the interview guides (see Table  5 , and Table S1 in Additional file 1 for more details). Research team members (GM, JG, GR, NV, PH, SC, SS) conducted 45–60 minute long semi-structured interviews in person or online between November 2019 and August 2021. To help understand the history and context of each case, key informants were strategic decision-makers and programme managers affiliated at the time with the organizations leading, participating in or supporting the local initiatives, and who were familiar with the history of how the coproduced innovations emerged, their developmental timeline and coproduction’s role in the overall system. Footnote 1

The interview guide questions probed about this history with a focus on the contextual factors that influenced adoption and implementation and the extent to which coproduction has been assimilated into routine practice. Data were gathered through investigator field notes, the audio-recording and transcription of interviews, timelines, hand-written notes and/or audio-recordings of team meetings to capture member checking with local collaborators, and case team memos of decision points.

To maintain participant anonymity, participant codes are used in the text, identified by a location code (for Case 1, JKG = Jönköping, Sweden; for Case 2, DND = Dundee, Scotland; for Case 3, OTH = Other [for example, national, international informants], PLP = Portage la Prairie, Manitoba, Canada; WPG = Winnipeg, Manitoba, Canada), and a participant number (that is, 01, 02, 03 and so on). For example, an informant from Dundee could be DND-03. Note that the perspectives of service providers and people with lived experience of structural vulnerability were not the focus here but are considered in subsequent waves of our data collection to understand their experiences of coproduction in practice.

Data analysis

A common coding framework was developed iteratively to capture factors and processes influencing adoption, implementation and assimilation by combining elements of the theoretical frameworks to remove overlap and promote consistency of understanding when coding and interpreting the data. Table S2 presents this in more detail (see Additional file 2 ).

The initial data extraction was performed by the research team affiliated with each case, and the project research coordinator worked with the local research coordinator for each case to ensure consistency across cases. Documentary evidence analysis primarily informed our understanding of the historical context and overview of each case. All data were coded and analysed using a deductive approach; a common coding scheme and thematic analysis were employed, respectively, based on the theoretical propositions and concepts in the CFIR and DOI models, and allowing for emergent themes, particularly in relation to the coproduction context [ 22 ]. A visual timeline was created to understand the initiation and growth of coproduction in each case. Interview data was triangulated with documentary evidence and field notes. Analysis proceeded on a case-by-case basis, followed by a cross-case analysis.

Qualitative validity and reliability

The research team comprised four members who were familiar with one of the three cases prior to the study (the ESTHER case), as well as eight members who were not familiar with any of the cases. One member of the team had been closely involved with the development of the ESTHER case over a long period of time. The use of a common and detailed case study protocol and data management system, central and local research coordination by case, monthly investigator meetings and tri-annual full team meetings including collaborating organization representatives were strategies used to enhance qualitative validity. The common coding framework and frequent team discussions helped to ensure consistency and enhanced reliability. Data were triangulated across sources, the analysis was triangulated across investigators and theories, and member checked at various stages with the full team of investigators and collaborators [ 23 ].

Ethical considerations

Research ethics clearance was obtained from the relevant academic research ethics boards (McMaster University Research Ethics Board [MREB Project ID 2066], Aston University Ethics Committee [Rec Ref #1611]; King’s College London Research Ethics Office [Reference Number MOD-19/20-17350]; SingHealth Centralized Institutional Review Board [CIRB Ref# 2020/2341]; and Swedish Ethical Review Authority [Etikprövningsmyndigheten, Dnr 2019-06373]), and in light of this, ethics review was waived by the boards of the collaborating organizations (Canadian Mental Health Association, Manitoba & Winnipeg branch, the East of Scotland Research Ethics Service). Participants received letters of information outlining the study objectives, protocol and risks prior to consenting in writing. Data were collected and stored locally and shared across sites as anonymized, encrypted and password-protected files.

We outline the historical context and analysis of contextual factors influencing adoption and implementation, discuss assimilation by case and then present a cross-case analysis. Tables 1 , 2 and 3 above capture the key features of each case, Figs.  1 , 2 and 3 summarize the adoption, implementation and assimilation timelines, and Tables  6 , 7 and 8 summarize the cross-case analysis.

Historical context: ESTHER is a complex system of public health and social care services run by 13 municipal councils in Region Jönköping County, Sweden that has brought intersectoral health and social care providers together since the 1990s to increase coordination and to redefine service experiences around the needs of the person receiving the services. In a context of restricted public sector funding, ESTHER began in 1997, initially for 2 years, with the aim of finding ways to meet population health needs using approaches other than increased hospital bed capacity. Hospital leaders in Region Jönköping County aimed to transform ways of working and to prevent hospital admissions through what informants called “radical customization”, which considered the needs of individual patients using a bottom-up change process referred to as health process re-engineering. This approach 'shadowed' a patient with complex needs through their health service experience journey and included interviews and surveys with patients, staff and government officials and observations of care encounters and processes to gain new insights into what was needed to improve the system from the patient perspectives. Storytelling of the experience of 'Esther', a persona of an elderly person with complex health needs, actualized this process, pointing out what needed to be done differently by demonstrating the importance of focusing on the experience of the person receiving care. The lessons learned from ESTHER fuelled health and social service-wide change, including coproduction with patients beginning in 2006 through patient roles on advisory committees and councils, and has expanded to include initiatives such as ESTHER cafes, ESTHER coach training and ESTHER family meetings, among others.

Adoption: In the ESTHER case 'adoption' of coproduction was an emergent phenomenon that took place over a 10 year period as ongoing improvement efforts, aimed from the outset at better capturing the lived experience of people with complex needs, evolved in terms of how their perspectives were incorporated in design and decision-making. This initially began with interviews and shadowing patients and bringing staff on board with this approach, until by 2006, Esthers became more directly involved in coproducing system improvements. In the internal context , healthcare process re-engineering efforts since the 1990s centred on the question of “What is best for Esther?” and demonstrated the importance of person-centred care and emphasizing the experiences of the person in need of complex care, laying the foundation for a coproduction approach to emerge. In the external context , system-wide efforts by health and social leaders to create a system map led to ESTHER becoming more than a health quality improvement project but rather a health and social systems-wide movement. From a process perspective, the initial project’s evaluation results indicated a 20% reduction in hospital beds, an achievement that earned recognition in the external context through two national awards. As project funding ended, the benefits of the ESTHER philosophy were recognized, and ESTHER transitioned from a project to a 'network' without funding. Over the next few years, the ESTHER Network further developed as 'cousins' emerged across Sweden, and the approach was adopted in other countries, including Italy, England, Scotland and France.

By 2006, ESTHER in Sweden transitioned toward adopting coproduction approaches that actively invited participation of people with lived experience expertise (Esthers) in coproducing ongoing innovations; however, this process was emergent and not uniform. The flexibility of a guiding philosophy was a key feature that enabled this emergence of innovation in the coproduction approach. By this time, some individual system leaders had come to recognize that keeping the focus on value and what is best for the person being treated in their daily lives would lead to better results than a preoccupation with resources and cost cutting. ESTHER had transformed relationships internally in hospitals to team-based (doctor‒nurse) coleadership and externally across the region via interorganizational collaboration between hospitals, primary care, community care and social care to improve Esthers’ care journeys. These collaborative ways of working were preparation for collaboration with Esthers, helping to create receptivity among senior leaders to coproduction. Nonetheless, at this stage of adoption there was still some internal resistance, particularly at middle management and staff levels, as Esthers began attending and sharing stories about their experiences at leadership meetings.

“I think one of the most important decisions was to take patient in the room. In addition, there was a lot of resistance”. [JKG-01]

Implementation: Once the decision to work directly with Esthers was taken, the implementation of coproduction has continued to unfold, albeit unevenly and opportunistically. Around this time, factors in the outer context shaped ESTHER’s continued development, as Esthers became increasingly present in local patient committees and began to participate in and influence the ESTHER steering committee. While ongoing primary care reform was a distraction for many health service managers, an external network of Esthers developed from different programmes across municipalities, and annual ESTHER 'family' meetings were held, where Esthers could convene to share experiences and ideas, strengthening the grassroots support. ESTHER was again gaining international recognition, becoming the subject of a BBC documentary film and being declared “one of the coolest innovations in the world” by CNN.

In the internal context , further developments included the creation of internal structures that were funded to support greater involvement of patients with multiple vulnerabilities in coproduction activities: The ESTHER Competence Center, training healthcare teams to follow the ESTHER philosophy, and ESTHER Coach quality improvement training programmes for approximately 30 health and social service providers to become new ESTHER Coaches each year, and with growing numbers of Esthers as faculty. Key features of the approach were supportive of grassroots growth. Coaches developed innovations on an ongoing basis with input from Esthers, and health and social service providers remarked that the ESTHER philosophy takes them back to the reasons they entered their professions. At the same time, the bottom-up nature driving innovation continued to be threatening to some individuals in senior leadership positions who were more distanced from observing the benefits.

“ESTHER is very much bottom-up. So, you are very close to ESTHER … you see what’s going on and what you can do better. The steering is from the bottom, and then the managers got a bit threatened. I think there was suddenly too much; the movement was suddenly too big. So, people were reacting to that. …That still is a challenge”. [JKG-01]

Creative approaches have been used to foster growth despite this resistance. Small changes such as renaming committees have enabled participation by Esthers.

“We had our ESTHER Strategy Days. It was once a year that we had a really big gathering about what we are going to focus on. And we invited managers, we invited the coaches, we invited Esthers. So, one-third of the group [of 30] were Esthers and the other were working in health and social care. And, for me, that was a very big success, but it also became a threat. So, they took it away because they said you can’t have strategy day because you are not a manager. So, we changed the name. Now we have the ESTHER Inspiration Day”. [JKG-01]

The implementation process has been incremental and iterative to balance the grassroots pressure for innovation with the internal resistance to patients as equal partners, while ensuring real change results. As an example, in 2007, ESTHER cafes were introduced to connect Esthers and to identify the improvement possibilities most important to Esther. These cafes continue to be held four times per year and have attracted a wide audience, including clinicians and politicians. Esthers share their stories to help leaders and practitioners understand individual experiences, but the process also builds credibility: it requires a check-in with leaders and service providers about what they heard and whether that is consistent with what the storyteller feels is most important, and agreements are reached before the meeting ends about specific action(s) that will be taken to address what is important to Esthers.

“When we listen to a story, we ask the group, ‘What did you hear?’ And we are trying to confirm whether we are hearing different things than [what] Esthers really mean. So, the staff sometimes think, ‘This is very important’. But when we give that back to Esther, she says, ‘Well, that’s not so important for me. For me, this is important’. So, the ESTHER cafe is an activity to identify improvement possibilities. That’s one of the activities”. [JKG-02]

Assimilation: By 2016, ESTHER had evolved from being a network to becoming assimilated as a mindset – the central concept driving innovation in the system in the Jönköping Region. By this time, the decision was made to withdraw funding specific to ESTHER other than to support coach education and to have no single person responsible as leader, as it is intended to be fully assimilated as part of the normal way of working. At the same time, without dedicated funding and leadership, questions remain about sustainability.

“As I said, it is a mindset. Now it is implemented in these programs – the question: ‘What’s best for Esther?’– you will find you can’t find one person who is responsible for ESTHER in Sweden, but there is a programme group and the programme group is trying to find out ways how to spread it in the whole region, because we have some difficulties there. It’s a mindset and it should be part of the daily work. And we are getting there. I think it’s very much dependent who is leading all these kind of leadership programmes, and do they really take the ESTHER philosophy to heart?” [JKG-02]

At this point, all steering groups were removed, being seen as no longer necessary. This removal of infrastructure (formal structures, funding) initially concerned committed leaders, with a risk of co-optation of the ESTHER concept without true adherence in practice. However, there was a widespread sense among interviewees that the ESTHER philosophy has been assimilated as a core value that continues to influence all activities, permeating the culture to become the routine practice in Jönköping.

“It’s a very normal mindset in one of our hospitals to ask the question, ‘What’s best for Esther?’ That’s just a normal way of working and people are just using that word and that question”. [JKG-FL-01]

See Fig. 1 for a summary of the Case 1 adoption, implementation and assimilation timeline.

