what is case study according to authors

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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• First Online: 02 January 2023

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The historical origin and strategy of case study research dates back many years in applied and natural sciences. Its roots are traceable to life sciences such as criminology, medicine, and psychology. In this regard, the case study method is recognized and widely used in social science, especially in political and cultural studies and sociology, and educational research.

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Additional Readings

Creswell, J. W., & Creswell, J. D. (2018). Research design: Qualitative, quantitative and mixed methods approaches (5th ed.). Sage.

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Tsang, E. (2013). Case study methodology: Causal explanation, contextualization and theorizing. Journal of International Management, 19 , 195–202. https://doi.org/10.1016/j.intman.2012.08.004

Yin, R. K. (2017). Case study research and applications: Designs and methods (6th ed.). Sage.

Zarnadze, S., Zarnadze, I., Baramidze, L., Sikharulidze, Z., Tabidze, D., & Bakradze, T. (2018). Problem based and case study methodology in medical education. European Scientific Journal, 120–128. https://doi.org/10.19044/esj.2018.c5p9

Online Resources

Case Study Research. https://www.youtube.com/watch?v=RPB3Q9cXmvs

Planning a Case Study. Part 2 of 3 on Case Studies. https://www.youtube.com/watch?v=o1JetXkFAr4

Qualitative analysis of interview data: A step-by-step guide for coding/indexing. https://www.youtube.com/watch?v=DRL4PF2u9XA

Qualitative Case Study. https://www.youtube.com/watch?v=QhvdC4vDjts

Replication or Single Cases. Part 3 of 3 on Case Studies. https://www.youtube.com/watch?v=b5CYZRyOlys

Types of Case Study. Part 1 of 3 on Case Studies. https://www.youtube.com/watch?v=gQfoq7c4UE4

What is case study and how to conduct case study research. https://www.youtube.com/watch?v=kynoEFQNEq8

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Ndame, T. (2023). Case Study. In: Okoko, J.M., Tunison, S., Walker, K.D. (eds) Varieties of Qualitative Research Methods. Springer Texts in Education. Springer, Cham. https://doi.org/10.1007/978-3-031-04394-9_11

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• Case Study | Definition, Examples & Methods

Case Study | Definition, Examples & Methods

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

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

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

Table of contents

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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The case study approach

Sarah crowe.

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

Kathrin Cresswell

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

Ann Robertson

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

Anthony Avery

Aziz sheikh.

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

Introduction

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

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

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

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

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

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

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

What is a case study?

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

Definitions of a case study

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

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

What are case studies used for?

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

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

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

How are case studies conducted?

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

Defining the case

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

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

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

Selecting the case(s)

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

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

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

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

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

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

Collecting the data

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

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

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

Analysing, interpreting and reporting case studies

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

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

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

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

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

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

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

Potential pitfalls and mitigating actions when undertaking case study research

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

Conclusions

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

Competing interests

The authors declare that they have no competing interests.

Authors' contributions

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

Pre-publication history

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

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

Acknowledgements

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

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Case study research: opening up research opportunities

RAUSP Management Journal

ISSN : 2531-0488

Article publication date: 30 December 2019

Issue publication date: 3 March 2020

The case study approach has been widely used in management studies and the social sciences more generally. However, there are still doubts about when and how case studies should be used. This paper aims to discuss this approach, its various uses and applications, in light of epistemological principles, as well as the criteria for rigor and validity.

Design/methodology/approach

This paper discusses the various concepts of case and case studies in the methods literature and addresses the different uses of cases in relation to epistemological principles and criteria for rigor and validity.

The use of this research approach can be based on several epistemologies, provided the researcher attends to the internal coherence between method and epistemology, or what the authors call “alignment.”

Originality/value

This study offers a number of implications for the practice of management research, as it shows how the case study approach does not commit the researcher to particular data collection or interpretation methods. Furthermore, the use of cases can be justified according to multiple epistemological orientations.

• Epistemology

Takahashi, A.R.W. and Araujo, L. (2020), "Case study research: opening up research opportunities", RAUSP Management Journal , Vol. 55 No. 1, pp. 100-111. https://doi.org/10.1108/RAUSP-05-2019-0109

Emerald Publishing Limited

Copyright © 2019, Adriana Roseli Wünsch Takahashi and Luis Araujo.

Published in RAUSP Management Journal . Published by Emerald Publishing Limited. This article is published under the Creative Commons Attribution (CC BY 4.0) licence. Anyone may reproduce, distribute, translate and create derivative works of this article (for both commercial and non-commercial purposes), subject to full attribution to the original publication and authors. The full terms of this licence may be seen at http://creativecommons.org/licences/by/4.0/legalcode

1. Introduction

The case study as a research method or strategy brings us to question the very term “case”: after all, what is a case? A case-based approach places accords the case a central role in the research process ( Ragin, 1992 ). However, doubts still remain about the status of cases according to different epistemologies and types of research designs.

Despite these doubts, the case study is ever present in the management literature and represents the main method of management research in Brazil ( Coraiola, Sander, Maccali, & Bulgacov, 2013 ). Between 2001 and 2010, 2,407 articles (83.14 per cent of qualitative research) were published in conferences and management journals as case studies (Takahashi & Semprebom, 2013 ). A search on Spell.org.br for the term “case study” under title, abstract or keywords, for the period ranging from January 2010 to July 2019, yielded 3,040 articles published in the management field. Doing research using case studies, allows the researcher to immerse him/herself in the context and gain intensive knowledge of a phenomenon, which in turn demands suitable methodological principles ( Freitas et al. , 2017 ).

Our objective in this paper is to discuss notions of what constitutes a case and its various applications, considering epistemological positions as well as criteria for rigor and validity. The alignment between these dimensions is put forward as a principle advocating coherence among all phases of the research process.

This article makes two contributions. First, we suggest that there are several epistemological justifications for using case studies. Second, we show that the quality and rigor of academic research with case studies are directly related to the alignment between epistemology and research design rather than to choices of specific forms of data collection or analysis. The article is structured as follows: the following four sections discuss concepts of what is a case, its uses, epistemological grounding as well as rigor and quality criteria. The brief conclusions summarize the debate and invite the reader to delve into the literature on the case study method as a way of furthering our understanding of contemporary management phenomena.

2. What is a case study?

The debate over what constitutes a case in social science is a long-standing one. In 1988, Howard Becker and Charles Ragin organized a workshop to discuss the status of the case as a social science method. As the discussion was inconclusive, they posed the question “What is a case?” to a select group of eight social scientists in 1989, and later to participants in a symposium on the subject. Participants were unable to come up with a consensual answer. Since then, we have witnessed that further debates and different answers have emerged. The original question led to an even broader issue: “How do we, as social scientists, produce results and seem to know what we know?” ( Ragin, 1992 , p. 16).

An important step that may help us start a reflection on what is a case is to consider the phenomena we are looking at. To do that, we must know something about what we want to understand and how we might study it. The answer may be a causal explanation, a description of what was observed or a narrative of what has been experienced. In any case, there will always be a story to be told, as the choice of the case study method demands an answer to what the case is about.

A case may be defined ex ante , prior to the start of the research process, as in Yin’s (2015) classical definition. But, there is no compelling reason as to why cases must be defined ex ante . Ragin (1992 , p. 217) proposed the notion of “casing,” to indicate that what the case is emerges from the research process:

Rather than attempt to delineate the many different meanings of the term “case” in a formal taxonomy, in this essay I offer instead a view of cases that follows from the idea implicit in many of the contributions – that concocting cases is a varied but routine social scientific activity. […] The approach of this essay is that this activity, which I call “casing”, should be viewed in practical terms as a research tactic. It is selectively invoked at many different junctures in the research process, usually to resolve difficult issues in linking ideas and evidence.

In other words, “casing” is tied to the researcher’s practice, to the way he/she delimits or declares a case as a significant outcome of a process. In 2013, Ragin revisited the 1992 concept of “casing” and explored its multiple possibilities of use, paying particular attention to “negative cases.”

According to Ragin (1992) , a case can be centered on a phenomenon or a population. In the first scenario, cases are representative of a phenomenon, and are selected based on what can be empirically observed. The process highlights different aspects of cases and obscures others according to the research design, and allows for the complexity, specificity and context of the phenomenon to be explored. In the alternative, population-focused scenario, the selection of cases precedes the research. Both positive and negative cases are considered in exploring a phenomenon, with the definition of the set of cases dependent on theory and the central objective to build generalizations. As a passing note, it is worth mentioning here that a study of multiple cases requires a definition of the unit of analysis a priori . Otherwise, it will not be possible to make cross-case comparisons.

These two approaches entail differences that go beyond the mere opposition of quantitative and qualitative data, as a case often includes both types of data. Thus, the confusion about how to conceive cases is associated with Ragin’s (1992) notion of “small vs large N,” or McKeown’s (1999) “statistical worldview” – the notion that relevant findings are only those that can be made about a population based on the analysis of representative samples. In the same vein, Byrne (2013) argues that we cannot generate nomothetic laws that apply in all circumstances, periods and locations, and that no social science method can claim to generate invariant laws. According to the same author, case studies can help us understand that there is more than one ideographic variety and help make social science useful. Generalizations still matter, but they should be understood as part of defining the research scope, and that scope points to the limitations of knowledge produced and consumed in concrete time and space.

Thus, what defines the orientation and the use of cases is not the mere choice of type of data, whether quantitative or qualitative, but the orientation of the study. A statistical worldview sees cases as data units ( Byrne, 2013 ). Put differently, there is a clear distinction between statistical and qualitative worldviews; the use of quantitative data does not by itself means that the research is (quasi) statistical, or uses a deductive logic:

Case-based methods are useful, and represent, among other things, a way of moving beyond a useless and destructive tradition in the social sciences that have set quantitative and qualitative modes of exploration, interpretation, and explanation against each other ( Byrne, 2013 , p. 9).

Other authors advocate different understandings of what a case study is. To some, it is a research method, to others it is a research strategy ( Creswell, 1998 ). Sharan Merrian and Robert Yin, among others, began to write about case study research as a methodology in the 1980s (Merrian, 2009), while authors such as Eisenhardt (1989) called it a research strategy. Stake (2003) sees the case study not as a method, but as a choice of what to be studied, the unit of study. Regardless of their differences, these authors agree that case studies should be restricted to a particular context as they aim to provide an in-depth knowledge of a given phenomenon: “A case study is an in-depth description and analysis of a bounded system” (Merrian, 2009, p. 40). According to Merrian, a qualitative case study can be defined by the process through which the research is carried out, by the unit of analysis or the final product, as the choice ultimately depends on what the researcher wants to know. As a product of research, it involves the analysis of a given entity, phenomenon or social unit.

Thus, whether it is an organization, an individual, a context or a phenomenon, single or multiple, one must delimit it, and also choose between possible types and configurations (Merrian, 2009; Yin, 2015 ). A case study may be descriptive, exploratory, explanatory, single or multiple ( Yin, 2015 ); intrinsic, instrumental or collective ( Stake, 2003 ); and confirm or build theory ( Eisenhardt, 1989 ).

both went through the same process of implementing computer labs intended for the use of information and communication technologies in 2007;

both took part in the same regional program (Paraná Digital); and

they shared similar characteristics regarding location (operation in the same neighborhood of a city), number of students, number of teachers and technicians and laboratory sizes.

However, the two institutions differed in the number of hours of program use, with one of them displaying a significant number of hours/use while the other showed a modest number, according to secondary data for the period 2007-2013. Despite the context being similar and the procedures for implementing the technology being the same, the mechanisms of social integration – an idiosyncratic factor of each institution – were different in each case. This explained differences in their use of resource, processes of organizational learning and capacity to absorb new knowledge.

On the other hand, multiple case studies seek evidence in different contexts and do not necessarily require direct comparisons ( Stake, 2003 ). Rather, there is a search for patterns of convergence and divergence that permeate all the cases, as the same issues are explored in every case. Cases can be added progressively until theoretical saturation is achieved. An example is of a study that investigated how entrepreneurial opportunity and management skills were developed through entrepreneurial learning ( Zampier & Takahashi, 2014 ). The authors conducted nine case studies, based on primary and secondary data, with each one analyzed separately, so a search for patterns could be undertaken. The convergence aspects found were: the predominant way of transforming experience into knowledge was exploitation; managerial skills were developed through by taking advantages of opportunities; and career orientation encompassed more than one style. As for divergence patterns: the experience of success and failure influenced entrepreneurs differently; the prevailing rationality logic of influence was different; and the combination of styles in career orientation was diverse.

A full discussion of choice of case study design is outside the scope of this article. For the sake of illustration, we make a brief mention to other selection criteria such as the purpose of the research, the state of the art of the research theme, the time and resources involved and the preferred epistemological position of the researcher. In the next section, we look at the possibilities of carrying out case studies in line with various epistemological traditions, as the answers to the “what is a case?” question reveal varied methodological commitments as well as diverse epistemological and ontological positions ( Ragin, 2013 ).

3. Epistemological positioning of case study research

Ontology and epistemology are like skin, not a garment to be occasionally worn ( Marsh & Furlong, 2002 ). According to these authors, ontology and epistemology guide the choice of theory and method because they cannot or should not be worn as a garment. Hence, one must practice philosophical “self-knowledge” to recognize one’s vision of what the world is and of how knowledge of that world is accessed and validated. Ontological and epistemological positions are relevant in that they involve the positioning of the researcher in social science and the phenomena he or she chooses to study. These positions do not tend to vary from one project to another although they can certainly change over time for a single researcher.