Case 1 ESTHER coproduction adoption, implementation and assimilation timeline

Historical context: Making Recovery Real gives people with lived experience of mental health difficulties the opportunity to be at the centre of decision-making, service design and practice development in the community of Dundee, Scotland by changing the terms of the dialogue about recovery, mental health and well-being. It began in 2015 as a collaboration of 10 local public, voluntary and community organizations who responded to a call from the Scottish Recovery Network (SRN) to work together to take a new approach to improve the experience and outcomes for people living with mental illness. Initially, the partner organizations endeavoured to develop and deliver more recovery-focused policies and practice by centring lived experience in answering the question: “How can we make recovery real in Dundee?” They brought together interested people, including those with lived experience, at collaborative cafes; a series of events where priorities and accompanying actions were identified, and where participants were equal contributors to the process and its outcomes. To foster the integration of lived experience into system design and practice, the priorities identified were to (i) collect and share recovery stories so that lived experience is at the core of service design, delivery and practice; (ii) develop peer support roles and training; and (iii) celebrate recovery [ 24 ].

Adoption: In the external context , the mental health system remained dominated by the medical model, a lack of system innovation and acute services prioritized over community services. Yet, recent Scottish health and social care system integration has supported partnership working. Simultaneously, SRN, a national voluntary organization established in 2004 to promote recovery principles within the mental health system, was shifting from working with the National Health Service towards building coalitions of change within communities and a whole-systems approach to promoting recovery. SRN solicited proposals from local groups and organizations, offering their support for community-based collaborations that would involve people with lived experience in developing local initiatives to support mental health.

Factors in Dundee’s internal context also converged to support a proposal put forward to SRN for an innovative approach. First, the Dundee Third Sector Interface (TSI), which supports the representation of third sector organizations in local authority planning, had been working to better involve people with lived experience in mental health system planning, and meetings with their network members were becoming more recovery focused. A recent inquiry into mental health services and a fairness commission on poverty (a longstanding local issue) also motivated the local council and Health and Social Care Partnership (HSCP) to take innovative action focused on prevention versus mitigation.

“And I think the Health and Social Care Partnership realized that they needed to do more than mitigation … they have been really, really clear on the need for new ways of doing things for about the last 10, 15 years”. [DND-02]

Furthermore, Dundee City was preparing to develop a new mental health strategic plan and, in the hope of influencing the strategic priorities and the future approach to engagement locally, the TSI brought partners from across community services, the local authority and representative groups who had been attempting to make change in the system to submit a proposal for SRN’s support. Individual leaders from within the partner organizations, motivated by their own lived or professional experience, were drawn by the innovation’s features : to support any concerned citizen to contribute their inherent resources through meaningful involvement and an asset-based approach:

“… So lived experience is essential, bringing people together, involving everybody who wants to be involved in each aspect of the process; so, firstly in agreeing what it is they want to achieve, then in making sure that it is carried out, also in having an actual role in actively carrying it out, so not just identifying things other people should do but having a vested interest and an active contribution to the activities that are going to be – whatever it is that’s going to be done differently, basically”. [DND-04]

SRN acted as a change agency, helping to alleviate tensions among the coalition and supporting their process of exploring the opportunity and submitting a successful proposal.

Implementation: First, SRN helped to bring the individuals involved together to establish a shared vision for the process among the local integration bodies (TSI and HSCP) and a TSI-supported service user network, reducing competition among the service provider partners. Within the inner context of the partnership, there was a commitment to coproduction processes and peer support as a critical opportunity to incorporate more lived experience into the mental health system. Despite these efforts, some of the original partners could not align themselves with the experience-led approach and discontinued their involvement knowing they could return at any time. Undaunted, the remaining partners proceeded by working with the “willing”, beginning with increasing local knowledge of recovery approaches and exploring what recovery meant to local citizens.

“… at the very start, it was a case of, ‘Right. We don’t really know where we want this to go. And actually, are we the ones to be dictating where this should go? No, we’re not. What’s most important is that we’re listening to people with lived experience, people on the ground, and they should be the ones that are telling us what needs to be changing’. So from the beginning, the sort of first step was looking at how we can engage with local people. And we were really keen to make sure that it was meaningful … And we thought this involvement can’t be tokenistic. People need to be on board, and it needs to be collaborative from the start”. [DND-05]

To build connection and trust between participants while shifting to a peer-led approach, the implementation process involved facilitating a series of coproduced, discussion-based events where people with lived experience were invited to be involved in all stages from planning and executing the events, to identifying and achieving priorities. The role of professionals shifted to “being on tap, not on top” [DND-02]. SRN provided developmental support to the Dundee partners to deliver the events, the features of which were welcoming and inclusive, avoiding formal presentations in favour of fun, health-promoting activities that allowed community members to feel heard, and demonstrated alignment with their own ideas and values.

“… what we did—and I would say I think that really set the tone – was rather than have lots of presentations, what we did was, at the event, we welcomed everybody, but we invited lots of the groups to run taster sessions of the things they did. So, that actually brought a lot of people with lived experience because they were coming along to demonstrate their finger painting. There was hula-hooping. There was wellness action planning. There was how to sleep well [sessions]. And in every corner of this venue, there was little groups of people who were painting pebbles, things like that. And then in the afternoon, we had a big conversation happen, world café style. And the sort of comments we got from people were, ‘I felt this was my event. This was for me. It wasn’t for them, the professionals’”. [DND-02]

From these discussions, it emerged that understanding local experiences of personal recovery was the most preferred and effective conveyor of local knowledge and motivator for change for the range of stakeholders. Storytelling became the primary vehicle for relationship building. Peoples’ stories were compiled into a film that premiered at a well-attended, prestigious 'red-carpet' event at a local cinema house, and subsequently became a tool to foster collaborative conversations at engagement events.

“And the film galvanised things and I think because we’d moved beyond that individual telling their story to having a 20 minute film of people reflecting on recovery, which is quite different from telling a story, say, of illness”. [DND-02]

The film drew strategic attention to MRR. This culminated into a consensus to embed recovery, backing for continued peer support and recovery work into the new Dundee Mental Health Strategy and accompanying action plan.

Assimilation: The MRR partner organizations have adopted a peer-led approach to their efforts to promote mental health recovery going forwards. Partners are also now far more involved in collectively determining the distribution of funding through the HSCP and in designing new mental health services.

Locally, the MRR approach has also been included in the Dundee Mental Health Strategy, granting the third sector more influence and collective power in local health and social care planning. The adoption of the MRR approach by the Dundee HSCP has strengthened the importance of mental health locally, dovetailing with the recommendations of the independent inquiry on poverty. At the national level, a Scottish government funding programme to increase the number of mental health workers in community-based services provided an opportunity for the HSCP to fund additional peer support roles, a key initiative within MRR.

Overall, the MRR partnership can be said to have had a transformative effect locally. It has led to better working relationships between providers and continues to drive progress. Furthermore, lived experience is being built into the system infrastructure through actions prioritized in experience-centred collaborative conversations: expansion of the local peer recovery network, development of peer support roles, implementation of peer-led services, peer support training provision and building recovery awareness. A key feature of ongoing progress has been that lived experience partners have been able to move in and out of active participation roles throughout the process, as their recovery journeys and contexts have allowed.

“There was that sense of collaboration that continued ... We kind of all came together to discuss how we felt our organizations could contribute to that bigger picture and the strategic objectives moving forward, and not just the strategic objectives in relation to Making Recovery Real but the wider kind of city and what they were looking for in relation to the local mental health strategy and the city plan”. [DND-05]

Participants describe the process as a difficult yet joyful and rewarding journey. For some organizations, the introduction of the MRR approach has motivated significant recovery-oriented change in their values and structure, further cementing system-level impact.

“Making Recovery Real has really been – I suppose we’ve adopted the principles and approaches … We try to adopt those as far as possible in all of our work. And we don’t badge it all Making Recovery Real, but we use the learning from it, I would say, in everything we do now, everything in the programme”. [DND-04]

See Fig. 2 for a summary of the Case 2 adoption, implementation and assimilation timeline.

Case 2 Making Recovery Real coproduction adoption, implementation and assimilation timeline

Historical context: CMHA Learning Centres began development in Manitoba in 2015 as a coproduced adaptation and renaming of Recovery Colleges, which originated in England in 2009 with a focus on people with lived/living experience of serious mental illness. The aim of Recovery Colleges is to bring the lived experience of people with mental illness and other community members together with professional expertise to locally plan, develop and deliver educational courses about mental health and recovery, with the aim of empowering people to support their mental health and well-being. The concept of recovery education originated in the USA [ 25 , 26 ], and before adopting the Recovery College model, CMHA Winnipeg had offered psychosocial rehabilitation (PSR)-based recovery education since the early 1990s. In 2015, the CMHA Winnipeg branch leader conducted an internal evaluation of this programming, which suggested that improvement was needed to meet the psychosocial health and well-being needs of the community. Around the same time, the new leader of the CMHA Central branch in Portage la Prairie, Manitoba sought a fresh approach to its clubhouse programme, a mutual support drop-in centre, in response to member feedback. Leaders and service users of both branches embraced the Recovery College and coproduction approach to better meet client needs. CMHA Learning Centres build on the Recovery College principles, with the programming and the target audience expanded to promote living well among the broader population, as well as recovery education for people with lived experience of mental illness. The CMHA Central branch’s Thrive Learning Centre and the CMHA Winnipeg and Manitoba branch’s Well-being Learning Centre opened in September 2017 and January 2018, respectively.

Adoption: In the external context , the national policy context was supportive of a recovery and well-being approach; it was the focus of consultations over the 2008–2012 period prior to the release of Canada’s mental health strategy [ 27 ]. This enabled Manitoba bureaucrats to pressure provincial government leaders to cosponsor a 'Recovery Days in Mental Health' conference held in Winnipeg in June 2015. An English Recovery College champion was a keynote speaker and sparked interest in the model among CMHA branches in Manitoba. The Winnipeg Regional Health Authority (RHA), the major funder of the Winnipeg CMHA branch, also supported recovery and mental health promotion approaches. Informants reported that Manitoba’s culture of innovation and solidarity, with its many small rural communities, also aligned with the coproduction philosophy of inclusive innovation.

In the internal context , the Recovery College model resonated with existing branch cultures of deep commitment to recovery-oriented work and strong peer support foundations. CMHA’s federated structure allowed each branch autonomy to develop its own programming, with support from a national office. Attractive innovation features were the existing evidence base, emphasis on lived experience through coproduction in course development and facilitation, opportunity for student skill building, and flexibility to accommodate local needs and strengths. The instructional climate was also appealing, as it could offer people with lived experience a sense of community and could promote their self-efficacy and confidence while reducing the power imbalance and fostering relationships between staff and students. The Recovery College model could also offer a more immediate response in terms of educational support to people needing care and facing long wait times for traditional services.

“I would say there’s probably many other things besides instruction. I think there’s relationship-building that happens so there are connections between students and between the facilitators and the learners. It’s the development of a space that allows for people to develop skills that are unrelated to the content. So, people also learn skills like sharing in a group context, so confidence-building, self-efficacy. When you can cultivate a skill in one area, you build confidence, and you start to believe that you have the ability to learn and to develop new skills. So that sense of self-efficacy is very integral to the recovery and well-being journey”. [WPG-02]

The importance of individual characteristics was demonstrated as passionate leaders in the Winnipeg and Central branches who were committed to advancing upstream mental health promotion and PSR were impressed by the model and together, they researched it further to inform adoption decisions. The coproduction process aligned with CMHA’s “nothing about us without us” approach and could foster a sense of ownership. In both branches, the name Recovery College was changed to Learning Centre during the adoption process, which better resonated with community and agency participants.

Implementation: In the external context , in early 2017, CMHA Winnipeg and Central branches met with CMHA National to implement Learning Centres. Although no new funding was made available by the RHAs, philosophical support enabled the repurposing of existing funding for recovery education and peer support. In 2018, CMHA National and CMHA Winnipeg leadership visited England to meet recovery-focused mental health services experts and to see the model in action. This visit was crucial in fostering strong relationships between the model initiators and CMHA leaders who discovered common visions to widen the target audience to anyone in the community interested in mental health issues, thereby making mental health a universal concern and promoting a living well approach. Collaboration with an Ontario-based psychiatric hospital, with similar values and interest in Recovery Colleges, supported programme evaluation to produce evidence of effectiveness.

Internally , the Winnipeg and Central branches collaborated on initial model and course development, and took a staged approach to opening their Learning Centres. In the Central branch, where resources were tighter and there was a large geographic area to serve, creative approaches to leverage local support and assets were used. Health professional placement students supported the small branch to prepare for launch and in doing so, encouraged staff buy-in. Another peer service organization provided funding support and this, along with community grants, covered staffing, technology, social marketing and other costs that are traditionally not eligible for provincial funding.

“[A] critical moment would be the establishment of a partnership. I think that was a critical moment. I walked away and I know my staff did, too, with an immense sense of relief after I could tell them that [a peer Manitoban mental health community organization] was on board to help make this a reality”. [PLP-22]

The Winnipeg branch also leveraged internal resources, including an existing peer support group whose members assisted in developing the first five courses.