Ontology is the starting point from which the epistemological and methodological positions of the research arise ( Grix, 2002 ). Ontology expresses a view of the world, what constitutes reality, nature and the image one has of social reality; it is a theory of being ( Marsh & Furlong, 2002 ). The central question is the nature of the world out there regardless of our ability to access it. An essentialist or foundationalist ontology acknowledges that there are differences that persist over time and these differences are what underpin the construction of social life. An opposing, anti-foundationalist position presumes that the differences found are socially constructed and may vary – i.e. they are not essential but specific to a given culture at a given time ( Marsh & Furlong, 2002 ).

Epistemology is centered around a theory of knowledge, focusing on the process of acquiring and validating knowledge ( Grix, 2002 ). Positivists look at social phenomena as a world of causal relations where there is a single truth to be accessed and confirmed. In this tradition, case studies test hypotheses and rely on deductive approaches and quantitative data collection and analysis techniques. Scholars in the field of anthropology and observation-based qualitative studies proposed alternative epistemologies based on notions of the social world as a set of manifold and ever-changing processes. In management studies since the 1970s, the gradual acceptance of qualitative research has generated a diverse range of research methods and conceptions of the individual and society ( Godoy, 1995 ).

The interpretative tradition, in direct opposition to positivism, argues that there is no single objective truth to be discovered about the social world. The social world and our knowledge of it are the product of social constructions. Thus, the social world is constituted by interactions, and our knowledge is hermeneutic as the world does not exist independent of our knowledge ( Marsh & Furlong, 2002 ). The implication is that it is not possible to access social phenomena through objective, detached methods. Instead, the interaction mechanisms and relationships that make up social constructions have to be studied. Deductive approaches, hypothesis testing and quantitative methods are not relevant here. Hermeneutics, on the other hand, is highly relevant as it allows the analysis of the individual’s interpretation, of sayings, texts and actions, even though interpretation is always the “truth” of a subject. Methods such as ethnographic case studies, interviews and observations as data collection techniques should feed research designs according to interpretivism. It is worth pointing out that we are to a large extent, caricaturing polar opposites rather characterizing a range of epistemological alternatives, such as realism, conventionalism and symbolic interactionism.

If diverse ontologies and epistemologies serve as a guide to research approaches, including data collection and analysis methods, and if they should be regarded as skin rather than clothing, how does one make choices regarding case studies? What are case studies, what type of knowledge they provide and so on? The views of case study authors are not always explicit on this point, so we must delve into their texts to glean what their positions might be.

Two of the cited authors in case study research are Robert Yin and Kathleen Eisenhardt. Eisenhardt (1989) argues that a case study can serve to provide a description, test or generate a theory, the latter being the most relevant in contributing to the advancement of knowledge in a given area. She uses terms such as populations and samples, control variables, hypotheses and generalization of findings and even suggests an ideal number of case studies to allow for theory construction through replication. Although Eisenhardt includes observation and interview among her recommended data collection techniques, the approach is firmly anchored in a positivist epistemology:

Third, particularly in comparison with Strauss (1987) and Van Maanen (1988), the process described here adopts a positivist view of research. That is, the process is directed toward the development of testable hypotheses and theory which are generalizable across settings. In contrast, authors like Strauss and Van Maanen are more concerned that a rich, complex description of the specific cases under study evolve and they appear less concerned with development of generalizable theory ( Eisenhardt, 1989 , p. 546).

This position attracted a fair amount of criticism. Dyer & Wilkins (1991) in a critique of Eisenhardt’s (1989) article focused on the following aspects: there is no relevant justification for the number of cases recommended; it is the depth and not the number of cases that provides an actual contribution to theory; and the researcher’s purpose should be to get closer to the setting and interpret it. According to the same authors, discrepancies from prior expectations are also important as they lead researchers to reflect on existing theories. Eisenhardt & Graebner (2007 , p. 25) revisit the argument for the construction of a theory from multiple cases:

A major reason for the popularity and relevance of theory building from case studies is that it is one of the best (if not the best) of the bridges from rich qualitative evidence to mainstream deductive research.

Although they recognize the importance of single-case research to explore phenomena under unique or rare circumstances, they reaffirm the strength of multiple case designs as it is through them that better accuracy and generalization can be reached.

Likewise, Robert Yin emphasizes the importance of variables, triangulation in the search for “truth” and generalizable theoretical propositions. Yin (2015 , p. 18) suggests that the case study method may be appropriate for different epistemological orientations, although much of his work seems to invoke a realist epistemology. Authors such as Merrian (2009) and Stake (2003) suggest an interpretative version of case studies. Stake (2003) looks at cases as a qualitative option, where the most relevant criterion of case selection should be the opportunity to learn and understand a phenomenon. A case is not just a research method or strategy; it is a researcher’s choice about what will be studied:

Even if my definition of case study was agreed upon, and it is not, the term case and study defy full specification (Kemmis, 1980). A case study is both a process of inquiry about the case and the product of that inquiry ( Stake, 2003 , p. 136).

Later, Stake (2003 , p. 156) argues that:

[…] the purpose of a case report is not to represent the world, but to represent the case. […] The utility of case research to practitioners and policy makers is in its extension of experience.

Still according to Stake (2003 , pp. 140-141), to do justice to complex views of social phenomena, it is necessary to analyze the context and relate it to the case, to look for what is peculiar rather than common in cases to delimit their boundaries, to plan the data collection looking for what is common and unusual about facts, what could be valuable whether it is unique or common:

Reflecting upon the pertinent literature, I find case study methodology written largely by people who presume that the research should contribute to scientific generalization. The bulk of case study work, however, is done by individuals who have intrinsic interest in the case and little interest in the advance of science. Their designs aim the inquiry toward understanding of what is important about that case within its own world, which is seldom the same as the worlds of researchers and theorists. Those designs develop what is perceived to be the case’s own issues, contexts, and interpretations, its thick descriptions . In contrast, the methods of instrumental case study draw the researcher toward illustrating how the concerns of researchers and theorists are manifest in the case. Because the critical issues are more likely to be know in advance and following disciplinary expectations, such a design can take greater advantage of already developed instruments and preconceived coding schemes.

The aforementioned authors were listed to illustrate differences and sometimes opposing positions on case research. These differences are not restricted to a choice between positivism and interpretivism. It is worth noting that Ragin’s (2013 , p. 523) approach to “casing” is compatible with the realistic research perspective:

In essence, to posit cases is to engage in ontological speculation regarding what is obdurately real but only partially and indirectly accessible through social science. Bringing a realist perspective to the case question deepens and enriches the dialogue, clarifying some key issues while sweeping others aside.

cases are actual entities, reflecting their operations of real causal mechanism and process patterns;

case studies are interactive processes and are open to revisions and refinements; and

social phenomena are complex, contingent and context-specific.

Ragin (2013 , p. 532) concludes:

Lurking behind my discussion of negative case, populations, and possibility analysis is the implication that treating cases as members of given (and fixed) populations and seeking to infer the properties of populations may be a largely illusory exercise. While demographers have made good use of the concept of population, and continue to do so, it is not clear how much the utility of the concept extends beyond their domain. In case-oriented work, the notion of fixed populations of cases (observations) has much less analytic utility than simply “the set of relevant cases,” a grouping that must be specified or constructed by the researcher. The demarcation of this set, as the work of case-oriented researchers illustrates, is always tentative, fluid, and open to debate. It is only by casing social phenomena that social scientists perceive the homogeneity that allows analysis to proceed.

In summary, case studies are relevant and potentially compatible with a range of different epistemologies. Researchers’ ontological and epistemological positions will guide their choice of theory, methodologies and research techniques, as well as their research practices. The same applies to the choice of authors describing the research method and this choice should be coherent. We call this research alignment , an attribute that must be judged on the internal coherence of the author of a study, and not necessarily its evaluator. The following figure illustrates the interrelationship between the elements of a study necessary for an alignment ( Figure 1 ).

In addition to this broader aspect of the research as a whole, other factors should be part of the researcher’s concern, such as the rigor and quality of case studies. We will look into these in the next section taking into account their relevance to the different epistemologies.

4. Rigor and quality in case studies

Traditionally, at least in positivist studies, validity and reliability are the relevant quality criteria to judge research. Validity can be understood as external, internal and construct. External validity means identifying whether the findings of a study are generalizable to other studies using the logic of replication in multiple case studies. Internal validity may be established through the theoretical underpinning of existing relationships and it involves the use of protocols for the development and execution of case studies. Construct validity implies defining the operational measurement criteria to establish a chain of evidence, such as the use of multiple sources of evidence ( Eisenhardt, 1989 ; Yin, 2015 ). Reliability implies conducting other case studies, instead of just replicating results, to minimize the errors and bias of a study through case study protocols and the development of a case database ( Yin, 2015 ).

Several criticisms have been directed toward case studies, such as lack of rigor, lack of generalization potential, external validity and researcher bias. Case studies are often deemed to be unreliable because of a lack of rigor ( Seuring, 2008 ). Flyvbjerg (2006 , p. 219) addresses five misunderstandings about case-study research, and concludes that:

[…] a scientific discipline without a large number of thoroughly executed case studies is a discipline without systematic production of exemplars, and a discipline without exemplars is an ineffective one.

theoretical knowledge is more valuable than concrete, practical knowledge;

the case study cannot contribute to scientific development because it is not possible to generalize on the basis of an individual case;

the case study is more useful for generating rather than testing hypotheses;

the case study contains a tendency to confirm the researcher’s preconceived notions; and

it is difficult to summarize and develop general propositions and theories based on case studies.

These criticisms question the validity of the case study as a scientific method and should be corrected.

The critique of case studies is often framed from the standpoint of what Ragin (2000) labeled large-N research. The logic of small-N research, to which case studies belong, is different. Cases benefit from depth rather than breadth as they: provide theoretical and empirical knowledge; contribute to theory through propositions; serve not only to confirm knowledge, but also to challenge and overturn preconceived notions; and the difficulty in summarizing their conclusions is because of the complexity of the phenomena studies and not an intrinsic limitation of the method.

Thus, case studies do not seek large-scale generalizations as that is not their purpose. And yet, this is a limitation from a positivist perspective as there is an external reality to be “apprehended” and valid conclusions to be extracted for an entire population. If positivism is the epistemology of choice, the rigor of a case study can be demonstrated by detailing the criteria used for internal and external validity, construct validity and reliability ( Gibbert & Ruigrok, 2010 ; Gibbert, Ruigrok, & Wicki, 2008 ). An example can be seen in case studies in the area of information systems, where there is a predominant orientation of positivist approaches to this method ( Pozzebon & Freitas, 1998 ). In this area, rigor also involves the definition of a unit of analysis, type of research, number of cases, selection of sites, definition of data collection and analysis procedures, definition of the research protocol and writing a final report. Creswell (1998) presents a checklist for researchers to assess whether the study was well written, if it has reliability and validity and if it followed methodological protocols.

In case studies with a non-positivist orientation, rigor can be achieved through careful alignment (coherence among ontology, epistemology, theory and method). Moreover, the concepts of validity can be understood as concern and care in formulating research, research development and research results ( Ollaik & Ziller, 2012 ), and to achieve internal coherence ( Gibbert et al. , 2008 ). The consistency between data collection and interpretation, and the observed reality also help these studies meet coherence and rigor criteria. Siggelkow (2007) argues that a case study should be persuasive and that even a single case study may be a powerful example to contest a widely held view. To him, the value of a single case study or studies with few cases can be attained by their potential to provide conceptual insights and coherence to the internal logic of conceptual arguments: “[…] a paper should allow a reader to see the world, and not just the literature, in a new way” ( Siggelkow, 2007 , p. 23).

Interpretative studies should not be justified by criteria derived from positivism as they are based on a different ontology and epistemology ( Sandberg, 2005 ). The rejection of an interpretive epistemology leads to the rejection of an objective reality: “As Bengtsson points out, the life-world is the subjects’ experience of reality, at the same time as it is objective in the sense that it is an intersubjective world” ( Sandberg, 2005 , p. 47). In this event, how can one demonstrate what positivists call validity and reliability? What would be the criteria to justify knowledge as truth, produced by research in this epistemology? Sandberg (2005 , p. 62) suggests an answer based on phenomenology:

This was demonstrated first by explicating life-world and intentionality as the basic assumptions underlying the interpretative research tradition. Second, based on those assumptions, truth as intentional fulfillment, consisting of perceived fulfillment, fulfillment in practice, and indeterminate fulfillment, was proposed. Third, based on the proposed truth constellation, communicative, pragmatic, and transgressive validity and reliability as interpretative awareness were presented as the most appropriate criteria for justifying knowledge produced within interpretative approach. Finally, the phenomenological epoché was suggested as a strategy for achieving these criteria.

From this standpoint, the research site must be chosen according to its uniqueness so that one can obtain relevant insights that no other site could provide ( Siggelkow, 2007 ). Furthermore, the view of what is being studied is at the center of the researcher’s attention to understand its “truth,” inserted in a given context.

The case researcher is someone who can reduce the probability of misinterpretations by analyzing multiple perceptions, searches for data triangulation to check for the reliability of interpretations ( Stake, 2003 ). It is worth pointing out that this is not an option for studies that specifically seek the individual’s experience in relation to organizational phenomena.