“And so we actually relied on some communities that existed within our CMHA. So we had a group of individuals who are peer supporters to one another. They had taken our workshops in the past. And then they created, on their own, their own support group, and designed that support group based on their needs and on an educational focus. So we actually asked them if they would be our initial coproduction group”. [WPG-04]

The passion of individual CMHA staff and leaders, many with their own lived experience, made them champions who demonstrated their commitment to valuing expertise derived from lived experience. These individuals also helped build the external linkages with organizations and key people both nationally and internationally. Innovation features allowed for initial small-scale implementation, leveraging local assets and community strengths before expanding further. The flexibility to offer “something for everyone” and promote “living well in your community” garnered broad interest and unanimous buy-in from community members. The flexibility of the model also allowed the Winnipeg branch to retain PSR influences from their colleagues at Boston College.

The collaborative coproduction process fostered a sense of ownership, friendship building, balance across perspectives and acceptance within the classroom. This affirming process allowed room for creative input and for trial and error, with the process itself evolving to become more effective over time. It also facilitated the expansion of course offerings, as students were encouraged to lead future course development. Accompanying changes to the physical space and staff roles helped in welcoming the whole community, meeting the needs of vulnerable groups in society and addressing access barriers.

Assimilation: The Central branch has been unable to coproduce new Learning Centre material during the COVID-19 pandemic, yet it continues to offer its existing content. The Winnipeg Learning Centre was able to shift to virtual and then hybrid online and in-person coproduction activities, while ensuring fidelity to the core Recovery College principles.

“And some of the other things that are in the fidelity assessment are: Are you recovery-focused? Are you community-focused? Are you collaborating with the people who are consuming your services? So, it’s a really easy fidelity to conform to but also have room to be kind of creative because they’re not dictating what courses you should have. The fidelity is that you provide courses”. [WPG-04]

In Winnipeg, the Learning Centre continues to expand and evolve, and is reported to have had a gradual but transformative impact on organizational context and values within the branch, by providing a universally accessible platform that demonstrates the value of engaging people with lived experience at every step. The coproduction approach to course development has ensured that content remains current and relevant through creativity, diversity and responsiveness to people’s needs. Leaders’ commitment to the model and ongoing evaluation to ensure it is meeting local needs have supported wider assimilation of coproduction approaches in other branch programming as well. New leadership in the Central branch has expressed the desire to revive the Learning Centre’s coproduction activities.

See Fig. 3 for a summary of the Case 3 adoption, implementation and assimilation timeline.

Case 3 CMHA Learning Centres coproduction adoption, implementation and assimilation timeline

Cross-case comparison

Adoption: Shifting ideas in the public policy realm and supportive external change agents created a conducive external context . In Cases 1 and 2, shifting ideas pertained to interprofessional and intersectoral collaboration and in Case 3, national and provincial discussions about a recovery and well-being orientation were important precursors to coproduction with people with lived experience. Internally , tension for change was evident in all cases; however, the process by which this unfolded differed, as a natural progression of ongoing improvement efforts in Cases 1 and 3 and as a deliberate response to an opportunity created by an external change agent for local system-wide transformative change in Case 2. In all cases, passionate individuals , many with their own lived experience, and a philosophical approach that resonated deeply and widely was a core feature leading to adoption (see Table  6 ).

Implementation: In all three cases, building local partnerships and/or networks in the external context was integral to implementation. These partnerships and networks helped to overcome internal resistance within existing power structures (Case 1), created a community coalition that could move forwards in the face of resistance within traditional mental health services (Case 2), and offered material support and expertise to support implementation (Case 3). In Cases 1 and 2, there was no 'programme' per se, rather a philosophy steered by guiding questions, and in Case 3, the Recovery College model itself was designed to realize its embedded philosophy through coproduced educational programming. These features drove a micro-level movement for change (all cases) that was locally adapted, for example, to become “something for everyone” (in Case 3). Philosophical alignment also helped in building trust across collaborating organizations to support implementation and as a shared foundation for overcoming differences during implementation. Implementation proceeded incrementally at the grassroots level in all cases and by working with the willing (see Table  7 ).

Assimilation: There have been different forms of assimilation across all three cases, with transformative impacts not only on the organizations involved but with impacts extending to the broader organizational and political context. A widely embraced mindset in the region, new structures and a growing international network (Case 1); impact on the local mental health strategy and continuing transformative effects on partnerships among community agencies (Case 2); and assimilation to other programmes and branches (Case 3) are some of the ongoing transformative impacts.

In Case 3, assimilation was characterized by customization, as both branches have changed the name and broadened the reach of Recovery Colleges, while maintaining fidelity to core principles. At the same time, challenges to sustaining such transformative change going forward were a concern without targeted leadership and funding (see Table  8 ).

The analysis of these cases of adoption, implementation and assimilation of innovation demonstrates a range of factors from existing frameworks that shaped the stories of these coproduced innovations. The analysis also suggests additional considerations beyond established frameworks when aiming to engage structurally vulnerable people in coproduction activities that can help to overcome structural barriers and address power differentials in legacy systems.

Existing frameworks and models were very helpful in pointing to the interplay between the many factors operating at different levels in each context. These comprehensive frameworks provided a wide lens that was useful for thoroughly investigating different contextual elements. However, at times, this comprehensiveness made it difficult to tease out the essential causal story from our data to understand how each set of coproduced innovations emerged [ 28 ]. In our analysis, existing frameworks were most helpful when comparing across cases to identify overarching patterns, such as the influence of shifting policy ideas and external change agents in the external context during adoption and the role of community partners and network building in the implementation phase.

At the same time, particularly compelling considerations involving structurally vulnerable groups identified here were less evident in existing frameworks. Notably, there were two important differences in the nature of the ‘programme’ in this context. First, existing frameworks suggest a predefined 'programme' to adopt; however, there was no predefined programme per se in two of our cases. Instead, change was more ideological/philosophical in nature, captured simply by a set of guiding questions (two cases) or embedded as a central feature of an existing program with lots of room for customization (one case). The central philosophy in these cases corresponded to efforts to raise the profile of traditionally marginalized voices by shifting normative paradigms about what types of knowledge (for example, lived experience) and whose voices (for example, structurally vulnerable service users) should be heard in traditional systems. Second, the process (coproduction) could not be disentangled from this essential philosophy and, in some cases, it was met with considerable resistance. Including vulnerable people as genuine partners in coproducing innovations was perceived as a 'threat' to some managers (Case 1) or to the prevailing orthodoxy of 'Quality Improvement' (Case 2).

These 'programme' features suggest a second consideration in terms of implementation processes . The clear intention to shift the existing power balance in systems and within organizations needed a set of resources that went beyond the capacity of any one organization. While high-level leaders with their own lived experience were instrumental in providing vision and support, the implementation process relied heavily on relationship building across partner organizations and networking at the grassroots levels rather than on top-down directives. Meaningful service user involvement was considered critical in making transformative service and system culture change, often disrupting traditional structures, networks and communication. Shared values, the development of a group-based belief system, core activities and a different relational environment and leadership [ 29 , 30 ] are central to social movement theories. Furthermore, the definitive objective of stepping outside organizations within the formal healthcare system to instead derive a new way of working across many community organizations led by people with lived experiences is not clearly captured in existing frameworks, which typically speak to innovation within existing structures of power in organizations and systems.

Finally, the cases analysed here suggest important differences in temporal dynamics at play that were not elaborated in existing models. Consistent with concepts of change in complex adaptive systems and theories of policy path dependence and agenda setting, adoption could occur through a slow internal tension for change that built over time and culminated in coproduction as a natural evolution of ongoing improvement efforts or through seemingly sudden 'transformative' reform where a confluence of interested groups came together in the face of an opportunity to do something differently. Ideas about change in complex adaptive systems such as emergence, self-organization, adaptation, change over time, distributed control and tipping points [ 31 ], and from policy literature such as path dependence [ 32 ], multiple streams theory [ 33 ] and distributed control could be informative in this respect [ 34 ]. Our participants suggested that because each case relates to a set of concepts and principles that were collectively generated over time, there was a need to better understand this process as it unfolded.

While existing models were helpful in considering a wide range of factors to consider and recent updates suggest a movement away from concepts such as 'programme' to 'innovation' [ 19 ], the temporal, relational and power dimensions discussed here were validated by our collaborators as equally important considerations. Exploring these dimensions will be the focus of future work.

Limitations and future work

This work is subject to several limitations. First, it is based on a case study of three examples of coproduction of health and social care innovations in different national contexts in the northern hemisphere. The findings may not be transferable elsewhere. Furthermore, when considering our findings in relation to the CFIR, DOI and assimilation frameworks, it is important to note that these frameworks were not specifically developed for an innovation process involving service users at all stages of innovation adoption, implementation and assimilation. However, the limitations in adopting and applying these frameworks here have led to a careful examination of what is unique to coproduction processes involving vulnerable populations. A forthcoming contribution will try to capture these unique elements and position them within the innovation, power, and social movement literatures. Finally, the analysis here is primarily based on our 'wave 1' home site findings from this longitudinal case study, and new insights may be gained from a deeper evaluation of our wave 2 and wave 3 findings. The latter pertain to processes of ongoing coproduction in practice and diffusion to other contexts, respectively, and will be analysed in forthcoming work.

While our case study was extremely helpful in identifying core considerations for factors influencing the adoption, implementation and assimilation of three cases of coproduced health and social care innovations, several nuanced considerations when applying existing theoretical frameworks in the coproduction context emerged: the nature of the 'intervention' being a philosophy rather than a concrete set of steps, the intertwining of intervention and process and the need to study evolution of the intervention itself as it emerges over time, greater attention to partnered processes as disruptors to existing power structures and an emphasis on driving transformational change in organizational cultures. Future work will explore these considerations further.

Availability of data and materials

The datasets generated and/or analysed during the current study are not publicly available due to the study’s small sample size and the key informants’ roles as leaders within small organizations, making it difficult to deidentify their data. However, the datasets are available from the corresponding author upon reasonable request.

In some cases, these individuals also had lived experience of vulnerability that also motivated their work, but this was not a specific requirement for study participation.

Abbreviations

Consolidated Framework for Implementation Research

(SingHealth) Centralized Institutional Review Board

Canadian Mental Health Association

Diffusion of innovation

Health and Social Care Partnership

McMaster University Research Ethics Board

Making Recovery Real

Portage la Prairie

Psychosocial rehabilitation

Regional health authority

Scottish Recovery Network

Third sector interface

United States

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Acknowledgements

We wish to thank all participants in this study for giving their time and for sharing their experiences. We also thank the study’s collaborators who provided important background to the cases contributing to the research design/direction, acted as local gatekeepers to the cases and/or who helped to interpret the data. Over the life of the research project, the collaborators have been: Louise Christie (Scottish Recovery Network), Marion Cooper (CMHA Manitoba & Winnipeg), Olivia Hanley (formerly of the Scottish Community Development Centre), Greg Kyllo (formerly of CMHA National), Erica McDiarmid (formerly of CMHA National), Susan Paxton (Scottish Community Development Centre), Denise Silverstone (CMHA National), Stephanie Skakun (CMHA Manitoba & Winnipeg) and Nicoline Vackerberg (Region Jönköping County). Without their involvement, this study would not have been possible. Finally, we thank Sophie Sarre for her contributions to wave 1 interviewing and early coding framework development and data coding.

This manuscript draws on research supported by the Social Sciences and Humanities Research Council Partnership Development grant no. 890-2018-0116. The funders had no role in the design of the study; in the collection, analysis and interpretation of data; or in writing the manuscript.

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GM, GR, ML, SK and SM conceived of and designed the study. GM, JG, NV, EL and SC collected and analysed the data under the guidance of GM, GR, ML and SK. GM, JG and PH interpreted the data. GM, GR, JG and PH drafted the manuscript. ML, NV, SK, SM, EL and SC reviewed and commented on different versions of the paper. GR, GM and JG revised the manuscript following peer review, in consultation with the other authors. All the authors have read and approved the final manuscript.

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Research ethics clearance was obtained from the relevant academic research ethics boards (McMaster University Research Ethics Board [MREB Project ID 2066], Aston University Ethics Committee [Rec Ref #1611]; King’s College London Research Ethics Office [Reference Number MOD-19/20-17350]; SingHealth Centralised Institutional Review Board [CIRB Ref# 2020/2341]; and Swedish Ethical Review Authority [Etikprövningsmyndigheten, Dnr 2019-06373]), and in light of this, ethics review was waived by the boards of the collaborating organizations (Canadian Mental Health Association, Manitoba & Winnipeg branch, the East of Scotland Research Ethics Service). Participants received letters of information outlining the study objectives, protocol and risks prior to consenting in writing.