In short, there are different ways of seeking rigor and quality in case studies, depending on the researcher’s worldview. These different forms pervade everything from the research design, the choice of research questions, the theory or theories to look at a phenomenon, research methods, the data collection and analysis techniques, to the type and style of research report produced. Validity can also take on different forms. While positivism is concerned with validity of the research question and results, interpretivism emphasizes research processes without neglecting the importance of the articulation of pertinent research questions and the sound interpretation of results ( Ollaik & Ziller, 2012 ). The means to achieve this can be diverse, such as triangulation (of multiple theories, multiple methods, multiple data sources or multiple investigators), pre-tests of data collection instrument, pilot case, study protocol, detailed description of procedures such as field diary in observations, researcher positioning (reflexivity), theoretical-empirical consistency, thick description and transferability.

5. Conclusions

The central objective of this article was to discuss concepts of case study research, their potential and various uses, taking into account different epistemologies as well as criteria of rigor and validity. Although the literature on methodology in general and on case studies in particular, is voluminous, it is not easy to relate this approach to epistemology. In addition, method manuals often focus on the details of various case study approaches which confuse things further.

Faced with this scenario, we have tried to address some central points in this debate and present various ways of using case studies according to the preferred epistemology of the researcher. We emphasize that this understanding depends on how a case is defined and the particular epistemological orientation that underpins that conceptualization. We have argued that whatever the epistemological orientation is, it is possible to meet appropriate criteria of research rigor and quality provided there is an alignment among the different elements of the research process. Furthermore, multiple data collection techniques can be used in in single or multiple case study designs. Data collection techniques or the type of data collected do not define the method or whether cases should be used for theory-building or theory-testing.

Finally, we encourage researchers to consider case study research as one way to foster immersion in phenomena and their contexts, stressing that the approach does not imply a commitment to a particular epistemology or type of research, such as qualitative or quantitative. Case study research allows for numerous possibilities, and should be celebrated for that diversity rather than pigeon-holed as a monolithic research method.

The interrelationship between the building blocks of research

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Chapter 3: Research Methods

This study seeks to provide insight into the process of conducting community-based research.  In order to do so, the study utilizes a qualitative case study approach to examine the methodology of community-based research. Two contrasting cases of CBR are described and analyzed in order to understand the issues that arise when conducting CBR, the factors that facilitate or hinder the process, and the benefits of conducting CBR.  Finally, these contrasting cases are considered to determine what this study can contribute to the field of CBR.  This chapter details case study methodology as well as multiple case design.  It also describes the methodology of community-based research, the participants of the study, data collection and analysis, and issues around credibility, including my own subjectivities that may have influenced the research. 

Methodological Framework

In order to explore the collaborative process of conducting community-based research, this study utilizes a qualitative case study approach.  Case studies can be particularly useful for studying a process, program or individual in an in-depth, holistic way that allows for deep understanding (Merriam, 1998).  As Merriam points out,

A case study design is employed to gain an in-depth understanding of the situation and meaning for those involved.  The interest is in process rather than outcomes, in context rather than a specific variable, in discovery rather than confirmation (p. 19).

There are some differences in how researchers define case study.  Some researchers think of case study as the object to be studied (Stake, 2000), while others define case study as a process of investigation (Creswell, 2002).  Creswell defines case study as "an in-depth exploration of a bounded system (e.g., an activity, event, process, or individuals) based on extensive data collection" (p. 485).  Creswell recommends case study as a methodology if the problem to be studied "relates to developing an in-depth understanding of a 'case' or bounded system" (p. 496) and if the purpose is to understand "an event, activity, process, or one or more individuals" (p. 496).  Patton (1990) suggests that case studies are valuable in creating deep understanding of particular people, problems or situations in comprehensive ways.  

This study is particularly suitable for a case study design because it is a bounded system, it is contextual, and it is a study of process (Merriam, 1998).  Like Creswell (2002), Stake (2000) defines case study as the study of a "bounded system" (p. 436).  According to Creswell (2002), "'Bounded' means that the case is separated out for research in terms of time, place, or some physical boundaries" (p. 485).  In other words, it is possible to create limits around the object to be studied (Merriam, 1998).  A case study can focus on a variety of different things.  A case could be an individual, a group, a school, a community (Merriam, 1998), or a case could also include "a program, events, or activities" (Creswell, 2002, p. 485).  The bounded systems in my contrasting case studies are my collaboration with the Coalition for Schools [2] in a western city and my collaboration with community members in a small, rural, mountain community to carry out community-based research.  The boundaries of these two cases are determined by the people and groups that I collaborate with in the CBR process.  

I chose a case study design because it involves "detailed, in-depth data collection involving multiple sources of information rich in context" (Creswell, 1998, p. 61).  Context is a key factor.  According to Merriam (1998), in focusing on a particular phenomenon in a case study, it is impossible to separate the phenomenon from its context.  However, in this study, it is important that the context is understood as part of the process.  As Yin (2003) says, "you would use the case study method because you deliberately wanted to cover contextual conditions-believing that they might be highly pertinent to your phenomenon of study" (p. 13).  Thus, using a case study approach allows for the possibility of gaining significant knowledge about the process of conducting community-based research in particular contexts.   According to Sanders (1981), "Case studies help us to understand processes of events, projects, and programs and to discover context characteristics that will shed light on an issue or object" (p. 44). 

The two case studies each took place over an extended period of time.  The first CBR project lasted nine months, and the second CBR project lasted eight months.  I worked with my collaborative partners to define research problems and questions, develop research designs, collect data, and analyze data.  However, this study does not focus on the data that I collected as part of that CBR work.  Instead, this study focuses on the process of the collaborative experience.  Since the study focuses primarily on the procedures of conducting community-based research, the study is considered a process study.  According to Patton (1990), when carrying out a process study, the "focus is on how something happens rather than on the outcomes or results obtained" (p.94).  And, as Merriam (1998) points out, "Case study is a particularly suitable design if you are interested in process" (p.33).  Therefore, case study was chosen since it allows for detailed monitoring of the collaborative process (Merriam, 1998). 

Types of Case Studies

Stake (2000) delineates three types of case studies: intrinsic, instrumental, and collective.  Intrinsic case studies focus on a case that is unusual and is of particular interest to the researcher (Creswell, 1998; Stake, 2000).  The intent is not to build theory (Stake, 2000).  An instrumental case study is pursued in order to provide insight about a particular issue that may be generalizable (Creswell, 2002).  The primary purpose of an instrumental case study is to help advance understanding (Stake, 2000).  The collective case study encompasses more than one case "in order to investigate a phenomenon, population, or general condition" (Stake, 2000, p. 437).  Since the purpose is to help advance understanding, a collective case study is a grouping of instrumental case studies (Stake, 2000).  Using a collective case study approach can allow for the possibility of stronger interpretation and "perhaps better theorizing" (Stake, 2000, p. 437). 

Though Stake (2000) uses the terminology "collective case study," this approach is known by other names such as, multiple case studies, cross-case studies, comparative case studies, and contrasting cases (Merriam, 1998; Yin, 2003).  With multiple case studies, data are analyzed for insights both within each case and across cases (Merriam, 1998).  Yin (2003) points out that multiple cases may be chosen to try to replicate insights that you find within individuals cases or to represent contrasting situations.  Regardless of whether the purpose is replication or contrast, multiple case studies are "considered more compelling, and the overall study is therefore regarded as more robust" (Yin, 2003, p. 46). 

When this study was first proposed, the original intent was to pursue a single case study of my experience of collaboration in carrying out a community-based research project.  After completing my work with the Coalition for Schools, I felt dissatisfied with the experience in that I did not view it to be a success.  Instead of focusing on that one experience, I decided to pursue another research option in the small town in which I live in order to have a contrasting experience to write about.  It turned out that the project I completed in my small town was more successful, therefore allowing me to present contrasting cases.  Since this study seeks to add insight to the field of methodology in CBR, it is important to understand the factors that impact the process of collaboration and the factors that support successful collaborations (Strand et al., 2003a). 

Methodology of Community-Based Research

Since the purpose of this study is to explore the process of carrying out CBR, it is important to understand the methodology of community-based research.  As mentioned in chapter two, community-based research is not as concerned with methods as it is with methodology (Hills & Mullett, 2000; Strand et al., 2003a).  Either quantitative or qualitative methods may be used; the choice depends on what would obtain the most useful data for the community (Greenwood & Levin, 2000).  The methodology of CBR is guided by the three principles outlined by Strand et al. (2003a): 1) collaboration, 2) validation of the knowledge of community members and the multiple ways of collecting and distributing information, and 3) "social action and social change for the purpose of achieving social justice" (p. 8).  Though community-based research is not limited to specific methods, it does follow the typical stages of research that most traditional academic research would follow: defining the research question, developing a research design, collecting data, analyzing data, and writing up the results.  The difference is that the researcher collaborates closely with the community throughout the research process (Strand et al., 2003a).  The community is involved in determining the problem and research questions, creating the research design, collecting data, analyzing data, and creating a presentation of findings (Strand et al., 2003a).  The researcher also continues to play a role in the final stage by assisting with the enactment of solutions to create change (Greenwood & Levin, 1998). 

Regarding knowledge, community-based research seeks to redefine how we conceptualize knowledge in relation to academic research (Strand et al., 2003a).  Researchers who conduct CBR projects recognize the important knowledge that community members possess on the subject of their environment and the issues they are dealing with (Cordes, 1998a, No Concrete section, para. 2; Hills & Mullett, 2000, p. 1), what Strand (2000) calls "local knowledge" (p. 88).  This knowledge is key throughout the research process.  This acceptance of community knowledge does require the researcher to rethink his or her role.  As Stringer (1996) says, "The role of the researcher is not that of an expert who does research, but that of a resource person" (p. 22).  The expertise that the researcher brings to the equation is still valued; however, the local knowledge that the community brings is recognized as integral to the research process (Strand et al., 2003a). 

I have provided a brief overview of the methodology of CBR.  However, the purpose of this chapter is to describe the case study methods that I used to carry out this process study.  The descriptions of data collection and data analysis that are included in this chapter pertain to the data that were collected and analyzed for the contrasting case studies.  A description of the data collection and analysis that was conducted for the CBR projects in each case study will be included in the case descriptions in chapters four and five. 

Participants and Setting

Though I came into contact with a variety of people in each case study, my primary research collaborators are the main participants of my study.  In the first case study that I carried out, my collaboration with the Coalition for Schools, there were initially two primary collaborators, one of the co-chairs of the Coalition, Marge Bowline, and the director of the Coalition, Lisa Brown.  As my collaboration progressed, I worked primarily with Lisa Brown. 

The Coalition for Schools is an organization that has been created to support greater academic achievement in an urban school district in a western city.  The Coalition has focused its efforts toward a feeder pattern of schools in a quadrant of the city that has a high percentage of students who are eligible for free or reduced lunches, a high percentage of minority students, and a high percentage of English language learners.  This feeder pattern includes five elementary schools, two middle schools, and three small high schools that were originally part of one large high school and that are housed in one building.  The Coalition is an alliance of non-profit organizations, foundations, parent organizations, universities and colleges, and the school district working together to support achievement in these low performing schools.  The Business and Schools United (BSU) organization is the lead partner for the Coalition, and the Coalition is housed at BSU.  Marge Bowline is the director of BSU and one of the co-chairs of the Coalition for Schools.  She helped to create the Coalition and to procure funding for the organization.  The Coalition was a year old when I began my work with them.  Lisa Brown was hired to direct the Coalition and replaced the first director.  She had been in her position for about six months when I began my work with the Coalition. 

The two primary collaborators in my work in a small, western, mountain town are John Brewer and Maria Swenson.  The town is a small rural community that has a rapidly growing immigrant population from Mexico, about half of which are Indians from a remote area of the country.  Both John Brewer and Maria Swenson work in positions that have direct contact with this population.  John Brewer is the director of the literacy program which offers free English courses for English as a Second Language (ESL) students.  He is also a member of the city council.  Marge Swenson, who is herself a former immigrant from South America, is the coordinator of the diversity office which provides services to immigrants in town.  The case descriptions in chapters four and five provide greater detail of the participants and setting. 

Data Collection

As I progressed through each case study, I pursued two streams of data collection; the data collected to pursue the CBR projects and data that were collected as part of this case study to study CBR.  This section describes only the data that were collected for the case studies.  A description of the CBR data that were collected for each collaboration is included in the case descriptions in chapters four and five. 

Since the purpose of case study research is to provide an in-depth exploration of the person, program, or process under study, it requires intensive data collection (Merriam, 1998; Yin, 2003) using "multiple forms of data" (Creswell, 2002, p. 486).  Data collection for case studies usually focuses on three sources of data: observations, interviews, and documents (Merriam, 1998).  Though all qualitative research is to some extent based on the idea of emergent design, this study was truly emergent.  Though the research questions that this study proposed to address did not shift throughout the study, the methods of data collection changed to accommodate emerging issues or ideas.  According to Patton (1990),

What is certain is that different methods produce quite different information.  The challenge is to find out which information is most needed and most useful in a given situation, and then employ those methods best suited to producing the needed information (p. 196).

Though I collected all three forms of data (observations, interviews, and documents) for each study, there are some variations that are detailed in the following sections.  Appendix A provides a list showing the dates of meetings and interviews for each case study. 

Observations

My primary source of data collection for both case studies was observation.  Since I was essentially observing myself as I collaborated with my community partner, all of the observations that I completed for my case study data collection were participant observations.  Creswell (2002) defines participant observation as "an observational role adopted by researchers when they take part in activities in the setting they observe" (p. 200).  In this role, the researcher "actually engages in activities at the site begin studied" (p. 200).  Glesne (1999) describes a continuum of participation that "ranges from mostly observation to mostly participation" (p. 44).  Based on this continuum, I was what Glesne (1999) describes as a "full participant" in every interaction relating to my collaborative work with my community partners since I was concurrently a member of the collaborative partnership as well as the researcher investigating the process.  

In all of the meetings that I conducted with my community partners in relation to our CBR work, I collected data around those interactions.  I utilized Merriam's (1998) checklist of elements to structure my observations: physical setting, participants, activities and interactions, conversation, subtle factors, and my own behavior (pp. 97-98).  When working on my first CBR project with the Coalition, I initially only maintained field notes.  I was concerned that if I taped our meetings that it would be intrusive and would impact the openness of our conversations (Merriam, 1998).  However, as my study progressed I realized that it was difficult to take effective notes while participating in the conversation.  I then asked my community partners if I could tape subsequent meetings.  After that, most of the meetings I had with Lisa Brown or Marge Bowline were taped and then transcribed.  As part of the transcription process, I added notes that clarified or contextualized the dialogue.  When I began my work with my community partners in my small town, I asked during the first meeting if I could tape all of our meetings; both John Brewer and Maria Swenson readily agreed.  I found that after the use of the tape recorder became routine, they did not seem to be inhibited by being recorded.  Using the tape recorder allowed me to collect much more extensive data from my observations of our meetings. 

            Interviews

As part of the data collection for both case studies, I collected both formal and informal interview data (Patton, 1990).  Informal conversational interview questions were interwoven into meetings that we had in relation to ongoing research (Merriam, 1998) and were recorded as part of observation transcriptions.  These informal questions typically addressed how the community partner felt the research process was progressing, whether the research was meeting their needs, or addressed immediate questions that arose through the process of continued interaction. 

I also collected formal interview data for both case studies; however, I conducted fewer formal interviews with my community partners from the Coalition for Schools.  As my work with the Coalition progressed, I sought to determine particular data collection procedures that would address my research questions.  Since I was working within a collaborative relationship, part of the consideration when choosing methods was the impact that various methods would have on the relationship with my community partner.  In this first case study, as I show in more detail in chapter four, it was challenging to develop a collaborative relationship with my community partners.  The lack of trust and communication within this relationship made it difficult to carry out formal interviews discussing our collaboration.  I felt that these kinds of interviews would create greater distance between us.  Instead I relied primarily on other forms of data collection, observations and documents.  However, I did interview both Lisa Brown and Marge Bowline once formally toward the end of our partnership.  This interview included questions about the work of the Coalition as well as questions relating to community-based research (Appendix B).  I also conducted a follow-up email interview with Lisa Brown after beginning the process of data analysis (Appendix B).   

In my collaboration with John Brewer and Maria Swenson in my small town, I was able to develop a much more honest and open relationship from the beginning and felt very comfortable conducting formal interviews about the process.  I interviewed John and Maria individually three times throughout our collaboration (Appendix B).  I used a semi-structured approach (Rubin & Rubin, 1995) when designing the interview protocols.  I prepared questions as a starting point, but allowed the conversation to flow in whatever direction was helpful to providing insight.  The first interview focused on getting a sense of their background and experiences with research, their expectations for our research, and strategies for effective communication.  The second interview focused on their satisfaction with how things were proceeding, whether they felt we were communicating effectively, and whether they were having the input they wanted to have in the process.  The final interview focused primarily on the research questions of the case study: what were the issues that arose, what helped or hindered our collaboration, and what benefits did they receive from the research.  I transcribed each interview and added additional notes for interpretation. 

As part of the data collection process, I also collected or created a variety of documents including: email communications, a reflective journal, a phone call log, and other items that were provided by my community partners such as newsletters and meeting minutes.  As part of my collaboration with the Coalition for Schools, we relied extensively on email for communication since I found it difficult to schedule face-to-face meetings with Marge Bowline and Lisa Brown.  These email conversations are an important source of data in compiling a picture of our collaborative experience.  I also collected email data during my second case study.  However, these email communications focused primarily on setting up logistics.  Most important conversations were conducted face-to-face. 

Throughout both case studies, I sought to engage in a reflective stance toward my role in the research process.  In order to aid my reflection, I maintained a journal in which I transcribed my thinking in relation to my experiences and the perceived experiences of my community partners.  Merriam (1998) expresses some concern about using personal documents such as journals as data.  Merriam (1998) says,

Personal documents are a reliable source of data concerning a person's attitudes, beliefs, and view of the world.  But because they are personal documents, the material is highly subjective in that the writer is the only  one to select what he or she considers important to record.  Obviously these documents are not representative or necessarily reliable accounts of what actually may have occurred (p. 116).

However, Merriam (1998) does point out that one of the goals of qualitative research is to "reflect the participant's perspective" (p. 116).  Since this is a process study, the perceptions of all participants are a key consideration (Patton, 1990).  As I am a participant in this study, my perceptions of my experience of the process are important. 

The other documents I collected consisted of a phone call log and documents obtained when meeting with my community partners.  The phone call log consisted of a brief description of phone calls that were made during the research process.  If the conversation was extensive, I tried to recreate the conversation as closely as possible.  The phone call log was used primarily during my collaboration with John Brewer and Maria Swenson.  I also obtained various documents from my community partners.  These mostly included newsletters, meeting minutes, and data collected from previous research.  Most of the documents related to the CBR work we were conducting; yet some of the documents also provided information for my case study research. 

Data Analysis

After completing both case studies, I had accumulated large volumes of data (more than 500 pages of data for each case study).  I organized the data from both cases into what Yin (2003) calls a case study data base .   I organized my case study data base in a chronological order so that I could move through the data from the beginning to the end of the process.  This allowed me to perceive the progression of the process and my changing views throughout.  However, I felt that I needed an additional frame from which to organize the data. 

Data analysis was an ongoing process throughout the implementation of each case study.  Periodically I composed analytic memos to begin to formulate ideas around particular findings.  As each study progressed, I looked for events with common elements within the data that had "issue-relevant meaning" (Creswell, 1998, p. 154) or significance for the study.  As I recognized these common elements, I focused on determining whether they continued to be supported throughout the data collection process.  Creswell (1998) calls this process categorical aggregation.  As categories within the data began to emerge, I began to look for patterns or themes that connected these categories.  Based on the literature and the categories and themes that emerged while conducting the cases, I created an analytic framework from which to organize and think about the data. 

Analytic Framework      

The analytic framework is composed of four categories: community, collaboration, knowledge creation, and change.  In creating this framework, I was influenced by Stoecker's (2003) delineation of radical and mainstream CBR.  I view each of the four constructs of my framework as existing on a continuum.  At one end, there is radical CBR, in the middle, mainstream CBR, and at the other end the professional expert model or consulting (see Figure 1).  Based on how I conceptualize this framework, the closer on the continuum the researcher moves toward radical CBR, the greater the potential for change that will benefit the community with which the researcher is collaborating. 

When considering the category of community, the goal is to work as closely as possible with the community.  Since the ultimate goal of CBR is "social change for social justice" (Stoecker, 2002a, p. 9), the closer the researcher is to the members of the community who are dealing with the problem (Stoecker, 2003), the greater the potential to empower.  The community continuum includes grassroots organizations on one end and organizations which do not represent the community or use practices that "disempower the community" (Strand et al., 2003a. p. 73) on the other (see Figure 1).  In between are organizations that are a level removed from grassroots organizations but still seek to represent the community democratically, what Strand et al. (2003a) call "midlevel organizations" (p. 74).  Conducting CBR projects with midlevel organizations is what Strand et al. (2003a) label " doing CBR in the middle " (p. 73). 

Within this analytic framework, I conceptualize collaboration as shared decision making.  The goal is that the community should have equal power with the researcher and that decision making should be a shared process throughout (Strand et al., 2003a).  When considering this concept within the continuum, shared decision making is at one end of the continuum and at the other end the decisions are made primarily by the researcher (see Figure 1).  A companion to collaboration is the concept of participation in knowledge creation.  The primary goal in relation to this aspect of the framework is that the community assists in the creation of all knowledge that is generated during the CBR process, thus leading to community empowerment.  This point of the framework is based on the principle that the knowledge of community members is valid (Strand et al., 2003a) and integral to creating strong results.  At one end of the continuum, the community is involved in all aspects of knowledge creation, at the other end, the researcher controls the creation of knowledge (see Figure 1). 

The final point of the analytic framework is change (see Figure 1).  If you consider CBR within the radical framework described by Stoecker (2003), the goal for change is "massive structural changes in the distribution of power and resources through far-reaching changes in governmental policy, economic practices, or cultural norms" (p. 36).  This goal can be difficult to achieve.  More often, CBR work leads to programmatic changes within an organization or other more limited changes (Strand et al., 2003a).  However, each change within a community can have a cumulative effect that can lead to broader change.  Community-based research that does not involve the community in close collaboration and knowledge creation is less likely to create change that benefits the community.

Analysis of Contrasting Cases

Since this study utilizes contrasting cases, data analysis occurs at two levels: within-case and across cases (Merriam, 1998).  Merriam (1998) describes this process:            

For the within-case analysis , each case is first treated as a comprehensive case in and of itself.  Data are gathered so the researcher can learn as much about the contextual variables as possible that might have a bearing on the case...Once the analysis of each case is completed, cross-case analysis begins.  A qualitative, inductive, multicase study seeks to build abstractions across cases (pp. 194-195).

For each case, I analyzed observations, interviews, and documents to develop a description of the case. This description depicts the setting and participants as well as a general chronology of events and provides the reader with an understanding of the particulars of the case (Creswell, 1998).  This allows the reader to develop an understanding of the case within the larger context (Creswell, 2002).  Then using the analytic framework I developed, I did some within-case analysis and organized the categories that emerged during each study around the four constructs of my analytic framework.  This within-case analysis focused on answering the primary research question: What is the process of collaborating with a community partner on a community-based research project?  Thus each case analysis consists of  "both description and thematic development" (Creswell, 2002, p. 486).           

After completing the within-case analysis, I focused on the cross-case analysis to address three of the sub-questions of the study: What kinds of issues arise when collaborating on a community-based research project? What facilitates or hinders the process of collaboration? and, What does the researcher gain through this collaborative process, and what are the benefits for the community?  In the cross-case analysis, I used data from both case studies to address these questions.  I explored the categories that had emerged throughout each case study and then compared to see if these categories were supported in both cases.  I used the categories and themes that emerged during the within-case analysis and the cross-case analysis to determine "naturalistic generalizations" (Creswell, 1998, p. 154) concerning the field of community-based research.  Creswell (1998) defines naturalistic generalizations as "generalizations that people can learn from the case either for themselves or for applying it to a population of cases" (p. 154).  These naturalistic generalizations address the final question of the study: What can we learn from these experiences to inform the field of CBR?

In order to lend credibility to the findings of my study, I incorporated a variety of validity procedures.  The first validity procedure I employed was prolonged engagement in the field (Creswell & Miller, 2000) or what Merriam (1998) calls "long-term observation" (p. 204).  I worked on my case study with the Coalition for a period of nine months, and I worked with John and Maria for a period of eight months.  During each of these case studies, I had consistent contact with my community partners.  Collaborating with my community partners for this length of time allowed me to develop tentative categories in my findings and then follow up on these preliminary findings through observations or interviews (Creswell & Miller, 2000).  Therefore, the length of each case study and the consistent contact I had with my community partners lends credibility to my perceptions of this experience.

In addition to prolonged engagement in the field, another important validity procedure I employed, which is integral to case study design, was triangulation (Creswell, 1998).  Merriam (1998) defines triangulation as "using multiple investigators, multiple sources of data, or multiple methods to confirm the emerging findings" (p. 204).  I employed methodological triangulation (Creswell & Miller, 2000) since I collected three forms of data: observations, interviews, and documents.  I also employed multiple sources of data since interviews were conducted with several participants (Creswell & Miller, 2000).  I used the process of triangulation to seek convergence in the data and to confirm or disconfirm emerging categories and themes (Creswell & Miller, 2000).  As part of this process, I employed another validity strategy, disconfirming evidence (Creswell &  Miller, 2000).  Categories or themes that emerged in the within-case analysis were compared across cases.  If a category did not hold true across cases, it was generally deemed to be unreliable.  However, I did utilize what Creswell (1998) calls direct interpretation.  In direct interpretation, "the case study researcher looks at a single instance and draws meaning from it without looking for multiple instances" (p. 154).  I did recognize that there were single incidents specific to only one case that were significant to the study as well. 

Since this case study focused on the study of process, my perceptions were an integral component of the research.  However, since I did write interpretations of what I considered to be the perceptions of others, I used member checking to ensure accurate portrayal (Creswell & Miller, 2000).  I conducted member checking toward the end of the study so that it would not potentially disrupt the collaborative process.  I shared an outline of findings with Lisa Brown with the Coalition and also John Brewer and Maria Swenson in my small town and allowed them the opportunity to provide feedback.  Lisa Brown responded to the findings through email and said, "Thanks for sharing [these findings].  I feel it is accurate, and that it was a learning experience for all of us."  Maria Swenson also responded to the findings that I shared with she and John.  She said, "I looked at [the findings] and it sounds good.  I agree with all said."  John also said that he thought that the findings looked good. 