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Additional file 1..

Provides additional details about the sampling frame (that is, the organizations the interviewees are associated with, the document titles and types).

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Demonstrates how concepts from the CFIR, DOI, and compatibility gaps frameworks were incorporated into the coding framework.

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Mulvale, G., Green, J., Robert, G. et al. Adopting, implementing and assimilating coproduced health and social care innovations involving structurally vulnerable populations: findings from a longitudinal, multiple case study design in Canada, Scotland and Sweden. Health Res Policy Sys 22 , 42 (2024). https://doi.org/10.1186/s12961-024-01130-w

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Heavy metal association with chronic kidney disease of unknown cause in central India-results from a case-control study

• Mahendra Atlani 1   na1 ,
• Ashok Kumar 2   na1 ,
• Rajesh Ahirwar 3 ,
• M. N. Meenu 1 ,
• Sudhir K. Goel 2 ,
• Ravita Kumari 2 ,
• Athira Anirudhan 1 ,
• Saikrishna Vallamshetla 4 &
• G. Sai Tharun Reddy 4  

BMC Nephrology volume  25 , Article number:  120 ( 2024 ) Cite this article

Metrics details

Chronic Kidney Disease of unknown cause (CKDu) a disease of exclusion, and remains unexplained in various parts of the world, including India. Previous studies have reported mixed findings about the role of heavy metals or agrochemicals in CKDu. These studies compared CKDu with healthy controls but lacked subjects with CKD as controls. The purpose of this study was to test the hypothesis whether heavy metals, i.e. Arsenic (As), Cadmium (Cd), Lead (Pb), and Chromium (Cr) are associated with CKDu, in central India.

The study was conducted in a case-control manner at a tertiary care hospital. CKDu cases ( n  = 60) were compared with CKD ( n  = 62) and healthy subjects ( n  = 54). Blood and urine levels of As, Cd, Pb, and Cr were measured by Inductively Coupled Plasma- Optical Emission Spectrometry. Pesticide use, painkillers, smoking, and alcohol addiction were also evaluated. The median blood and urine metal levels were compared among the groups by the Kruskal-Wallis rank sum test.

CKDu had significantly higher pesticide and surface water usage as a source of drinking water. Blood As levels (median, IQR) were significantly higher in CKDu 91.97 (1.3–132.7) µg/L compared to CKD 4.5 (0.0–58.8) µg/L and healthy subjects 39.01 (4.8–67.4) µg/L ( p  < 0.001) On multinominal regression age and sex adjusted blood As was independently associated with CKDu[ OR 1.013 (95%CI 1.003–1.024) P  < .05].Blood and urinary Cd, Pb, and Cr were higher in CKD compared to CKDu ( p  > .05). Urinary Cd, Pb and Cr were undetectable in healthy subjects and were significantly higher in CKDu and CKD compared to healthy subjects ( P  = < 0.001). There was a significant correlation of Cd, Pb and Cr in blood and urine with each other in CKDu and CKD subjects as compared to healthy subjects. Surface water use also associated with CKDu [OR 3.178 (95%CI 1.029–9.818) p  < .05).

The study showed an independent association of age and sex adjusted blood As with CKDu in this Indian cohort. Subjects with renal dysfunction (CKDu and CKD) were found to have significantly higher metal burden of Pb, Cd, As, and Cr as compared to healthy controls. CKDu subjects had significantly higher pesticide and surface water usage, which may be the source of differential As exposure in these subjects.

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Chronic kidney disease of unknown cause (CKDu) has been reported in various parts of the world (i.e., Nicaragua, El Salvador, Sri Lanka), including India, as an endemic disease. The disease is a diagnosis of exclusion, made when a patient fulfils the Kidney Disease Improving Global Outcomes (KDIGO) CKD criteria but without the evidence of a recognized cause such as diabetes, hypertension, or glomerulonephritis [ 1 ]. No uniform and definite cause has yet been identified, though various environmental factors have been associated with and suggested to play a role in the pathogenesis. For example, heat stress, strenuous exercise, agrochemicals, and heavy metals have been held responsible for Mesoamerican nephropathy [ 2 ]. Mixed evidence has been reported for association with agrochemicals, heavy metals, and genetic variability for CKDu in Sri Lanka [ 3 , 4 , 5 ]. In India, one small study reported an association of heavy metals with CKD [ 6 ]. A study done on groundwater samples from the Uddanam region of Andhra Pradesh (India), which has a high prevalence of CKDu reported water as acidic (pH < 6.5) and to contain higher silica and lead in wet and dry seasons, respectively. Phthalates were also detected in the groundwater [ 7 ]. Previous studies have attempted to find a correlation between heavy metals and CKDu by comparing cases and endemic and nonendemic controls [ 4 ]. No study has yet tried to find the association of heavy metals comparing CKDu with CKD. Furthermore, previous studies have used urinary metal levels as a biomarker of metal exposure. There is an inherent issue of reverse causality i.e., reduced excretion of metals in urine with a reduction in glomerular filtration rate (GFR) [ 8 ]. Measurement of metals in blood has also been reported to be a promising biomarker of metal exposure [ 9 , 10 ]. Some studies have employed urine to blood ratio for deciding whether urine or blood levels should be used for a particular metal. For metals with urine/blood ratio more than one blood metal levels, whereas for metals with urine/blood ratio less than one, urine metal levels were used in estimation analysis [ 11 ]. The purpose of this study was to test hypothesis whether heavy metals i.e. Arsenic (As), Cadmium (Cd), Lead (Pb) and Chromium (Cr) are associated with CKDu, in central India using blood and urine levels as biomarker of metal exposure.

Materials and methods

Study setting and population.

Study was conducted in a tertiary care hospital setting in the Department of Nephrology in India in a case-control design between December 2019 to June 2022. Participants were enrolled between December 2019 -December 2021. The data collection was done simultaneously. The sample analysis was carried out between January to June-2022. The study was performed according to the guidelines of the Declaration of Helsinki. The study objective was to compare CKDu cases with CKD and healthy controls with regard to biomarkers of exposure of heavy metals [blood and urine levels of cadmium (Cd), lead (Pb), arsenic (As) and chromium (Cr)]. The study included adults aged 18–70 years with CKDu and two groups of the control population, one with CKD and another group of healthy controls without evidence of CKD.

The CKDu and CKD cases were inducted among the patients visiting the nephrology outpatient department and based on pre-defined criteria. At the same time, healthy controls were inducted among the healthy relatives accompanying the patients visiting other departments of the institute for treatment. Written informed consent was obtained from all the participants.

The case definition of CKDu was based on criteria proposed by the Indian Society of Nephrology for the diagnosis of CKDu [ 12 ]. The inclusion criteria included- eGFR < 60 mL/min/1.73m2 (CKD-EPI) [ 13 ] and albumin-to-creatinine ratio (ACR) > 30 mg/g for more than 3 months with:

Urine protein creatinine ratio(PCR) less than 2g/g.

No history of glomerulonephritis, pyelonephritis, renal calculi, polycystic kidneys or obstruction on renal ultrasound.

Not on treatment for diabetes and HbA1c less than 6.5%.

Blood pressure less than 140/90 if CKD stage 1 and 2; and less than 160/100 if CKD stage 3,4, and 5 and on a single drug for blood pressure control.

Case definition of CKD was based on: eGFR < 60 mL/min/1.73m2 (CKD-EPI) and albumin-to-creatinine ratio > 30 mg/g for more than 3 months. Patients were included in the CKD group only if PCR > 2g/g. Hypertension with BP > 140/90 in stages 1–2 and > 160/100 in stages 3–5 or on two or more drugs for BP control.

CKD staging was based on the KDIGO-2008 classification [ 1 ]. The same stages were applied to categorize the renal functions of subjects with CKDu.

Inclusion criteria for healthy controls included: Absence of CKD as evidenced by eGFR more than 90 ml/min/1.73m2, ACR < 30mg/g and lack of anatomical renal disease, obstruction or stone on renal ultrasound, no history of diabetes, HbA1C less than 6.5 and BP less than 140/90.

Biases were kept a minimum by adhering to the case definition described above, and study exposures are mainly objectively assessed with very less dependency on recall i.e. for pesticide or painkiller use. The urine metal levels were adjusted for urine dilution by estimating metals per gram of creatinine in urine.

Sample size

Assuming a difference of moderate effect size (0.25), between three groups (CKDu cases, CKD Controls, Normal Controls) with a confidence level of 95% and power of 80%, the calculated sample size was 159. The final sample size estimated, including a 10% non-response rate, was 180 (60 per group).

Specimen collection and analysis

For the analysis of heavy metals, venous blood (2 ml) was collected in trace element free Trace Element K2-EDTA Vacutainer (Cat# BD 368381). Whole blood was stored at -40 °C until analysis. Ten millilitres (10 ml) of first-morning urine was collected in 50 ml polypropylene tubes. Urine was stored at -40 °C in aliquots until analysis. Serum and urine creatinine was measured using a modified kinetic Jaffe’s method using a Random Access Fully Automated Chemistry Analyzer (Beckman Coulter). Urinary protein and urine albumin were estimated using a colorimetric and immune-turbidimetric methods, respectively, using a Random Access Fully Automated Chemistry Analyzer (Beckman Coulter). HbA1c was analyzed by ion-exchange high pressure liquid chromatography method using a D10 Haemoglobin testing system (BioRad Laboratories). eGFR was calculated from serum creatinine and CKD -EPI equation (Ref). A kidney ultrasound was performed in standard B Mode grey scale in 3.5–5 MHz, the longitudinal length was measured along with the width and thickness of the kidney, renal stones, and any other anatomical abnormality.

Estimation of heavy metals in blood and urine

Levels of Cd, Pb, Cr and As were measured in whole blood and urine. Urinary spot sample results of metal analysis were adjusted for dilution by urine creatinine. Metal analysis was carried out at NIREH, Bhopal (India).

Levels of various heavy metals, viz. Cd, Pb, Cr, As in the collected blood and urine samples were analyzed through inductively coupled plasma optical emission spectroscopy (iCAP® 7400 Duo ICP-OES, ThermoFisher Scientific® Pvt. Ltd). Blood and urine samples were acid-digested in a microwave oven prior to metal detection on ICP-OES. For blood digestion, 1 mL of whole blood sample was mixed with 6 ml of a freshly prepared mixture of concentrated trace metal grade nitric acid (HNO3) and hydrogen peroxide (H2O2) in a ratio 2:1 (v/v) in high-purity polytetrafluoroethylene (PTFE-TFM) vessels. For urine digestion, 5 mL of urine sample was mixed with 6 ml of a freshly prepared mixture of HNO3 and H2O2 in a ratio of 2:1. After gentle mixing of these reactants with blood, the PTFE-TFM vessels were arranged in the rotor (24HVT80, Anton PAAR) and digestion was carried out in the Anton Paar, multi microwave PRO Reaction System at 200 C for 15 min. Digested samples were cooled to 40°C and diluted to 30 ml with distilled water. Blank was prepared for each cycle of digestion using distilled water, nitric acid, and hydrogen peroxide mixture. All the chemicals were trace-element free.

Before the analysis of metal ions in processed blood and urine samples, calibration standards for each element were prepared from multi-element stock solutions (1000 mg L − 1) in triple distilled water. Detection of Cd, Pb, and Cr was performed using a standard sample introduction setup, whereas for As, the hydride generation sample introduction system was utilized. Online hydride generation for As was achieved with an Enhanced Vapor System sample introduction kit using 0.5% m/v sodium tetrahydroborate (NaBH4) stabilized in 0.5% m/v NaOH and 50% v/v HCl solution. Emission data acquisition was performed using the Qtegra ISDS Software at interference-free wavelengths.

Statistical analysis

Statistical analyses were performed with R version 4.2 (R Foundation for Statistical Computing, Vienna, Austria) and IBM SPSS 26 version. The distribution of data in groups was evaluated with Shapiro-Wilk, kurtosis, skewness, and histograms. Skewed data for three groups was compared with the Kruskal-Wallis test. Subgroup analysis in three groups was performed with pairwise comparisons by Dunn test. Parameters with homogeneous distribution were compared with the chi-square test. Data are presented as %, for categorical variables or as median (Q1-Q3) for continuous variables.

Detection rates for blood and urinary metal levels were calculated. For urine metal levels, all statistical analyses were performed with creatinine-adjusted metal concentrations.