Finally, I used the validity procedure of thick description when writing about the study in order to give the reader a sense of being there and to capture the essence of the experience (Creswell & Miller, 2000).  This is an important feature in case study design that is presented to the reader through the case description.  The case description for each contrasting case is included in chapters four and five.  

            Subjectivity

Another method of creditability I used continuously throughout the research process was researcher reflexivity (Creswell & Miller, 2000).  I incorporated researcher reflexivity by constantly questioning my assumptions about what I thought was happening.  I sought to maintain a heightened sense of awareness of the biases that I brought to the study and maintained this awareness when adding contextual data to field notes, observations transcriptions, and interview transcriptions, and also when writing journal entries. 

Since my perceptions of the research process played a major part in the findings of the study, it was important that I attend to the idea of subjectivity.  Peshkin (1988), defines subjectivity as "the quality of the investigator that affects the results of observational investigation" (p. 17).  Peshkin (1988) points out that an individual's subjectivity is not something that can be removed, and it is therefore something researchers need to be aware of throughout the research process.  Peshkin (1988) identified the various facets of his subjectivities through a series of I's, for example, the "justice-seeking I" (p. 18) and "the community-maintenance I" (p. 18).  Though Peshkin does not view subjectivity as necessarily negative, he does feel it is something that researchers need to realize and acknowledge.  It was important to examine my own subjectivities throughout the research process so that I was aware of how these subjectivities could influence my interpretations and portrayal of events.  As Strand (2000) points out, "the researcher's values, experiences, and personal points of view are as much a part of the research process as those of the people studied, and they should be discussed and acknowledged" (p. 91). 

Since the two CBR projects I worked on were in different settings and related to different types of work, I dealt with different subjectivities within each case study.  In my work with the Coalition for Schools many of the subjectivities that I brought to that collaboration arose from my past experience as a classroom teacher.  I hold the perception that people who do not have experience in a K-12 classroom do not generally understand the issues that classroom teachers have to address.  I can be defensive and overly sensitive to criticism that I feel puts the blame on teachers.  There were many times during my partnership with the Coalition that I realized this subjectivity was influencing my reactions to statements made by Lisa Brown or Marge Bowline.  I also think that this perception at times clouded my view of the knowledge that Lisa brought to the equation.  Though I felt that she was very knowledgeable in certain areas, I questioned her understanding of what was actually happening in the schools that are part of the Coalition.  I tried to be aware of my bias in this area, though I do not believe I was always successful in controlling how this bias influenced my work with Lisa. 

Another bias that I brought to my work with the Coalition was the idea that a successful partnership should not have conflict.  I tend to avoid conflict in my personal life.  I have difficulty at times recognizing the benefits that conflict can bring.  Because of this, I did not communicate as effectively with Lisa as I could have.  If had been more willing to risk conflict, we may have been able to develop a more productive working relationship.  When I began my work with John Brewer and Maria Swenson, I determined that I would not avoid conflict in this collaboration.  When a situation did arise where John and I disagreed, I engaged him, and we talked through the matter.  The outcome was that we both were able to see the value of the other's viewpoint. 

Though I was able to address the issue of conflict avoidance in my work in John Brewer and Maria Swenson, there were other subjectivities and biases of which I had to be aware.  I am liable to have the perception that small towns tend to discriminate against minorities.  Since all of the projects that I completed with John and Maria involved the immigrant population in town, I felt at times that I was waiting for someone to say something that would demonstrate their prejudice.  At times, I would jump to the conclusion that a particular statement was pejorative.  When looking back again at the statement in the context of the full conversation, I realized at times that I may have misinterpreted particular statements.  I had to make a concerted effort not to single out statements just because they supported my bias.  Nevertheless, this subjectivity did influence whom I chose to partner with during this case study.  I had originally planned to include Maria's supervisor, Jennifer Payton, in our collaboration.  However, after meeting with Jennifer in October 2003, I decided not to collaborate with her since she made several comments during the meeting that I perceived to be pejorative.  If I had decided to work with Jennifer, I may have found that these comments did not represent discrimination but rather a lack of understanding of the impact of language choices. 

Two other subjectivities that I brought into my work on both projects related to my experience with previous CBR projects.  As I was involved in another community-based research project before working on my dissertation, I already had an initial perception of how the process works.  One concern that arose during my previous experience was the issue of communicating with my community partner.  I had difficulty developing a research question because the conversations that I shared with my community partner seemed circuitous.  We talked around questions during several meetings before I was finally able to gain a sense of what she was hoping to achieve from the research.  Though these past experiences with community-based research helped me to anticipate some of the issues that arose, I tried to make sure that the anticipation of issues did not create issues. 

When entering into CBR projects, it is important to me that I am doing work that I view as meaningful.  Work that is meaningful to me would be research that allows me to consistently interact with members of the community on a personal level.  However, I tried to maintain the awareness that the research that I wished to pursue was not necessarily the research that the people I was collaborating with wished to pursue.  I continued to remind myself that these discrepancies should not interfere with the development of a research design that was beneficial to my community partner and had the potential to bring about effective change.  Since change is the goal of community-based research, I needed to be sure that the change I was assisting to create was the change that the community partner was seeking to make rather than the change that I would have liked to pursue. 

Finally, when a researcher carries out a qualitative study, it is also important to attend to the subjectivities that the researcher brings based on gender, age, ethnicity, and socioeconomic status.  I feel at times that I lack self-awareness of how these orientations impact the way that I view the world.  Though I tried to be conscious of these factors while doing my research, I am not sure that I was successful in completely exploring how these subjectivities may have influenced my research.  I do feel, however, that my status was an issue in the work that I conducted with the Coalition for Schools.  My status in relation to my age (under 40) and my position as a graduate student influenced how my community partners at the Coalition viewed my role, and my socioeconomic background impacted the level of confidence that I felt when working with members of the Coalition.  I come from a working class background while my community partners at the Coalition come from backgrounds of higher status both in relation to levels of education and socioeconomic status.  At times, I did feel out of place moving through the world of the Coalition in that I often felt that I was from a lower class than many of the people with which I came into contact.  I felt most comfortable when interacting with teachers or parents. 

In order to minimize the impact of my subjectivities, I closely monitored my feelings as I carried out my research.  I looked for situations where I felt uncomfortable or that I wanted to avoid as well as situations where I felt comfortable and that I wanted to continue.  When these feelings arose, I realized that I was usually being influenced by subjectivity (Glesne, 1999; Peshkin, 1988).  I analyzed my feelings and considered how they related to my subjectivities, then took note of these occurrences in my journal (Peshkin, 1988).  Throughout the research process, I was mindful of previously identified subjectivities.  I also tried to be aware of newly emerging subjectivities that I may not have considered (Peshkin, 1988) that would potentially influence my research. 

Limitations of This Study

This study seeks to compare two cases of conducting community-based research.  However, there are differences between the two experiences that may have impacted the findings of the study.  In my work with the Coalition, I was a paid employee.  Though I was hired with the understanding that I would be a collaborative researcher, I believe my position as an employee impacted how Marge Bowline and Lisa Brown viewed my role, and it also impacted my reactions to various situations.  The fact that I was an employee in the first case study when collaborating with the Coalition but in the second case study I was independent, may have created some of the differences that were apparent in the two cases. 

Another limitation of this study is that it primarily focuses on the researcher's experience of this process.  Though I did interview my community partners, the number of interviews in the first case study was more limited.  If I had conducted additional interviews throughout the first case study, I might have additional information to support or contradict some of my observations.  However, the purpose of this study is to provide insight into this process for practitioners in the field of community-based research, thus it is beneficial to explore the researcher's perspective of these two experiences. 

The final limitation of this study relates to the timeline of the completion of the study.  Since I only recently finalized data collection in relation to my work with John Brewer and Maria Swenson, I am not really able to make an assessment at this point as to whether any of the work we completed will affect change.  My work with the Coalition was completed almost a year ago so it easier to assess the impact of that work.  However, even with the first case study, there is a possibility that some of the work that I completed could eventually lead to change.  If I were to conduct a long-term case study in relation to either of these collaborations, it would be more feasible to assess the impact of our work. 

This chapter provided an overview to the case study methods that were used to conduct this study.  I detailed a rationale for choosing this method, then described data collection, analysis, and procedures in relation to validity.  Since this is a process study of the methodology of CBR, I also described the foundations of this methodology.  The next three chapters will present the findings of this study.  Chapters four and five provide a synopsis of the within-case analysis of each of the contrasting cases.  I begin each chapter with a chronological overview of the major events of the case and then present within-case analysis organized around the four concepts of my analytic framework.  In chapter six, I present the findings from the cross-case analysis that address the sub-questions of the study and identify the "naturalistic generalizations" (Creswell, 1998, p. 154) that emerged from the study with recommendations for further research. 

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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.

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• 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."

Houston’s flood problems offer lessons for cities trying to adapt to a changing climate

Professor Emeritus of Climate and Space Sciences and Engineering, University of Michigan

Disclosure statement

Richard Rood receives funding from the National Oceanographic and Atmospheric Administration and the National Science Foundation. He is a co-principal investigator at the Great Lakes Integrated Sciences and Assessment Center at the University of Michigan.

University of Michigan provides funding as a founding partner of The Conversation US.

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Scenes from the Houston area looked like the aftermath of a hurricane in early May after a series of powerful storms flooded highways and neighborhoods and sent rivers over their banks north of the city.

Hundreds of people had to be rescued from homes, rooftops and cars, according to The Associated Press. Huntsville registered nearly 20 inches of rain from April 29 to May 4, 2024.

Floods are complex events, and they are about more than just heavy rain. Each community has its own unique geography and climate that can exacerbate flooding. On top of those risks, extreme downpours are becoming more common as global temperatures rise.

I work with a center at the University of Michigan that helps communities turn climate knowledge into projects that can reduce the harm of future climate disasters. Flooding events like the Houston area experienced provide case studies that can help cities everywhere manage the increasing risk.

Flood risks are rising

The first thing recent floods tell us is that the climate is changing.

In the past, it might have made sense to consider a flood a rare and random event – communities could just build back. But the statistical distribution of weather events and natural disasters is shifting.

What might have been a 1-in-500-years event may become a 1-in-100-years event , on the way to becoming a 1-in-50-years event. When Hurricane Harvey hit Texas in 2017, it delivered Houston’s third 500-year flood in the span of three years.

Basic physics points to the rising risks: Global greenhouse gas emissions are increasing global average temperatures. Warming leads to increasing precipitation and more intense downpours, and increased flood potential, particularly when storms hit on already saturated ground.

Communities aren’t prepared

Recent floods are also revealing vulnerabilities in how communities are designed and managed.

Pavement is a major contributor to urban flooding, because water cannot be absorbed and it runs off quickly. The Houston area’s frequent flooding illustrates the risks. Its impervious surfaces expanded by 386 square miles between 1997 and 2017, according to data collected by Rice University . More streets, parking lots and buildings meant more standing water with fewer places for rainwater to sink in.

If the infrastructure is well designed and maintained, flood damage can be greatly reduced. However, increasingly, researchers have found that the engineering specifications for drainage pipes and other infrastructure are no longer adequate to handle the increasing severity of storms and amounts of precipitation. This can lead to roads being washed out and communities being cut off . Failures in maintaining infrastructure, such as levees and storm drains, are a common contributor to flooding.

In the Houston area, reservoirs are also an essential part of flood management, and many were at capacity from persistent rain. This forced managers to release more water when the storms hit.

For a coastal metropolis such as the Houston-Galveston area, rapidly rising sea levels can also reduce the downstream capacity to manage water. These different factors compound to increase flooding risk and highlight the need to not only move water but to find safe places to store it.

The increasing risks affect not only engineering standards, but zoning laws that govern where homes can be built and building codes that describe minimum standards for safety, as well as permitting and environmental regulations.

By addressing these issues now, communities can anticipate and avoid damage rather than only reacting when it’s too late.

Four lessons from case studies

The many effects associated with flooding show why a holistic approach to planning for climate change is necessary, and what communities can learn from one another. For example, case studies show that:

Floods can damage resources that are essential in flood recovery, such as roads, bridges and hospitals . Considering future risks when determining where and how to build these resources enhances the ability to recover from future disasters . Jackson, Mississippi’s water treatment plant was knocked offline by flooding in 2022, leaving people without safe running water. Houston’s Texas Medical Center famously prepared to manage future flooding by installing floodgates, elevating backup generators and taking other steps after heavy damage during Tropical Storm Allison in 2001.

Flood damage does not occur in isolation. Downpours can trigger mudslides , make sewers more vulnerable and turn manufacturing facilities into toxic contamination risks . These can become broad-scale dangers, extending far beyond individual communities.

It is difficult for an individual or a community to take on even the technical aspects of flood preparation alone – there is too much interconnectedness. Protective measures like levees or channels might protect one neighborhood but worsen the flood risk downstream . Planners should identify the appropriate regional scale, such as the entire drainage basin of a creek or river, and form important relationships early in the planning process.

Natural disasters and the ways communities respond to them can also amplify disparities in wealth and resources. Social justice and ethical considerations need to be brought into planning at the beginning.

Learning to manage complexity

In communities that my colleagues and I have worked with , we have found an increasing awareness of the challenges of climate change and rising flood risks.

In most cases, local officials’ initial instinct has been to protect property and persist without changing where people live. However, that might only buy time for some areas before people will have little option but to move .

When they examine their vulnerabilities, many of these communities have started to recognize the interconnectedness of zoning, storm drains and parks that can absorb runoff, for example. They also begin to see the importance of engaging regional stakeholders to avoid fragmented efforts to adapt that could worsen conditions for neighboring areas.

This is an updated version of an article originally published Aug. 25, 2022 .

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Up to 40pc of mental health conditions are linked to child abuse and neglect, study finds

In 1996, Ange McAuley was just 11 years old when ABC's Four Corners profiled her family living on Brisbane's outskirts.

At the time her mother was pregnant with her sixth child and her father had long ago moved back to Perth.

WARNING: This story contains details that may be distressing to some readers.

It was a story about child protection and the program was profiling the role of community volunteers helping her mother, who had been in and out of mental health wards.

Ange was the eldest and it fell to her to get her younger siblings ready for school.

By the time the new baby arrived, she would stay home and change nappies.

"It was pretty crazy back then — I wasn't going to school a lot," she said.

By that age she was already holding a secret — she'd been sexually abused at age six by her stepfather, who would later be convicted of the crime.

"Back in the nineties, a lot of people kept stuff hidden and it wasn't spoken about outside of the family," she said.

"I've carried all these big burdens that weren't even mine. Sexual abuse happened to me. I didn't ask for it."

She says the trauma triggered a lifetime of mental health problems from substance abuse and self-harm as a teen, right through to post-natal depression.

Hidden source of our mental health crisis

A new study from the University of Sydney's Matilda Centre has established just how much Australia's mental health crisis can be traced back to this kind of childhood abuse and neglect.

The research has found that childhood maltreatment is responsible for up to 41 per cent of common mental health conditions including anxiety, depression, substance abuse, self-harm and suicide attempts.

The research, which draws on a 2023 meta-analysis of 34 research studies covering 54,000 people, found maltreatment accounted for 41 per cent of suicide attempts in Australia, 35 per cent of self-harm cases and 21 per cent of depression episodes.

It defined childhood maltreatment as physical, sexual, emotional abuse, emotional or physical neglect and domestic violence before the age of 18.

Lead researcher Lucy Grummitt said it is the first piece of work to quantify the direct impact of child abuse on long-term mental health. 

It found if childhood maltreatment was eradicated it would avert more than 1.8 million cases of depression, anxiety and substance use disorders.

"It shows just how many people in Australia are suffering from mental health conditions that are potentially preventable," she said.

Dr Grummitt said they found in the year 2023 child maltreatment in Australia accounted for 66,143 years of life lost and 118,493 years lived with disability because of the associated mental health conditions.

"We know that when a child is exposed to this level of stress or trauma, it does trigger a lot of changes in the brain and body," Dr Grummitt said.

"Things like altering the body's stress response will make a child hyper-vigilant to threat. It can lead to difficulties with emotion regulation, being able to cope with difficult emotions."

While some areas of maltreatment are trending down, figures from the landmark Australian child maltreatment study last year show rising rates of sexual abuse by adolescents and emotional abuse.

That study found more than one in three females and one in seven males aged 16 to 24 had experienced childhood sexual abuse.

Dr Grummit says childhood trauma can affect how the brain processes emotions once children become teens.

"It could be teenagers struggling to really cope with difficult emotions and certainly trauma can play a huge role in causing those difficult emotions," she said.

Mental health scars emerge early

For Ange, the trauma of her early years first showed itself in adolescence when she started acting out — she remembers punching walls and cars, binge drinking and using drugs.

"I would get angry and just scream," she said.

"I used to talk back to the teachers. I didn't finish school. Mum kicked me out a lot as a teenager. I was back and forth between mum and dad's."

By the time she disclosed her abuse, she was self-harming and at one point tried to take her own life.

"I was just done," she said.

"I was sick of having to get up every day. I didn't want to do it anymore."

Later on, she would have inappropriate relationships with much older men and suffered from depression, including post-natal depression.

"It's definitely affected relationships, it's affected my friendships, it's affected my intimate relationships," she said.

"Flashbacks can come in at the most inappropriate times — you're back in that moment and you feel guilt and shame.

"I feel like it's held me back a lot."

Calls for mental health 'immunisation'

Dr Grummitt said childhood abuse and neglect should be treated as a national public health priority.

In Australia, suicide is the leading cause of death for young people. 

"It's critical that we are investing in prevention rather than putting all our investments into treatment of mental health problems," she said.

Her team has suggested child development and mental health check-ins become a regular feature across a person's lifetime and have proposed a mental health "immunisation schedule".

Chief executive of mental health charity Prevention United, Stephen Carbone, said they estimate that less than 1 per cent of mental health funding goes toward prevention.

"There's been a big steady increase in per capita funding for mental health over the last 30 years but that hasn't translated into reductions," Dr Carbone, a GP, said. 

"You're not going to be able to prevent mental health conditions unless you start to tackle some of these big causes, in particular child maltreatment."

He said most of Australia's child protection system was about reacting to problems rather than trying to prevent them.

"If you're not tackling the upstream risk factors or putting in place protective factors you just keep getting more and more young people experiencing problems and services being overwhelmed," he said.

Now a mother of two teens herself, Ange says she wants to break the cycle and has been going to therapy regularly to help identify and avoid destructive patterns that she's seen herself fall into.

"I love my girls so much and I want better for them."

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Sustainability in semiconductor operations: Toward net-zero production

Climate change is creating many life-threatening disruptions, including extreme weather, rising sea levels, and droughts. Faced with irrefutable evidence of global warming, almost 200 countries have committed to the 2016 Paris Agreement, a treaty that calls for accelerated decarbonization. This agreement is designed to limit the mean rise in temperature to 1.5 degrees Celsius from preindustrial levels to mitigate or prevent some of the most dangerous effects of climate change.

About the authors

This article is a collaborative effort by Ondrej Burkacky , Sebastian Göke, Mark Nikolka, Mark Patel , and Peter Spiller , representing views from McKinsey’s Semiconductors Practice.

While some semiconductor companies have created ambitious targets for reducing their emissions  and remaining on a 1.5°C pathway, many others have been less ambitious. The pressure to act may soon increase, however, since businesses across industries are now scrutinizing emissions along their entire supply chain—and in many cases, semiconductor companies will account for a substantial amount of them. Already, some of the semiconductor industry’s most important end customers, including Apple, Google, and Microsoft, have committed to reaching net-zero emissions for their full value chain and set aggressive timelines for achieving their goals.

Some semiconductor companies have responded by setting their own emissions goals. For instance, Infineon plans to reduce greenhouse-gas (GHG) emissions by 70 percent by 2025, compared with its 2019 baseline, and aspires to reach carbon neutrality for emissions directly under its control by the end of 2030. Intel recently committed to net-zero GHG emissions in its global operations by 2040 and has targeted achieving 100 percent use of renewable electricity as an interim milestone in 2030. Several semiconductor players have also committed to science-based targets, including STMicroelectronics, NXP, and UMC. Over the next few months or years, more semiconductor companies are expected to commit to ambitious and actionable emissions targets.

Achieving substantial emission reductions will require collaboration with peers and suppliers, as well as new technologies, innovative thinking, and the complete engagement of fabs. To help companies move forward, we reviewed the current state of greenhouse-gas emissions within the semiconductor sector and collected best practices for abatement. Our analysis allowed us to identify both short- and long-term solutions along the entire semiconductor value chain. This article focuses on scope 1 and 2 emissions, which are the ones that semiconductor fabs can directly control .

Achieving substantial emission reductions will require collaboration with peers and suppliers, as well as new technologies, innovative thinking, and the complete engagement of fabs.

Major sources of emissions from fabs

With about 80 percent of semiconductor manufacturing emissions falling into either scope 1 or scope 2 categories, fabs control a large portion of their GHG profile (Exhibit 1). 1 Scope 1 emissions are those from direct or controlled sources; scope 2 emissions are from generation of purchased electricity, steam, heating, and cooling equipment; scope 3 upstream emissions include all other indirect emissions in a company’s value chain; and scope 3 downstream emissions are related to the use of products containing semiconductors. Scope 2 emissions, which represent the highest proportion of GHG from semiconductor companies, are linked to the energy required to run their extensive production facilities. The sources of these emissions include the following:

• tool fleets containing hundreds of manufacturing tools, such as lithography equipment, ion implanters, and high-temperature furnaces
• large clean rooms requiring climate and humidity control with overpressure and particle filtration
• extensive subfab facilities for gas abatement, exhaust pumps, water chillers, and water purification

As the node size of chips continues to shrink, energy requirements at production facilities are expected to rise significantly.

Scope 1 emissions, which also significantly add to fabs’ GHG emission profile, arise from process gases used during wafer etching, chamber cleaning, and other tasks. These gases, which include PFCs, HFCs, NF3, and N20, have high global-warming potential (GWP); they rise as node size shrinks. 2 Perfluorocarbons, hydrofluorocarbons, nitrogen trifluoride, and nitrous oxide. Scope 1 emissions may also arise from high-GWP heat transfer fluids that may leak into the atmosphere when fabs use them in chillers to control wafer temperature during manufacturing processes.

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Additional emissions may come from upstream scope 3 sources, such as suppliers, chemicals and raw materials, or from transportation to customer facilities. These upstream emissions generally account for only about 20 percent of fabs’ GHG profile, however.

Semiconductor companies also generate downstream scope 3 emissions, which are related to use of products containing semiconductors. These vary significantly by use case. For instance, handheld devices with low power consumption during intermittent usage will have much lower emissions than data centers that operate 24/7. As will be discussed in a later article, product design influences scope 3 emissions, giving fabs little control over them during operations.

Critical levers for emissions improvement

To help fabs achieve substantial emissions reductions and accelerate decarbonization, we identified three areas that need immediate attention, as well as relevant improvement levers.

Decreasing energy consumption

Levers for reducing energy consumption are often directly aligned with other operational targets, such as cost reduction, making them easier to achieve. The many options available can be grouped into two major categories. The first group focuses on reducing tool-related energy consumption—for instance, by upgrading and replacing tools with more energy-efficient ones, implementing smart control systems to enable coupling and regulation of facilities and tools. The second group encompasses activities that involve reducing facility-related energy consumption though various measures, such as exclusive sourcing and use of energy from renewable sources, greater energy efficiency of buildings, and replacing existing lighting in fabs with LED fixtures.

To identify the greatest opportunities for decreasing energy consumption, fabs could look at benchmark-based targets and sources of energy loss. They could also review existing levers for energy reduction by tool and facility type. For instance, fabs might discover that they can improve energy consumption in clean rooms by reducing air pressure, increasing humidity, limiting air exchange in unused areas, or eliminating leaks in air-supply lines.

When optimizing process recipes, equipment engineers typically focus on overall equipment effectiveness (OEE) and give little attention to tool-fleet energy consumption. New incentives, such as rewards for creating energy-efficient recipes, might help change this mindset. Fabs can also help decrease GHG emissions during operation by encouraging experts to share their knowledge of and experience with energy efficiency, using the same tools and mechanisms they employ when sharing strategies for optimizing OEE. To boost their odds of succeeding, fabs can include additional stakeholders in their power-consumption efforts, focusing on external tool suppliers that might be able to modify their equipment to increase efficiency, or those that offer retrofits or energy-saving options for new tools.

Optimizing energy supply

To ensure that sufficient power is always available, fabs often source their electricity from a combination of on-grid and off-grid sources. Most off-grid power comes from fab-owned fossil fuel power plants. Over the short term, fabs can significantly reduce the energy consumption of these plants by pursuing efficiency improvements or switching to alternative fuels such as biogas or green hydrogen. They can generate further gains by developing new off-grid power sources that rely on green technologies, such as photovoltaics, fuel cells, and battery energy storage systems. But these supplies often only complement, rather than replace, a fab’s long-standing on-grid sources.

For on-grid power, fabs may be able to reduce consumption by purchasing renewable electricity from utilities through green premium energy offerings, although the offerings vary widely by region. In Europe and the United States, for instance, renewable on-grid sourcing is readily available and accounts for up to 31 percent of grid energy; in many parts of Asia, however, renewable on-grid sourcing can be challenging because of limited availability (Exhibit 2).

Access to renewable energy may be a major factor as companies decide where they should build new fabs—something that is becoming more common as they try to increase capacity to alleviate the chip shortage.

Reducing process-gas emissions

Process gases can significantly increase global warming (Exhibit 3). Their emissions will vary based on a fab’s age and the sophistication of its abatement technology, but all facilities face some common challenges. Four levers, which are at different stages of maturity, may help reduce process-gas related emissions. Because of economic constraints and other issues, some fabs may not be able to apply some of these levers widely until the technology improves.

Process improvements. Fabs can reduce emissions by adjusting process parameters, such as temperature and chamber pressure. Process engineers often overlook this lever and instead focus solely on yield during optimization efforts, partly because they lack the knowledge and operational experience required to identify strategies for reducing GHG emissions. Similarly, the suppliers involved in daily tool operations and maintenance may prioritize cost and uptime targets over energy savings. If fabs address knowledge gaps and collaborate more closely with tool suppliers, they may improve emissions—for instance, by simultaneously optimizing yield and energy consumption during cleaning protocols.

Use of alternative chemistries. Fabs can sometimes lower emissions by switching to chemicals that have a lower environmental impact. However, they often encounter obstacles when attempting to use these chemistries; for example, it can be difficult to get suppliers on board with their plans. In addition, developing new solutions is both costly and time consuming, as is the process for qualifying new chemicals on existing processes and tools.