Urine to blood ratio was calculated for all metal levels. Spearman correlation coefficient was used to find the association between blood and urine metal levels of individual metals as well as for the association between different metals both in blood and urine. Correlation of blood and urine As with GFR was also performed.

We performed multinominal regression analysis for significantly different metal level in CKDu cases with respect to CKD and healthy controls. We included age and gender (confounding factors) in the model to see the y independence of association and effect estimate of the factor associated with CKDu. Regression model matrices and goodness-of-fit were also determined by the pseudo R 2 coefficient and Hosmer-Lemeshow goodness-of-fit test.

For all analyses, we have considered a p -value less than 0.05 as statistically significant.

A total of 568 patients who visited Nephrology OPD during the study period were screened for inclusion in the study. Out of these, 66 CKDu and 70 CKD cases were found eligible to enroll in the study. Eight patients withdrew consent in the CKD group, whereas four patients in the CKDu group had uncontrolled blood pressure with a single drug, and two withdrew consent. Finally, 60 CKDu and 62 CKD cases were included in the study for outcome analysis. We have approached 120 relatives of patients attending other OPDs and screened them for eligibility criteria of the healthy control group. Out of these, 60 were eligible, and 54 provided consent for participation in the study.

Demography and lab parameters

The CKD and CKDu subjects were similar in demographics for age and sex. However, healthy subjects were younger (Table  1 ). There was no significant difference between CKDu and CKD with reference to stage V (32 vs. 44, P-0.107).There were 05 diabetic kidney disease 04 CKD due to secondary glomerular disease patients (3-lupus nephritis, 1-FSGS), 12 hypertension-associated renal disease, 01 ADPKD, 36 Chronic glomerulonephritis patients, and 04 Chronic pyelonephritis patients in the CKD group. Use of smoking, Alcohol, and painkillers was similar across the three groups (Table  1 ). A significant difference was found between the three study groups with respect to the source of drinking water (ground or surface water). A significantly higher number of CKDu subjects used surface water as a source of drinking water (Table  1 and Table-S 1 and Fig-S 1 ) and a higher number of CKDu subjects reported pesticide usage. As shown in Table  1 , blood pressures were significantly higher in CKD subjects compared to CKDu and healthy subjects and reflect the inclusion criteria with appropriate patient inclusion in three groups. Both ACR and PCR were also significantly different between CKD and CKDu. The eGFR was calculated based on the CKD-EPI formula and was not significantly different between the CKD and CKDu subjects, however, CKD subjects had lower median eGFR compared to CKDu subjects. The healthy subjects had significantly higher eGFR compared to both groups. HbA1c, were similar across the three groups (Table  1 ).

Analytical results

The urinary and blood levels of As, Cd, Pb, and Cr (Table  2 ) were measured in ppb (micrograms per litre), and median with interquartile ranges were reported. Urinary metal levels were also measured in ppb (micrograms per liter) and then adjusted for urinary dilution by urine creatinine value and were finally expressed as micrograms/grams of urine creatinine (Table  2 ).

Detection limits

The lowest detectable concentrations of various heavy metals analyzed on ICP OES with a signal-to-noise ratio of 1 were as follows: As (193.759 nm) - 0.191 ppb; Cd (214.438 nm) - 0 ppb; Pb (220.353 nm) - 0.822 ppb; Cr (283.563 nm) - 3.156 ppb (Table  2 , Figs-S 2 -S 5 ).

Detection percentage

The number of subjects with blood and urine metal levels above the respective detection limits in each study group is reported in Table  2 .

Urine to blood ratio

A urine/blood ratio for each metal in all study groups was calculated for patients with metal levels above the detection limit. The distribution of urine/blood ratios for all metals is presented in Table  2 . Ratios were different between healthy and subjects with deranged kidney functions i.e. low GFR (CKD and CKDu). Median urine/blood Ratio for As was > 1 in healthy subjects and < 1 in CKD and CKDu, reflecting higher urinary levels compared to blood in healthy and reverse in CKD and CKDu subjects. For Pb, it was < 1 in healthy subjects and > 1 in subjects with CKD and CKDu, reflecting higher blood levels compared to urine in healthy and reverse in CKD and CKDu subjects. For Cd and Cr the ratio were < 1 across all three groups suggesting higher urine levels compared to blood levels.

Correlation

A spearman correlation (ρ) was also performed to see the association between each urine and blood metal and among the metals with each other as well. In CKDu, UAs were negatively associated with BAs (ρ-0.260, p -0.11) and in CKD positively (0.138, p -0.37). There was a positive association between urine and blood levels of As,Pb, and Cr and negative association of urine and blood Cd in CKD. In CKDu, a positive association was found in blood and urine Cd,Pb and Cr. In addition, there was a strong correlation of blood Cd, Pb, and Cr ( p  < 0.01) [ρ = 0.68 (BCd and BPb), 0.88 (BCd and BCr), 0.71 (BPb and BCr) in CKDu and [ρ = 0.55 (BCd and BPb), 0.82 (BCd and BCr), 0.65 (BPb and BCr) in CKD. The Urine Cd, Pb, and Cr also had strong correlations [ρ = 0.33 (UCd and UPb), and 0.48(UPb and UCr)] in CKD and [ρ = 0.19(UCd and UPb), 0.67 (UCd and UCr), and 0.69 (UPb and UCr)] in CKDu < 0.05 (Table-S 2 -S 4 and Fig-S 6 ). Association of Blood and urine As with GFR was also evaluated, and BAs were found to be negatively associated with GFR (ρ = -0.097, p  = 0.56), whereas UAs were positively associated (ρ = 0.14, p  = 0.25) with GFR (Table-S 5 ). Metal levels: Blood As: was significantly higher in CKDu ( n  = 37) subjects compared to CKD ( n  = 41) and healthy ( n  = 53) subjects (Table  2 ). On the other hand, the urinary As (UAs) was significantly low in CKD ( n  = 50) and CKDu ( n  = 48) subjects compared to healthy subjects ( n  = 38) and was non significantly higher in CKD subjects compared to CKDu subjects (Fig.  1 , Table  2 ).The blood and urine As values were below detection limits in 21.6%, 35.7%, and 18.8% and in 6%, 16.6%, and 0% of subjects in CKDu, CKD, and healthy groups, respectively.

Box plot for distribution of blood and urine arsenic according to diagnosis categories. Median; microgram/Lt (blood); microgram/gm(urine); UAs- Urine arsenic;CKDu-Chronic kidney disease of unknown cause; CKD-Chronic kidney disease

Blood Cd also was significantly higher in CKD and CKDu subjects compared to healthy subjects. Urinary Cd (UCd) levels were significantly higher in CKD and CKDu subjects compared to healthy subjects,. There was a weak association of ( p  = 0.06) UCd with CKD subjects compared to CKDu subjects.UCd was higher in CKD subjects compared to CKDu (Fig.  2 , Table  2 ). The blood and urine Cd values were below detection limits in 8.3%, 8.1%, and 0% and 37.2%, 19.3%, and 75.9% of subjects in CKDu, CKD, and healthy groups, respectively.

Box plot for distribution of blood and urine cadmium according to diagnosis categories. Median, microgram/Lt (blood); micrograms/gm (urine); UCd- Urine cadmium;CKDu-Chronic kidney disease of unknown cause; CKD-Chronic kidney disease

Pb levels in the blood of CKD and CKDu as well as in urine of CKD and CKDu subjects were significantly higher compared to healthy subjects. The Pb levels were higher in CKD subjects compared to CKDu subjects, but it was not statistically significant (Fig.  3 , Table  2 ). The blood and urine Pb values were below detection limits in 15%, 20%, and 25.9% and 23.3%, 19.4% and 70.4% of subjects in CKDu, CKD, and healthy groups, respectively.

Box plot for distribution of blood and urine lead according to diagnosis categories. microgram/Lt (blood); microgram/gm(urine); UPb- Urine lead;CKDu-Chronic kidney disease of unknown cause; CKD-Chronic kidney disease

As shown in Table  2 and Fig.  4 , urinary and blood Cr was significantly higher in CKD, and CKDu patients than healthy subjects. The blood and urine Cr values were below detection limits in 13%, 0%, and 0% and 13.3%, 14.5% and 85.2% of subjects in CKDu, CKD, and healthy groups, respectively.

Box plot for distribution of blood and urine chromium according to diagnosis categories. Median; microgram/Lt(blood); microgram/gm(urine); UCr-urine chromium, CKDu-Chronic kidney disease of unknown cause; CKD-Chronic kidney disease

Multinominal regression

Though age, gender, were not significantly different between CKDu and CKD, on univariate analysis, we included these In the multinominal regression analysis between CKDu and CKD in reference to healthy subjects in addition to factors found significantly different ( p  < 0.01 on univariate analysis) i.e. blood As and source of drinking water.After the final model, gender had no association with CKDu. Blood As, surface water as drinking water source and age were independently associated with CKDu. Age was associated independently with CKD also (Table  3 ).

To the best of our knowledge, this is the first study wherein an attempt has been made to analyze the association of heavy metals with CKDu in central India, using blood and urine levels as biomarkers of metal exposure. In addition, CKD and healthy subjects have been used as control groups.

The current study showed that blood and urine creatinine-adjusted urinary levels of heavy metals Cd, Pb and Cr were significantly higher in patients with CKD and CKDu as compared to healthy subjects. The urinary levels of the above metals were undetectable in healthy subjects. The study also showed a weak association of ( p  = < 0.06) higher urinary Cd in CKD subjects compared to CKDu subjects of this Indian cohort.

The study also showed that Blood As was significantly higher in CKDu subjects compared to CKD and healthy subjects. On multinominalregression, blood As was independently ( p  < 0.05) associated with CKDu after age adjustment.

In our study, median GFR was rather high in CKDu subjects [14.5 (7.0, 34.2)] compared to GFR in CKD subjects [9.0 (6.0, 17.0)ml/min/1.73m 2 )] and it was non significantly different between the two groups. On correlation analysis, there was a negative correlation between Blood As and GFR and a positive correlation of urine As with GFR. Based on this, the higher blood As in CKDu with higher GFR appears to be truly elevated.

Previously a study from Sri Lanka has also reported an association of CKDu with chronic As toxicity. In that study, 48% of CKDu patients and 17.4% of the control subjects fulfilled the criteria to be diagnosed with chronic arsenical toxicity(CAT), indicating the potential link between CAT and CKDu and suggesting agrochemicals could be the possible source [ 14 ]. Later, it was reported that glyphosate was the most widely used pesticide in Sri Lanka, which contains an average of 1.9 mg/kg arsenic. Findings suggest that agrochemicals, especially phosphate fertilizers, are a major source of inorganic arsenic in CKDu endemic areas [ 15 ]. However, another study from Sri Lanka did not find any difference in UAs levels in patients of CKDu in endemic areas and controls from endemic and nonendemic areas [ 4 ].

Some other studies have reported associations of As with CKD. A study from Taiwan found total UAs to be associated with a four-fold risk of CKD [ 6 ]. Another study reported an association of MMA V (mono methyl arsenate pentavalent) and DMA V (dimethyl arsenate pentavalent) in urine with prevalence of CKD [ 16 ]. However, in both studies, the type of CKD was not reported.

The higher blood As in CKDu compared to CKD may be associated with exposures in our study; a significantly higher number of subjects in CKDu group reported use of pesticides, surface water as a source of drinking water in CKDu subjects.On regression analysis also, surface water was independently associated with CKDu.

A study from north India reported increased levels of OCPs, namely α-HCH, aldrin, and β-endosulfan, in CKDu patients as compared to healthy control and CKD patients of known etiology [ 17 ] and it is also known that arsenic is an important component of pesticides [ 18 ]. The contamination of surface water with various pollutants i.e. pesticides, is common [ 19 ]. Arsenic is a known nephrotoxin, and one of the case reports where kidney histopathology was evaluated reported As causes tubulointerstitial disease (TID) [ 20 ]. The difference in methylation processes of As has also been found responsible for various diseases associated with As i.e. for example, high proportions of urinary MMAs (%U-MMAs) have been associated with a higher risk of cancers and skin lesions [ 21 ]. In contrast, high %U-DMAs has been associated with diabetes risk [ 22 ]. We have measured only iAs in our study. Whether methylation resulting in various metabolite species has different associations with CKDu or CKD should be explored further. We recently found a significant association of single nucleotide polymorphism in a gene coding for sodium-dependent dicarboxylate transporter (SLC13A3) with the susceptibility to CKDu [ 23 ].

In the current study, the UAs results suggest that As levels of 97 µg/gm of creatinine in healthy subjects were not associated with decreased GFR or proteinuria. Similar results were reported by a study from China where researchers found a lower confidence limit on the benchmark dose (LBMD) of 102 and 0.88 µg/gm creatinine for As and Cd, respectively, in order to prevent renal damage in the general population co-exposed to arsenic and cadmium [ 24 ]. The UAs in healthy subjects in our study were nearly similar to the LBMD reference and, not surprisingly, not to be associated with CKD or proteinuria.

Some studies have reported lead to be associated with CKDu. An Indian study reported high levels of lead and silicon concentrations in Indian groundwater in the endemic Uddanam area [ 7 ]. Jaysuman et al. also reported higher levels of Pb (26.5 µg/gm) in the urine of patients with Sri Lankan agricultural nephropathy compared to endemic and nonendemic control [ 25 ].

In the current study, although the median level of blood Pb was almost double in CKD patients compared to CKDu, the result was not statistically significant.

Our study showed that Cd was significantly associated with renal disease. Blood Cd and urine Cd (UCd) levels were significantly higher in patients with renal disease (CKD and CKDu) as compared to healthy subjects. The findings of UCd also showed a weak association (p-0.06) of Cd with CKD compared to CKDu among patients with renal diseases. There are some concerns that UCd may not be truly reflective of metal burden in patients with advanced CKD [ 26 ], because initially, in the course of Cd toxicity with early tubular damage, the normal reabsorption of cadmium-metallothionein decreases, and the UCd concentration increases. However, in the long run, cadmium-induced kidney damage gives rise to low Cd concentrations in both the kidney and urine, while the tubular damage remains [ 27 ]. The U/B ratio of < 1 for Cd in our study supports the above findings.

The mean eGFR in our CKD cohort was lower compared to CKDu; despite this, higher UCd values in patients with CKD compared to CKDu in our study indicate a potential association of Cd with CKD.

Studies have reported variable association of Cd with CKDu when compared to healthy subjects. Nanayakkara et al. [ 28 ] did not find an association of UCd with CKDu in stages 1–4 compared to healthy controls. Whereas another Sri Lankan [ 4 ] study found significantly high UCd in patients with CKDu against the endemic and nonendemic controls. We also observed significantly higher UCd in CKDu vs. healthy controls.

In the current study, urinary Cr (UCr) was not detected in healthy subjects, whereas it was significantly higher in patients with CKD and CKDu as compared to healthy subjects. UCr levels were higher in CKD compared to CKDu. Epidemiologically, Cr exposure has been reported to be associated with kidney damage in occupational populations [ 26 ]. Recently, a study from Taiwan reported that a significant and independent association between Cr exposure and decreased renal function in the general population, and co-exposure to Cr with Pb and Cd is potentially associated with an additional decline in the GFR in Taiwanese adults [ 27 ]. A study from Bangladesh reported outcomes similar to our study; however, the study included only CKD ( n  = 30) patients and compared them with healthy subjects ( n  = 20). In that study, compared to the controls, CKD patients exhibited significantly higher levels of Pb, Cd, and Cr levels in their urine samples. This signifies a potential association between heavy metal co-exposure and CKD [ 29 ]. In the current study a significant correlation between blood Cd, Pb, and Cr and urine Cd, Pb, and Cr were found in CKDu and CKD subjects compared to healthy subjects. The levels of UCd, UPb, and UCr in CKD and CKDu patients were significantly higher compared to healthy controls; The possibility of the combined effect of Cd, Pb, and Cr in the causation of renal diseases could be evaluated further in future studies. As CKDu is an endemic disease, the results of our study suggest an association of arsenic with CKDu in the Indian population, and so the generalizability of the result should be used with caution.

Strengths and limitations

This is the first study which has included two controls (CKD and healthy) and compared metal levels in patients with CKDu. In addition, the comparison of metals in both blood and urine is another advantage, as falling GFR levels and urine levels of several metals do not reflect true metal burden in patients. Inclusion of CKDu patients, as per the suggested definition by the Indian society of Nephrology, is another strength of our study.

The small sample size of our study may be a limitation of our study though it was calculated scientifically. The study involved Indian patients and controls only so the generalization of the results should be with caution. Healthy controls were of younger age is also a limitation of the study.

Also the study included patients from central India, comparatively a larger area and does not points out endemicity.

The study finds an association of environmental toxins with CKDu and CKD. The age and sex-adjusted As were observed to have an independent association with CKDu. A weak association of Cd with CKD was also observed in this Indian cohort. Subjects with renal dysfunction (CKDu and CKD) were observed to have a significantly higher metal burden of Pb, Cd, As, and Cr as compared to healthy controls. CKDu patients may have higher exposure to As via pesticides, surface water usage, or both.

Availability of data and materials

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

Abbreviations

Chronic Kidney Disease of unknown cause

Chronic Kidney Disease

Kidney Disease Improving Global Outcomes

Glomerular filteration rate

Institutional Human Ethics committee

Concentrated trace metal grade nitric acid

Hydrogen peroxide

High-purity polytetrafluoroethylene

Inorganic As

Tubulo-interstitial disease

Pentavalent monomethylarsonic acid

Pentavalent dimethylarsinic acid

Methylarsenous acid

Sodium-dependent dicarboxylate transporter

Limit on the benchmark dose

Arsenobetaine

Urinary MMAs

Urinary DMAs

Blood lead levels

End-stage kidney disease

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Acknowledgements

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The Study was funded by Indian council of Medical Research (ICMR),New Delhi, India. Sanction no.:5/4/7-14/2019-NCD-II.

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Mahendra Atlani and Ashok Kumar contributed equally to this work.

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Department of Nephrology, All India Institute of Medical Sciences (AIIMS), Room No-3022, Academic Block, 3rd Floor, Saket Nagar, Bhopal, Madhya Pradesh, 462020, India

Mahendra Atlani, M. N. Meenu & Athira Anirudhan

Department of Biochemistry, All India Institute of Medical Sciences (AIIMS), Saket Nagar, Bhopal, Madhya Pradesh, 462020, India

Ashok Kumar, Sudhir K. Goel & Ravita Kumari

Department of Environmental Biochemistry, ICMR-National Institute for Research in Environmental Health (NIREH), Bhopal, Madhya Pradesh, India

Rajesh Ahirwar

All India Institute of Medical Sciences (AIIMS), Bhopal, Madhya Pradesh, India

Saikrishna Vallamshetla & G. Sai Tharun Reddy

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MA and AK were equally involved in conceptualising the study, winning the grant, analyzing the results, monitoring the progress of study. MA prepared the manuscript. AK and SKG did the editing. RA supervised analysis of metal levels, sample collection done by MMN, RK. Metal analysis done by AA. Data entry and file preparation for results done by MMN, AA, SKV and STR.

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Atlani, M., Kumar, A., Ahirwar, R. et al. Heavy metal association with chronic kidney disease of unknown cause in central India-results from a case-control study. BMC Nephrol 25 , 120 (2024). https://doi.org/10.1186/s12882-024-03564-4

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Research Roundup April 2024: Recently Published Findings From AFSP-Funded Studies

April 2, 2024 – 7 min read

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Researcher : Bradley Watts, MD, MPH Institution: Dartmouth College Grant Type: 2019 Standard Research Grant – $99,468 Grant Title: Medication Assisted Treatment for Opioid Dependence to Reduce the Risk of Death by Suicide

Treating opioid use disorder (OUD) with opioid agonist treatments that work to prevent withdrawal and reduce cravings, such as methadone and buprenorphine, has been shown to be an effective approach in reducing mortality from all causes, overdose mortality, and suicide mortality. However, due to differences in requirements for getting treatment –– methadone requires daily visits to a dispensing facility while buprenorphine can be received with weekly or monthly prescriptions –– there has been a push to compare these two treatment approaches.

To look at potential differences between these two approaches, Dr. Bradley Watts collected data from 61,997 US Department of Veteran Affairs patients with a diagnosis of OUD who received opioid agonist treatment between 2010 and 2019. After analyzing the data, Dr. Watts found significantly lower all-cause mortality and suicide mortality rates for patients who received buprenorphine treatment compared to methadone. These results support the less restrictive prescribing practices of buprenorphine treatment for OUD.

Citation : Gottlieb, D. J., Shiner, B., Hoyt, J. E., Riblet, N. B., Peltzman, T., Teja, N., & Watts, B. V. (2023). A comparison of mortality rates for buprenorphine versus methadone treatments for opioid use disorder. Acta psychiatrica Scandinavica, 147(1), 6–15. https://doi.org/10.1111/acps.13477

Researcher : Enrique Baca-Garcia, MD, PhD Institution: Fundación Jimenez Diaz (Spain)   Grant Type: 2017 Linked Standard Research Grant – $299,394 Grant Title:

Advancements in technology offer the field of suicide prevention many promising opportunities when it comes to predicting when risk will occur and intervening when it does. One way these opportunities are manifesting is with real-time smartphone monitoring. By collecting data from willing participants, researchers are given the chance to construct predictive models based on patterns in behavior and changes in these patterns over time. These changes are considered critical periods, and their relationship with suicide-risk events has been in need of further study.  

To test the predictive capacities of this type of technology, Dr. Enrique Baca-Garcia and his colleagues recruited 225 patients with a history of suicidal thoughts and behaviors and passively tracked data from their smartphones (e.g., food intake, sleep schedule, distance walked, steps taken, time spent at home, and app usage) for six months. Using an algorithm that constructed daily activity profiles for participants according to the data, Dr. Baca-Garcia was able to detect changes in behavior patterns of the participants. By the end of the study period, 18 (8%) of participants had attempted suicide and 14 (6.2%) presented to the emergency department for psychiatric care. After assessing the data, Dr. Baca-Garcia found that the and behavior in a time frame of one week, indicating strong accuracy. Early detection of risk is a critical feature of intervening to save lives.

Citation : Barrigon, M. L., Romero-Medrano, L., Moreno-Muñoz, P., Porras-Segovia, A., Lopez-Castroman, J., Courtet, P., Artés-Rodríguez, A., & Baca-Garcia, E. (2023). One-Week Suicide Risk Prediction Using Real-Time Smartphone Monitoring: Prospective Cohort Study. Journal of medical Internet research, 25, e43719. https://doi.org/10.2196/43719   

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• Open access
• Published: 27 June 2011

The case study approach

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

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

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

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Introduction

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

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

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

What is a case study?

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

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

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

What are case studies used for?

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

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

How are case studies conducted?

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

Defining the case

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

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

Selecting the case(s)

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

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

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

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

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

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

Collecting the data

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

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

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

Analysing, interpreting and reporting case studies

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

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

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

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

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

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

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

Conclusions

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

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Acknowledgements

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

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Sarah Crowe & Anthony Avery

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

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Murk W , Goralnick E , Brownstein JS , Landman AB. Quality of Layperson CPR Instructions From Artificial Intelligence Voice Assistants. JAMA Netw Open. 2023;6(8):e2331205. doi:10.1001/jamanetworkopen.2023.31205

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Quality of Layperson CPR Instructions From Artificial Intelligence Voice Assistants

• 1 Department of Emergency Medicine, Albert Einstein College of Medicine, The Bronx, New York
• 2 Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
• 3 Harvard Medical School, Boston, Massachusetts
• 4 Innovation and Digital Health Accelerator, Boston Children’s Hospital, Boston, Massachusetts

Despite widespread cardiopulmonary resuscitation (CPR) courses, 46% of out-of-hospital cardiac arrest cases have layperson CPR performed. 1 Layperson CPR is associated with an increase survival by 2- to 4-fold. 2 Artificial intelligence (AI) voice assistants (VAs) are becoming ubiquitous and may be a novel method to provide verbal CPR instructions during an emergency. These technologies are used by nearly half of US adults 3 and are increasingly being used for health care needs. 4 Although bystanders may obtain CPR instructions from emergency dispatchers, such services are not universally available, and their use may be limited by language barriers, poor audio quality, call disconnection, fear of law enforcement, and perceived costs. 5 VAs may therefore serve as a source of readily accessible CPR instruction when it otherwise may be unavailable.

We aimed to evaluate 4 VAs for their out of the box ability to provide appropriate CPR instruction. We also tested a recently developed AI large language model (LLM) for its ability to provide CPR instruction. Although this LLM natively offers only text-based interaction and is therefore not a VA, we sought to evaluate its performance given that it may reflect future VA capabilities.