To address these roadblocks, fabs could emphasize that GHG reduction is a top priority when communicating with suppliers and note that they want to explore new solutions, including green-chemistry approaches. Fabs could then work closely with their partners to develop a path forward. For instance, fabs and suppliers could jointly create road maps for process-gas substitutions or codevelop alternatives. But even with this push, fabs must temper their short-term expectations about GHG improvement because few green solutions are now viable alternatives to current gases. (While fabs have already implemented some major improvements, such as increased use of NF3, many other shifts, including the replacement of NF3 with F2 or ozone, are still nascent.) Over the long term, fabs could see more gains if they continue encouraging suppliers to explore new solutions.

Strategies to lead in the semiconductor world

Gas abatement. Gas abatement will be the main lever to address emissions from process gases over the short to midterm, and this will remain the case until alternative gases with fewer emissions are available, or until gas recycling is widely adopted. Fabs that want to increase gas abatement can select from multiple options, including point-of-use (POU) systems for individual production tools, point-of-area (POA) systems, and central abatement systems. As they roll out and install new systems, fabs must balance the trade-offs related to cost, impact on operations, destruction and removal efficiency (DRE), and timing. Further adoption will also require suppliers to provide innovative technical solutions to do the following:

• Address space constraints, especially in older, 200-millimeter fabs with limited subfab space (for instance, by providing integrated solutions with a smaller footprint).
• Keep by-products, such as nitrogen oxides and carbon monoxide, low while increasing DRE.
• Prevent downtime of production tools during installation and maintenance of abatement systems.
• Enable regular system qualification, without affecting production, to achieve and report higher DREs.

Gas recycling. Fabs can capture unutilized process gases and by-products through various means, such as membrane separation, cryogenic recovery, adsorption, and desorption. They can then refine them into pure process gases that can be used again, potentially reducing process-gas emissions. For this lever to become economically viable, researchers will need to address major challenges related to the separation of process-gas outflows and purification.

Putting GHG emission reduction on the agenda

To help the semiconductor industry meet the critical challenge of reducing GHG emissions, fabs can take four steps to accelerate their decarbonization efforts:

• Create transparency about their scope 1, 2, and 3 (upstream) emissions.
• Set near-term and long-term emission targets.
• Consolidate existing ideas and estimate their expected costs and impact. This will involve defining a portfolio of innovative technologies to be developed jointly with external partners over the next few years.
• Generate an abatement cost curve to serve as a road map for short-, mid-, and long-term decarbonization efforts.

The abatement cost curve can help fabs identify all potential areas for GHG reduction, as well as associated implementation costs and savings. Fabs should first implement the levers that would result in a net cost reduction, and then move to those with net abatement costs that are close to zero and those that will be costly until regulations change or other advances make implementation less expensive. Exhibit 4 shows an example abatement cost curve for a typical fab.

As they embark on their net-zero programs, semiconductor companies will benefit from internal collaboration among staff from R&D, operations, supply chain, and other functions. Among other advantages, such efforts will help ensure that they implement key elements of the decarbonization program simultaneously. External engagement is also essential, since no single company can reach its GHG goals without partners, such as industry peers, suppliers, and customers.

Successfully reducing emissions to remain on the 1.5°C pathway will require both commitment and endurance. While short-term goals are important, semiconductor companies ultimately want to reduce their emissions by about 50 percent within ten years. Within fab operations, many processes or tools may need to be replaced by greener alternatives, some of which are still in the early stages of development. With global warming reaching a critical point, fabs should accelerate their current decarbonization plans and consider developing other green initiatives.

Ondrej Burkacky is a senior partner in McKinsey’s Munich office, where Mark Nikolka is a senior associate; Sebastian Göke is an associate partner in the Berlin office; Mark Patel is a senior partner in the Bay Area office; and Peter Spiller is a partner in the Frankfurt office.

This article was edited by Eileen Hannigan, a senior editor based in the Waltham, Massachusetts, office.

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The case study approach

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

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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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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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Summer 2023 was the hottest in 2,000 years: study

Agence france-presse.

Last year's northern hemisphere summer was the hottest in 2,000 years, according to a new study published on Tuesday.

Scientists say 2023 was the hottest year globally since records began in 1850, but the study in the journal Nature indicates human-caused climate change pushed northern summer highs well beyond anything seen in two millennia.

"We shouldn't be surprised," the study's lead author Jan Esper told AFP.

"For me it's just the continuation of what we started by releasing greenhouse gases" that cause global warming, said Esper, a professor of climatology at Germany's Johannes Gutenberg University.

Scientists used tree-ring data from sites across the northern hemisphere to estimate global temperatures between the first century AD and 1850, before the advent of modern observational instruments.

The conservative estimate found that 2023 was at least 0.5 degrees Celsius hotter than the warmest northern hemisphere summer of that period in AD246.

Otherwise, it was 1.19 degrees warmer.

Study co-author Max Torbenson told reporters that 25 of the last 28 years exceeded the summer highs of AD246 -- the hottest year before modern temperature records began.

By contrast the coolest summer of that 2,000-year period was nearly four degrees below 2023 summer temperatures in the northern hemisphere due to a major volcanic eruption.

Scientists say volcanic activity could bring about cooler conditions in future as they did in the past, but that ultimately humanity's release of greenhouse gases would keep trapping heat in the atmosphere.

In 1992, an eruption the previous year helped soften the impact of the El Nino weather system, which warms the Pacific Ocean and can bring hotter global conditions.

After the effect subsided, temperatures soared in 1998, which the study noted was one of the warmest summers after 2023 and 2016 respectively -- both also El Nino years.

Esper said the only way to curb rising temperatures was to immediately start cutting emissions and "the longer we wait, the more difficult and expensive it will be".

- Health risks -

A separate study published on Tuesday warned that higher temperatures and ageing populations would see tens of millions of older people being exposed to dangerous heat extremes by 2050.

Already 14 percent of elderly people are exposed to days exceeding 37.5 degrees, which can aggravate health conditions and even lead to death, said the study in the journal Nature Communications.

That number is expected to climb to 23 percent by the middle of the century, the study said.

"Different countries in the world are facing similar issues... but the level of preparedness, the adaptive capacity of people and of society is different," the study's lead author Giacomo Falchetta told AFP.

Europe has systems in place to support people during heatwaves but faces considerable change as one of the fastest warming regions on Earth, said Falchetta of the Euro-Mediterranean Center on Climate Change.

The share of elderly people in Africa and Asia is set to grow dramatically though populations in poorer regions lack access to sufficient clean water or healthcare to cope with heat extremes, Falchetta said.

"It raises questions of inequality around the world in terms of how governments and regions are equipped to cope with this," he said.

While 2050 appears far off, Falchetta said people as young as 40 today would be among those vulnerable to future heatwaves.

Aging populations cannot be avoided but "reducing emissions can really reduce to some extent the heat exposure that will be felt", he said.

Stories Chosen For You

Should trump be allowed to run for office, how trump’s campaign meets the 4 'primary characteristics' of fascism: author.

In his new book, "The Wannabe Fascists: A Guide to Understanding the Greatest Threat to Democracy," historian/author Federico Finchelstein examines authoritarian movements around the world — and cites Donald Trump's MAGA movement as an example.

Casey Michel of The Human Rights Foundation applauds the book as informative, if imperfect, in a review published by the conservative website The Bulwark on May 14.

Finchelstein, according to Michel, identifies four "primary characteristics" of fascism and lays out some reasons why "Trump and the other budding autocrats rising alongside him" are "so dangerous."

READ MORE: George Conway: Trump’s New York trial is proving to be 'the perfect case'

"As Finchelstein ably argues, it's only in properly defining Trump — and properly understanding his historical context, American and otherwise — that we can truly understand the threat he poses and navigate the world he’s ushered in," Michel explains . "Indeed, much of the book is devoted to definitions, and to identifying where the lines between populism and fascism truly lie."

The four pillars of fascism that Finchelstein identifies in his book are xenophobia, propaganda, political violence, and dictatorship.

According to Michel , Trump has "clearly built out planks" of the first three but "has been unable to construct a full dictatorship."

"In that sense…. Trump is simply an aspiring fascist, rather than a fully realized one," Michel argues . "He is, as Finchelstein writes, a 'populist aspirant to fascism' — or…. a 'wannabe fascist.'"

READ MORE: Trump's price for selling the planet: $1 billion

Finchelstein's book, according to Michel , underscores the dangers of Trump possibly winning the United States' 2024 presidential election.

"Right now, with a U.S. election less than six months away, the American wannabe despot is eager to take power once more in Washington — this time without any need for a self-coup," Michel warns . "It's for Americans themselves to decide whether they'd like to offer Trump the opportunity, as a would-be fascist, to finally get what he wants."

Israel's deadly bombing of World Central Kitchen convoy was no anomaly: report

A deadly attack on a convoy of World Central Kitchen aid workers which killed 7 people last month was not a one-off occurrence, Human Rights Watch said Tuesday, but rather representative of a documented pattern in which Israel military forces have targeted relief personnel and infrastructure despite being informed of the exact locations of those operations.

"Even though aid groups had provided their coordinates to the Israeli authorities to ensure their protection," an analysis by HRW found that eight such attacks on such operations, including the April 1 bombing of the WCK in Deir al-Balah, have been carried out by Israeli Defense Forces (IDF) over the last seven months.

According to the group's report , "Israeli authorities did not issue advance warnings to any of the aid organizations before the strikes, which killed or injured at least 31 aid workers and those with them."

"Israel's allies need to recognize that these attacks that have killed aid workers have happened over and over again, and they need to stop." —Belkis Willi, HRW

Details of the various attacks, said HRW, show that the WCK bombing was "far from being an isolated 'mistake,'" as the Israeli government has claimed.

Citing figures from the United Nations, HRW notes that over 250 aid workers have been killed in Gaza by Israel since the Hamas-led attack on October 7 of last year.

"Israel's killing of seven World Central Kitchen aid workers was shocking and should never have happened under international law," said Belkis Wille, associate crisis, conflict, and arms director at Human Rights Watch. "Israel's allies need to recognize that these attacks that have killed aid workers have happened over and over again, and they need to stop."

The other seven attacks documented in the report are:

• Attack on a Médecins Sans Frontières (MSF or Doctors without Borders) convoy, November 18, 2023
• Attack on a guest house of the United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA), December 9, 2023
• Attack on an MSF shelter, January 8, 2024
• Attack on an International Rescue Committee (IRC) and Medical Aid for Palestinians (MAP) guest house, January 18, 2024
• Attack on an UNRWA convoy, February 5, 2024
• Attack on an MSF guest house, February 20, 2024
• Attack on a home sheltering an American Near East Refugee Aid Organization (Anera) employee, March 8, 2024

Human Rights Watch sent a letter to Israeli authorities requesting more information about these documented incidents, but said it received no response.

"Israel should make public the findings of investigations into attacks that have killed and injured aid workers, and into all other attacks that caused civilian casualties," the group said on Tuesday. "The Israeli military's long track record of failing to credibly investigate alleged war crimes underscores the importance of the International Criminal Court's (ICC) inquiry into serious crimes committed by all parties to the conflict."

In addition to military targeting of relief operations, the Israeli military has been accused of various crimes, including indiscriminate bombing of civilian populations, forced displacement, and the targeting of medical facilities.

Also on Tuesday, Médecins Sans Frontières (MSF/Doctors Without Borders) released a report documenting Israel's pattern of attacking its facilities, including hospitals, clinics, and ambulance services in Gaza during the current campaign.

"In view of this extensive timeline of reprehensible actions, MSF once again calls on all parties to respect and protect healthcare facilities, healthcare workers and patients in Gaza and the West Bank," the group said Tuesday. "An immediate and sustained ceasefire must be implemented in Gaza now to put an end to the suffering of people and the destruction of Gaza. We demand an immediate and unfettered flow of aid into the entirety of the Gaza Strip. We demand accountability for our colleagues and their family members who have been killed and wounded, and for patients."

In early May, following a month pause of Gaza operations following the deadly attack, WCK announced it was resuming its relief efforts in the area. It has also started construction on a new kitchen facility to elevate and support its mission to feed the people of Gaza as Israel's assault not only continues but intensifies.

"We have spent the past few weeks honoring the lives of Saif, Zomi, Damian, Jacob, James, John, and Jim. We are restarting our operation with the same energy, dignity, and focus on feeding people as these seven heroes brought to their work every single day," the groups said on May 5. "As our work in Gaza resumes, our demand for an impartial and international investigation into the April 1 attack remains."

'Damning evidence': Jury hears Trump's reaction to federal case against Michael Cohen

Former attorney Michael Cohen revealed to a Manhattan jury what one analyst called "damning" legal evidence against former President Donald Trump.

At a Manhattan court hearing on Tuesday, prosecutors talked to Cohen about what made him "flip" on Trump after federal authorities searched his home in connection to hush money payments to adult film star Stormy Daniels, who said she had an affair with the then-president.

"I felt reassured because I had the president of the United States protecting me," Cohen told the jury .

"[Trump] said to me don't worry. I'm the president of the United States. There's nothing here. Everything's going to be okay. Stay tough. You're going to be okay," he added .

ALSO READ: 'Most transparent president' Trump won't meet financial transparency deadline. Again .