This case series did not include human participants and did not meet the criteria for human participant research by the Mass General Brigham Institutional Review Board. In February 2023, we tested several ways of asking about CPR on 4 VAs (Amazon Alexa on Echo Show 5, Apple Siri on iPhone 14 Pro [iOS 16.2], Google Assistant on Nest Mini, and Microsoft Cortana on a Windows 10 [ 21H2] laptop). We asked 8 verbal queries of each VA. Transcriptions of interactions were reviewed to verify that queries were accurately captured. We also asked the queries to the LLM ChatGPT version 3.5 (OpenAI) on February 13 via text. The quality of responses was rated by 2 board-certified emergency medicine physicians (E.G. and A.B.L.).

Figure 1 illustrates VA responses to CPR queries. Of 32 responses, 19 responses (59%) were related to CPR. There were 9 responses (28%) that suggested calling emergency services, 11 responses (34%) that provided any (verbal or textual) CPR instructions, and 4 responses (12%) that provided verbal instructions. Differences in appropriateness of responses were noted. For example, while 1 VA more frequently provided CPR instructions than other VAs, these instructions were textual only ( Figure 2 ). The LLM provided relevant CPR information for 100% of queries and textual CPR instructions for 75% of queries ( Figure 2 ). Among 17 responses from VAs or the LLM providing CPR instruction, 71% described hand positioning, 47% described compression depth, and 35% described compression rate.

This case series study found that nearly half of queries were answered by VAs with information unrelated to CPR, often constituting grossly inappropriate responses. These findings suggest that a layperson seeking to use a VA for CPR guidance may experience delays or fail to find appropriate content. For example, with only 28% of VA responses suggesting calling emergency services, use of a VA may be associated with delays in contact with medical care. Although the LLM had improved performance compared with VAs, its responses were inconsistent. Study limitations include a small number of queries and not assessing how responses changed over time.

These findings suggest that bystanders should prioritize calling emergency services over using a VA, especially given that bystanders may not recognize a patient in cardiac arrest. This recognition can be challenging even for dispatchers, and this may be another problem that can be addressed with machine learning. 6

VAs need to better support CPR by: (1) building CPR instructions into core functionality, (2) designating common phrases to activate CPR instructions, and (3) establishing a single set of evidence-based content items across devices, including prioritizing calling emergency services for suspected cardiac arrest. The technology industry could partner with the medical community and professional societies to standardize VA support for CPR instruction.

Accepted for Publication: July 21, 2023.

Published: August 28, 2023. doi:10.1001/jamanetworkopen.2023.31205

Open Access: This is an open access article distributed under the terms of the CC-BY License . © 2023 Murk W et al. JAMA Network Open .

Corresponding Author: Adam B. Landman, MD, MS, MIS, MHS, Department of Emergency Medicine, Brigham and Women’s Hospital, 75 Francis St, Boston MA 02115 ( [email protected] ).

Author Contributions: Dr Murk had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Murk, Goralnick, Landman.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Murk, Landman.

Critical review of the manuscript for important intellectual content: Murk, Brownstein, Landman.

Statistical analysis: Murk.

Supervision: Brownstein, Landman.

Conflict of Interest Disclosures: Dr Landman reported receiving personal fees from Abbott during the conduct of the study. No other disclosures were reported.

Data Sharing Statement: See the Supplement .

Additional Contributions: We thank the late Walter L. Rosenzweig, MS (Micromaster Corporation), for inspiring the idea that virtual assistants could deliver real-time cardiopulmonary resuscitation instruction to bystanders and help save lives. We also thank Melissa S. Landman, BS (School Snapshot, LLC), for her thoughtful review of the manuscript draft. No compensation was provided for these contributions.

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Continuing to enhance the quality of case study methodology in health services research

Shannon l. sibbald.

1 Faculty of Health Sciences, Western University, London, Ontario, Canada.

2 Department of Family Medicine, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada.

3 The Schulich Interfaculty Program in Public Health, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada.

Stefan Paciocco

Meghan fournie, rachelle van asseldonk, tiffany scurr.

Case study methodology has grown in popularity within Health Services Research (HSR). However, its use and merit as a methodology are frequently criticized due to its flexible approach and inconsistent application. Nevertheless, case study methodology is well suited to HSR because it can track and examine complex relationships, contexts, and systems as they evolve. Applied appropriately, it can help generate information on how multiple forms of knowledge come together to inform decision-making within healthcare contexts. In this article, we aim to demystify case study methodology by outlining its philosophical underpinnings and three foundational approaches. We provide literature-based guidance to decision-makers, policy-makers, and health leaders on how to engage in and critically appraise case study design. We advocate that researchers work in collaboration with health leaders to detail their research process with an aim of strengthening the validity and integrity of case study for its continued and advanced use in HSR.

Introduction

The popularity of case study research methodology in Health Services Research (HSR) has grown over the past 40 years. 1 This may be attributed to a shift towards the use of implementation research and a newfound appreciation of contextual factors affecting the uptake of evidence-based interventions within diverse settings. 2 Incorporating context-specific information on the delivery and implementation of programs can increase the likelihood of success. 3 , 4 Case study methodology is particularly well suited for implementation research in health services because it can provide insight into the nuances of diverse contexts. 5 , 6 In 1999, Yin 7 published a paper on how to enhance the quality of case study in HSR, which was foundational for the emergence of case study in this field. Yin 7 maintains case study is an appropriate methodology in HSR because health systems are constantly evolving, and the multiple affiliations and diverse motivations are difficult to track and understand with traditional linear methodologies.

Despite its increased popularity, there is debate whether a case study is a methodology (ie, a principle or process that guides research) or a method (ie, a tool to answer research questions). Some criticize case study for its high level of flexibility, perceiving it as less rigorous, and maintain that it generates inadequate results. 8 Others have noted issues with quality and consistency in how case studies are conducted and reported. 9 Reporting is often varied and inconsistent, using a mix of approaches such as case reports, case findings, and/or case study. Authors sometimes use incongruent methods of data collection and analysis or use the case study as a default when other methodologies do not fit. 9 , 10 Despite these criticisms, case study methodology is becoming more common as a viable approach for HSR. 11 An abundance of articles and textbooks are available to guide researchers through case study research, including field-specific resources for business, 12 , 13 nursing, 14 and family medicine. 15 However, there remains confusion and a lack of clarity on the key tenets of case study methodology.

Several common philosophical underpinnings have contributed to the development of case study research 1 which has led to different approaches to planning, data collection, and analysis. This presents challenges in assessing quality and rigour for researchers conducting case studies and stakeholders reading results.

This article discusses the various approaches and philosophical underpinnings to case study methodology. Our goal is to explain it in a way that provides guidance for decision-makers, policy-makers, and health leaders on how to understand, critically appraise, and engage in case study research and design, as such guidance is largely absent in the literature. This article is by no means exhaustive or authoritative. Instead, we aim to provide guidance and encourage dialogue around case study methodology, facilitating critical thinking around the variety of approaches and ways quality and rigour can be bolstered for its use within HSR.

Purpose of case study methodology

Case study methodology is often used to develop an in-depth, holistic understanding of a specific phenomenon within a specified context. 11 It focuses on studying one or multiple cases over time and uses an in-depth analysis of multiple information sources. 16 , 17 It is ideal for situations including, but not limited to, exploring under-researched and real-life phenomena, 18 especially when the contexts are complex and the researcher has little control over the phenomena. 19 , 20 Case studies can be useful when researchers want to understand how interventions are implemented in different contexts, and how context shapes the phenomenon of interest.

In addition to demonstrating coherency with the type of questions case study is suited to answer, there are four key tenets to case study methodologies: (1) be transparent in the paradigmatic and theoretical perspectives influencing study design; (2) clearly define the case and phenomenon of interest; (3) clearly define and justify the type of case study design; and (4) use multiple data collection sources and analysis methods to present the findings in ways that are consistent with the methodology and the study’s paradigmatic base. 9 , 16 The goal is to appropriately match the methods to empirical questions and issues and not to universally advocate any single approach for all problems. 21

Approaches to case study methodology

Three authors propose distinct foundational approaches to case study methodology positioned within different paradigms: Yin, 19 , 22 Stake, 5 , 23 and Merriam 24 , 25 ( Table 1 ). Yin is strongly post-positivist whereas Stake and Merriam are grounded in a constructivist paradigm. Researchers should locate their research within a paradigm that explains the philosophies guiding their research 26 and adhere to the underlying paradigmatic assumptions and key tenets of the appropriate author’s methodology. This will enhance the consistency and coherency of the methods and findings. However, researchers often do not report their paradigmatic position, nor do they adhere to one approach. 9 Although deliberately blending methodologies may be defensible and methodologically appropriate, more often it is done in an ad hoc and haphazard way, without consideration for limitations.

Cross-analysis of three case study approaches, adapted from Yazan 2015

The post-positive paradigm postulates there is one reality that can be objectively described and understood by “bracketing” oneself from the research to remove prejudice or bias. 27 Yin focuses on general explanation and prediction, emphasizing the formulation of propositions, akin to hypothesis testing. This approach is best suited for structured and objective data collection 9 , 11 and is often used for mixed-method studies.

Constructivism assumes that the phenomenon of interest is constructed and influenced by local contexts, including the interaction between researchers, individuals, and their environment. 27 It acknowledges multiple interpretations of reality 24 constructed within the context by the researcher and participants which are unlikely to be replicated, should either change. 5 , 20 Stake and Merriam’s constructivist approaches emphasize a story-like rendering of a problem and an iterative process of constructing the case study. 7 This stance values researcher reflexivity and transparency, 28 acknowledging how researchers’ experiences and disciplinary lenses influence their assumptions and beliefs about the nature of the phenomenon and development of the findings.

Defining a case

A key tenet of case study methodology often underemphasized in literature is the importance of defining the case and phenomenon. Researches should clearly describe the case with sufficient detail to allow readers to fully understand the setting and context and determine applicability. Trying to answer a question that is too broad often leads to an unclear definition of the case and phenomenon. 20 Cases should therefore be bound by time and place to ensure rigor and feasibility. 6

Yin 22 defines a case as “a contemporary phenomenon within its real-life context,” (p13) which may contain a single unit of analysis, including individuals, programs, corporations, or clinics 29 (holistic), or be broken into sub-units of analysis, such as projects, meetings, roles, or locations within the case (embedded). 30 Merriam 24 and Stake 5 similarly define a case as a single unit studied within a bounded system. Stake 5 , 23 suggests bounding cases by contexts and experiences where the phenomenon of interest can be a program, process, or experience. However, the line between the case and phenomenon can become muddy. For guidance, Stake 5 , 23 describes the case as the noun or entity and the phenomenon of interest as the verb, functioning, or activity of the case.

Designing the case study approach

Yin’s approach to a case study is rooted in a formal proposition or theory which guides the case and is used to test the outcome. 1 Stake 5 advocates for a flexible design and explicitly states that data collection and analysis may commence at any point. Merriam’s 24 approach blends both Yin and Stake’s, allowing the necessary flexibility in data collection and analysis to meet the needs.

Yin 30 proposed three types of case study approaches—descriptive, explanatory, and exploratory. Each can be designed around single or multiple cases, creating six basic case study methodologies. Descriptive studies provide a rich description of the phenomenon within its context, which can be helpful in developing theories. To test a theory or determine cause and effect relationships, researchers can use an explanatory design. An exploratory model is typically used in the pilot-test phase to develop propositions (eg, Sibbald et al. 31 used this approach to explore interprofessional network complexity). Despite having distinct characteristics, the boundaries between case study types are flexible with significant overlap. 30 Each has five key components: (1) research question; (2) proposition; (3) unit of analysis; (4) logical linking that connects the theory with proposition; and (5) criteria for analyzing findings.

Contrary to Yin, Stake 5 believes the research process cannot be planned in its entirety because research evolves as it is performed. Consequently, researchers can adjust the design of their methods even after data collection has begun. Stake 5 classifies case studies into three categories: intrinsic, instrumental, and collective/multiple. Intrinsic case studies focus on gaining a better understanding of the case. These are often undertaken when the researcher has an interest in a specific case. Instrumental case study is used when the case itself is not of the utmost importance, and the issue or phenomenon (ie, the research question) being explored becomes the focus instead (eg, Paciocco 32 used an instrumental case study to evaluate the implementation of a chronic disease management program). 5 Collective designs are rooted in an instrumental case study and include multiple cases to gain an in-depth understanding of the complexity and particularity of a phenomenon across diverse contexts. 5 , 23 In collective designs, studying similarities and differences between the cases allows the phenomenon to be understood more intimately (for examples of this in the field, see van Zelm et al. 33 and Burrows et al. 34 In addition, Sibbald et al. 35 present an example where a cross-case analysis method is used to compare instrumental cases).

Merriam’s approach is flexible (similar to Stake) as well as stepwise and linear (similar to Yin). She advocates for conducting a literature review before designing the study to better understand the theoretical underpinnings. 24 , 25 Unlike Stake or Yin, Merriam proposes a step-by-step guide for researchers to design a case study. These steps include performing a literature review, creating a theoretical framework, identifying the problem, creating and refining the research question(s), and selecting a study sample that fits the question(s). 24 , 25 , 36

Data collection and analysis

Using multiple data collection methods is a key characteristic of all case study methodology; it enhances the credibility of the findings by allowing different facets and views of the phenomenon to be explored. 23 Common methods include interviews, focus groups, observation, and document analysis. 5 , 37 By seeking patterns within and across data sources, a thick description of the case can be generated to support a greater understanding and interpretation of the whole phenomenon. 5 , 17 , 20 , 23 This technique is called triangulation and is used to explore cases with greater accuracy. 5 Although Stake 5 maintains case study is most often used in qualitative research, Yin 17 supports a mix of both quantitative and qualitative methods to triangulate data. This deliberate convergence of data sources (or mixed methods) allows researchers to find greater depth in their analysis and develop converging lines of inquiry. For example, case studies evaluating interventions commonly use qualitative interviews to describe the implementation process, barriers, and facilitators paired with a quantitative survey of comparative outcomes and effectiveness. 33 , 38 , 39

Yin 30 describes analysis as dependent on the chosen approach, whether it be (1) deductive and rely on theoretical propositions; (2) inductive and analyze data from the “ground up”; (3) organized to create a case description; or (4) used to examine plausible rival explanations. According to Yin’s 40 approach to descriptive case studies, carefully considering theory development is an important part of study design. “Theory” refers to field-relevant propositions, commonly agreed upon assumptions, or fully developed theories. 40 Stake 5 advocates for using the researcher’s intuition and impression to guide analysis through a categorical aggregation and direct interpretation. Merriam 24 uses six different methods to guide the “process of making meaning” (p178) : (1) ethnographic analysis; (2) narrative analysis; (3) phenomenological analysis; (4) constant comparative method; (5) content analysis; and (6) analytic induction.

Drawing upon a theoretical or conceptual framework to inform analysis improves the quality of case study and avoids the risk of description without meaning. 18 Using Stake’s 5 approach, researchers rely on protocols and previous knowledge to help make sense of new ideas; theory can guide the research and assist researchers in understanding how new information fits into existing knowledge.

Practical applications of case study research

Columbia University has recently demonstrated how case studies can help train future health leaders. 41 Case studies encompass components of systems thinking—considering connections and interactions between components of a system, alongside the implications and consequences of those relationships—to equip health leaders with tools to tackle global health issues. 41 Greenwood 42 evaluated Indigenous peoples’ relationship with the healthcare system in British Columbia and used a case study to challenge and educate health leaders across the country to enhance culturally sensitive health service environments.

An important but often omitted step in case study research is an assessment of quality and rigour. We recommend using a framework or set of criteria to assess the rigour of the qualitative research. Suitable resources include Caelli et al., 43 Houghten et al., 44 Ravenek and Rudman, 45 and Tracy. 46

New directions in case study

Although “pragmatic” case studies (ie, utilizing practical and applicable methods) have existed within psychotherapy for some time, 47 , 48 only recently has the applicability of pragmatism as an underlying paradigmatic perspective been considered in HSR. 49 This is marked by uptake of pragmatism in Randomized Control Trials, recognizing that “gold standard” testing conditions do not reflect the reality of clinical settings 50 , 51 nor do a handful of epistemologically guided methodologies suit every research inquiry.

Pragmatism positions the research question as the basis for methodological choices, rather than a theory or epistemology, allowing researchers to pursue the most practical approach to understanding a problem or discovering an actionable solution. 52 Mixed methods are commonly used to create a deeper understanding of the case through converging qualitative and quantitative data. 52 Pragmatic case study is suited to HSR because its flexibility throughout the research process accommodates complexity, ever-changing systems, and disruptions to research plans. 49 , 50 Much like case study, pragmatism has been criticized for its flexibility and use when other approaches are seemingly ill-fit. 53 , 54 Similarly, authors argue that this results from a lack of investigation and proper application rather than a reflection of validity, legitimizing the need for more exploration and conversation among researchers and practitioners. 55

Although occasionally misunderstood as a less rigourous research methodology, 8 case study research is highly flexible and allows for contextual nuances. 5 , 6 Its use is valuable when the researcher desires a thorough understanding of a phenomenon or case bound by context. 11 If needed, multiple similar cases can be studied simultaneously, or one case within another. 16 , 17 There are currently three main approaches to case study, 5 , 17 , 24 each with their own definitions of a case, ontological and epistemological paradigms, methodologies, and data collection and analysis procedures. 37

Individuals’ experiences within health systems are influenced heavily by contextual factors, participant experience, and intricate relationships between different organizations and actors. 55 Case study research is well suited for HSR because it can track and examine these complex relationships and systems as they evolve over time. 6 , 7 It is important that researchers and health leaders using this methodology understand its key tenets and how to conduct a proper case study. Although there are many examples of case study in action, they are often under-reported and, when reported, not rigorously conducted. 9 Thus, decision-makers and health leaders should use these examples with caution. The proper reporting of case studies is necessary to bolster their credibility in HSR literature and provide readers sufficient information to critically assess the methodology. We also call on health leaders who frequently use case studies 56 – 58 to report them in the primary research literature.

The purpose of this article is to advocate for the continued and advanced use of case study in HSR and to provide literature-based guidance for decision-makers, policy-makers, and health leaders on how to engage in, read, and interpret findings from case study research. As health systems progress and evolve, the application of case study research will continue to increase as researchers and health leaders aim to capture the inherent complexities, nuances, and contextual factors. 7

Adopting, implementing and assimilating coproduced health and social care innovations involving structurally vulnerable populations: findings from a longitudinal, multiple case study design in Canada, Scotland and Sweden

Affiliations.

• 1 DeGroote School of Business, McMaster University, 4350 South Service Road, Suite 421, Burlington, ON, L7L 5R8, Canada. [email protected].
• 2 DeGroote School of Business, McMaster University, 4350 South Service Road, Suite 421, Burlington, ON, L7L 5R8, Canada.
• 3 Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, London, United Kingdom.
• 4 The Jönköping Academy for Improvement of Health and Welfare, School of Health and Welfare, Jönköping University, Jönköping, Sweden.
• 5 Institute of Health and Neurodevelopment, Aston University, Birmingham, United Kingdom.
• 6 Region Jönköping County, Jönköping, Sweden.
• 7 Department of Health Research Methods, Evidence, and Impact (HEI), Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada.
• 8 School of Rehabilitation Science, McMaster University, Hamilton, ON, Canada.
• 9 School of Health and Welfare, Jönköping University, Jönköping, Sweden.
• 10 SingHealth Office of Regional Health, Singapore Health Services, Singapore, Singapore.
• PMID: 38566129
• DOI: 10.1186/s12961-024-01130-w

Background: Innovations in coproduction are shaping public service reform in diverse contexts around the world. Although many innovations are local, others have expanded and evolved over time. We know very little, however, about the process of implementation and evolution of coproduction. The purpose of this study was to explore the adoption, implementation and assimilation of three approaches to the coproduction of public services with structurally vulnerable groups.

Methods: We conducted a 4 year longitudinal multiple case study (2019-2023) of three coproduced public service innovations involving vulnerable populations: ESTHER in Jönköping Region, Sweden involving people with multiple complex needs (Case 1); Making Recovery Real in Dundee, Scotland with people who have serious mental illness (Case 2); and Learning Centres in Manitoba, Canada (Case 3), also involving people with serious mental illness. Data sources included 14 interviews with strategic decision-makers and a document analysis to understand the history and contextual factors relating to each case. Three frameworks informed the case study protocol, semi-structured interview guides, data extraction, deductive coding and analysis: the Consolidated Framework for Implementation Research, the Diffusion of Innovation model and Lozeau's Compatibility Gaps to understand assimilation.

Results: The adoption of coproduction involving structurally vulnerable populations was a notable evolution of existing improvement efforts in Cases 1 and 3, while impetus by an external change agency, existing collaborative efforts among community organizations, and the opportunity to inform a new municipal mental health policy sparked adoption in Case 2. In all cases, coproduced innovation centred around a central philosophy that valued lived experience on an equal basis with professional knowledge in coproduction processes. This philosophical orientation offered flexibility and adaptability to local contexts, thereby facilitating implementation when compared with more defined programming. According to the informants, efforts to avoid co-optation risks were successful, resulting in the assimilation of new mindsets and coproduction processes, with examples of how this had led to transformative change.

Conclusions: In exploring innovations in coproduction with structurally vulnerable groups, our findings suggest several additional considerations when applying existing theoretical frameworks. These include the philosophical nature of the innovation, the need to study the evolution of the innovation itself as it emerges over time, greater attention to partnered processes as disruptors to existing power structures and an emphasis on driving transformational change in organizational cultures.

Keywords: Adoption; Assimilation; Case study; Coproduction; Implementation; Structurally vulnerable populations; Transformation.

© 2024. The Author(s).

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• 890-2018-0116/Social Sciences and Humanities Research Council of Canada

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Opinion | Fact-checking’s impact on elections: A case study from Portugal

Elections are the ultimate expression of democracy and the prime metric for assessing the influence of fact-checking within democratic societies

This commentary was published in commemoration of International Fact-Checking Day 2024 , held April 2 each year to recognize the work of fact-checkers worldwide. Filipe Pardal is chief operating officer of Polígrafo, a Portugal-based fact-checking group.

A study conducted by a Portuguese university revealed that the fact-checking website Polígrafo was the most viral Portuguese media outlet on X during the first week of the Portuguese electoral campaign in February 2024. Polígrafo also garnered one of the highest levels of interactions and reach on Facebook and Instagram. These data points are even more important when you learn that Polígrafo is the only Portugal-based news website that uses the fact-checking format as its core activity.

Fact-checking must be based on methodology and principles. That’s why organizations like the International Fact-Checking Network, on a global scale, and the European Fact-Checking Standards Network, regionally, play a pivotal role in bolstering the credibility of a community still navigating growing pains. The public is still learning about independent fact-checking and how it differs from traditional campaign news coverage.

The Portugal example shows that when it comes to project sustainability and social impact, local efforts are where the true difference is made. It involves breaking out of the bubble and tailoring content to the specific society in focus. It means engaging with audiences and crafting formats that instill trust in fact-checking work without patronizing, all while upholding one nonnegotiable value: facts.

That’s what we’ve been trying to do: with a website with daily fact checks, with a weekly television program that is the most watched (in the information segment) in all Portuguese television (more than 1.2 million viewers in each episode), and with digital communication, through social networks. We’ve fostered a unique level of engagement with readers, including those inclined to criticize us. We’ve, of course, identified classic criticisms echoed worldwide: Who verifies the fact-checkers? Who funds you? What is your political affiliation? How can I verify your sources? When we answer those questions publicly, it increases both transparency and trust.

One of the most iconic instances of the fact-checking of the campaign — from a fact-checker’s perspective — occurred during a nationally televised debate between the two main candidates for prime minister on Feb. 19. The Socialist Party candidate showed, at one point, a printed Polígrafo fact-check to try to demonstrate that his opponent was lying . In turn, his opponent (now prime minister of Portugal) asked, in an attempt to gain some time: “You’re showing Polígrafo, aren’t you?”

Indeed, he was. This small gesture, previously witnessed in past elections by other political protagonists, demonstrates our impact in local terms, but it demonstrates more than that: It makes very clear how important fact-checking can be in deepening democracy. On many occasions, it has been directly observable that politicians refrain from lying when aware of the presence of Polígrafo, which scrutinizes their statements on the same day they make them.

This is evident in references to our publication by opinion leaders, politicians at rallies, comedians, columnists and all other actors involved in the campaign.

This premise demonstrates the potential of fact-checking activities during elections. It also shows that it is possible to use digital strategies — without neglecting positive interaction with audiences — to combat disinformation/misinformation in increasingly challenging times.

Some have asked us: Is the truth enough? Absolutely! Truth stands as the cornerstone, a nonnegotiable principle. But, let’s face it, it would have little impact without strategies effectively reaching the average reader/viewer.

It is not yet clear to us whether the impact on audiences and recognition of fact-checking in Portugal is due to its presence on national television, its digital communication approach, or whether it benefits from the country’s small size. These are clues that deserve further investigation to find replicable models that can benefit the community around the world.

What is clear is that fact-checking in Portugal has come out of the bubble (the bubble burst!) and it is undeniable that if someone is holding a printed fact-check to prove an argument they are actually “showing Polígrafo.”

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