Although Trump never spoke to Cohen again, the former attorney said he believed the then-president was communicating with him when he cautioned against "flipping" in Twitter postings.

"Stay in the fold. Stay loyal. I have you. [...] Don't flip," said Cohen of his interpretation of one particular Trump tweet .

MSNBC analyst Katie Phang said the prosecution had landed a blow against the defense.

"DAMNING evidence from Michael Cohen here," she wrote .

8 ways Trump doesn’t become president

The big lie is meant to finish off america, home depot's political committee just got jacked.

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• Open access
• Published: 09 May 2024

Evaluation of integrated community case management of the common childhood illness program in Gondar city, northwest Ethiopia: a case study evaluation design

• Mekides Geta 1 ,
• Geta Asrade Alemayehu 2 ,
• Wubshet Debebe Negash 2 ,
• Tadele Biresaw Belachew 2 ,
• Chalie Tadie Tsehay 2 &
• Getachew Teshale 2  

BMC Pediatrics volume  24 , Article number:  310 ( 2024 ) Cite this article

89 Accesses

Metrics details

Integrated Community Case Management (ICCM) of common childhood illness is one of the global initiatives to reduce mortality among under-five children by two-thirds. It is also implemented in Ethiopia to improve community access and coverage of health services. However, as per our best knowledge the implementation status of integrated community case management in the study area is not well evaluated. Therefore, this study aimed to evaluate the implementation status of the integrated community case management program in Gondar City, Northwest Ethiopia.

A single case study design with mixed methods was employed to evaluate the process of integrated community case management for common childhood illness in Gondar town from March 17 to April 17, 2022. The availability, compliance, and acceptability dimensions of the program implementation were evaluated using 49 indicators. In this evaluation, 484 mothers or caregivers participated in exit interviews; 230 records were reviewed, 21 key informants were interviewed; and 42 observations were included. To identify the predictor variables associated with acceptability, we used a multivariable logistic regression analysis. Statistically significant variables were identified based on the adjusted odds ratio (AOR) with a 95% confidence interval (CI) and p-value. The qualitative data was recorded, transcribed, and translated into English, and thematic analysis was carried out.

The overall implementation of integrated community case management was 81.5%, of which availability (84.2%), compliance (83.1%), and acceptability (75.3%) contributed. Some drugs and medical equipment, like Cotrimoxazole, vitamin K, a timer, and a resuscitation bag, were stocked out. Health care providers complained that lack of refreshment training and continuous supportive supervision was the common challenges that led to a skill gap for effective program delivery. Educational status (primary AOR = 0.27, 95% CI:0.11–0.52), secondary AOR = 0.16, 95% CI:0.07–0.39), and college and above AOR = 0.08, 95% CI:0.07–0.39), prescribed drug availability (AOR = 2.17, 95% CI:1.14–4.10), travel time to the to the ICCM site (AOR = 3.8, 95% CI:1.99–7.35), and waiting time (AOR = 2.80, 95% CI:1.16–6.79) were factors associated with the acceptability of the program by caregivers.

Conclusion and recommendation

The overall implementation status of the integrated community case management program was judged as good. However, there were gaps observed in the assessment, classification, and treatment of diseases. Educational status, availability of the prescribed drugs, waiting time and travel time to integrated community case management sites were factors associated with the program acceptability. Continuous supportive supervision for health facilities, refreshment training for HEW’s to maximize compliance, construction clean water sources for HPs, and conducting longitudinal studies for the future are the forwarded recommendation.

Peer Review reports

Integrated Community Case Management (ICCM) is a critical public health strategy for expanding the coverage of quality child care services [ 1 , 2 ]. It mainly concentrated on curative care and also on the diagnosis, treatment, and referral of children who are ill with infectious diseases [ 3 , 4 ].

Based on the World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF) recommendations, Ethiopia adopted and implemented a national policy supporting community-based treatment of common childhood illnesses like pneumonia, Diarrhea, uncomplicated malnutrition, malaria and other febrile illness and Amhara region was one the piloted regions in late 2010 [ 5 ]. The Ethiopian primary healthcare units, established at district levels include primary hospitals, health centers (HCs), and health posts (HPs). The HPs are run by Health Extension Workers (HEWs), and they have function of monitoring health programs and disease occurrence, providing health education, essential primary care services, and timely referrals to HCs [ 6 , 7 ]. The Health Extension Program (HEP) uses task shifting and community ownership to provide essential health services at the first level using the health development army and a network of woman volunteers. These groups are organized to promote health and prevent diseases through community participation and empowerment by identifying the salient local bottlenecks which hinder vital maternal, neonatal, and child health service utilization [ 8 , 9 ].

One of the key steps to enhance the clinical case of health extension staff is to encourage better growth and development among under-five children by health extension. Healthy family and neighborhood practices are also encouraged [ 10 , 11 ]. The program also combines immunization, community-based feeding, vitamin A and de-worming with multiple preventive measures [ 12 , 13 ]. Now a days rapidly scaling up of ICCM approach to efficiently manage the most common causes of morbidity and mortality of children under the age of five in an integrated manner at the community level is required [ 14 , 15 ].

Over 5.3 million children are died at a global level in 2018 and most causes (75%) are preventable or treatable diseases such as pneumonia, malaria and diarrhea [ 16 ]. About 99% of the global burden of mortality and morbidity of under-five children which exists in developing countries are due to common childhood diseases such as pneumonia, diarrhea, malaria and malnutrition [ 17 ].

In 2013, the mortality rate of under-five children in Sub-Saharan Africa decreased to 86 deaths per 1000 live birth and estimated to be 25 per 1000live births by 2030. However, it is a huge figure and the trends are not sufficient to reach the target [ 18 ]. About half of global under-five deaths occurred in sub-Saharan Africa. And from the top 26 nations burdened with 80% of the world’s under-five deaths, 19 are in sub-Saharan Africa [ 19 ].

To alleviate the burden, the Ethiopian government tries to deliver basic child care services at the community level by trained health extension workers. The program improves the health of the children not only in Ethiopia but also in some African nations. Despite its proven benefits, the program implementation had several challenges, in particular, non-adherence to the national guidelines among health care workers [ 20 ]. Addressing those challenges could further improve the program performance. Present treatment levels in sub-Saharan Africa are unacceptably poor; only 39% of children receive proper diarrhea treatment, 13% of children with suspected pneumonia receive antibiotics, 13% of children with fever receive a finger/heel stick to screen for malaria [ 21 ].

To improve the program performance, program gaps should be identified through scientific evaluations and stakeholder involvement. This evaluation not only identify gaps but also forward recommendations for the observed gaps. Furthermore, the implementation status of ICCM of common childhood illnesses has not been evaluated in the study area yet. Therefore, this work aimed to evaluate the implementation status of integrated community case management program implementation in Gondar town, northwest Ethiopia. The findings may be used by policy makers, healthcare providers, funders and researchers.

Method and material

Evaluation design and settings.

A single-case study design with concurrent mixed-methods evaluation was conducted in Gondar city, northwest Ethiopia, from March 17 to April 17, 2022. The evaluability assessment was done from December 15–30, 2021. Both qualitative and quantitative data were collected concurrently, analyzed separately, and integrated at the result interpretation phase.

The evaluation area, Gondar City, is located in northwest Ethiopia, 740 km from Addis Ababa, the capital city of the country. It has six sub-cities and thirty-six kebeles (25 urban and 11 rural). In 2019, the estimated total population of the town was 338,646, and 58,519 (17.3%) were under-five children. In the town there are eight public health centers and 14 health posts serving the population. All health posts provide ICCM service for more than 70,852 populations.

Evaluation approach and dimensions

Program stakeholders.

The evaluation followed a formative participatory approach by engaging the potential stakeholders in the program. Prior to the development of the proposal, an extensive discussion was held with the Gondar City Health Department to identify other key stakeholders in the program. Service providers at each health facility (HCs and HPs), caretakers of sick children, the Gondar City Health Office (GCHO), the Amhara Regional Health Bureau (ARHB), the Minister of Health (MoH), and NGOs (IFHP and Save the Children) were considered key stakeholders. During the Evaluability Assessment (EA), the stakeholders were involved in the development of evaluation questions, objectives, indicators, and judgment criteria of the evaluation.

Evaluation dimensions

The availability and acceptability dimensions from the access framework [ 22 ] and compliance dimension from the fidelity framework [ 23 ] were used to evaluate the implementation of ICCM.

Population and samplings

All under-five children and their caregivers attended at the HPs; program implementers (health extension workers, healthcare providers, healthcare managers, PHCU focal persons, MCH coordinators, and other stakeholders); and ICCM records and registries in the health posts of Gondar city administration were included in the evaluation. For quantitative data, the required sample size was proportionally allocated for each health post based on the number of cases served in the recent one month. But the qualitative sample size was determined by data saturation, and the samples were selected purposefully.

The data sources and sample size for the compliance dimension were all administrative records/reports and ICCM registration books (230 documents) in all health posts registered from December 1, 2021, to February 30, 2022 (three months retrospectively) included in the evaluation. The registries were assessed starting from the most recent registration number until the required sample size was obtained for each health post.

The sample size to measure the mothers’/caregivers’ acceptability towards ICCM was calculated by taking prevalence of caregivers’ satisfaction on ICCM program p  = 74% from previously similar study [ 24 ] and considering standard error 4% at 95% CI and 10% non- responses, which gave 508. Except those who were seriously ill, all caregivers attending the ICCM sites during data collection were selected and interviewed consecutively.

The availability of required supplies, materials and human resources for the program were assessed in all 14HPs. The data collectors observed the health posts and collected required data by using a resources inventory checklist.

A total of 70 non-participatory patient-provider interactions were also observed. The observations were conducted per each health post and for health posts which have more than one health extension workers one of them were selected randomly. The observation findings were used to triangulate the findings obtained through other data collection techniques. Since people may act accordingly to the standards when they know they are observed for their activities, we discarded the first two observations from analysis. It is one of the strategies to minimize the Hawthorne effect of the study. Finally a total of 42 (3 in each HPs) observations were included in the analysis.

Twenty one key informants (14 HEWs, 3 PHCU focal person, 3 health center heads and one MCH coordinator) were interviewed. These key informants were selected since they are assumed to be best teachers in the program. Besides originally developed key informant interview questions, the data collectors probed them to get more detail and clear information.

Variables and measurement

The availability of resources, including trained healthcare workers, was examined using 17 indicators, with weighted score of 35%. Compliance was used to assess HEWs’ adherence to the ICCM treatment guidelines by observing patient-provider interactions and conducting document reviews. We used 18 indicators and a weighted value of 40%.

Mothers’ /caregivers’/ acceptance of ICCM service was examined using 14 indicators and had a weighted score of 25%. The indicators were developed with a five-point Likert scale (1: strongly disagree, 2: disagree, 3: neutral, 4: agree and 5: strongly agree). The cut off point for this categorization was calculated using the demarcation threshold formula: ( \(\frac{\text{t}\text{o}\text{t}\text{a}\text{l}\, \text{h}\text{i}\text{g}\text{h}\text{e}\text{s}\text{t}\, \text{s}\text{c}\text{o}\text{r}\text{e}-\,\text{t}\text{o}\text{t}\text{a}\text{l}\, \text{l}\text{o}\text{w}\text{e}\text{s}\text{t} \,\text{s}\text{c}\text{o}\text{r}\text{e}}{2}) +total lowest score\) ( 25 – 27 ). Those mothers/caregivers/ who scored above cut point (42) were considered as “satisfied”, otherwise “dissatisfied”. The indicators were adapted from the national ICCM and IMNCI implementation guideline and other related evaluations with the participation of stakeholders. Indicator weight was given by the stakeholders during EA. Indicators score was calculated using the formula \(\left(achieved \,in \%=\frac{indicator \,score \,x \,100}{indicator\, weight} \right)\) [ 26 , 28 ].

The independent variables for the acceptability dimension were socio-demographic and economic variables (age, educational status, marital status, occupation of caregiver, family size, income level, and mode of transport), availability of prescribed drugs, waiting time, travel time to ICCM site, home to home visit, consultation time, appointment, and source of information.

The overall implementation of ICCM was measured by using 49 indicators over the three dimensions: availability (17 indicators), compliance (18 indicators) and acceptability (14 indicators).

Program logic model

Based on the constructed program logic model and trained health care providers, mothers/caregivers received health information and counseling on child feeding; children were assessed, classified, and treated for disease, received follow-up; they were checked for vitamin A; and deworming and immunization status were the expected outputs of the program activities. Improved knowledge of HEWs on ICCM, increased health-seeking behavior, improved quality of health services, increased utilization of services, improved data quality and information use, and improved child health conditions are considered outcomes of the program. Reduction of under-five morbidity and mortality and improving quality of life in the society are the distant outcomes or impacts of the program (Fig.  1 ).

Integrated community case management of childhood illness program logic model in Gondar City in 2022

Data collection tools and procedure

Resource inventory and data extraction checklists were adapted from standard ICCM tool and check lists [ 29 ]. A structured interviewer administered questionnaire was adapted by referring different literatures [ 30 , 31 ] to measure the acceptability of ICCM. The key informant interview (KII) guide was also developed to explore the views of KIs. The interview questionnaire and guide were initially developed in English and translated into the local language (Amharic) and finally back to English to ensure consistency. All the interviews were done in the local language, Amharic.

Five trained clinical nurses and one BSC nurse were recruited from Gondar zuria and Wegera district as data collectors and supervisors, respectively. Two days training on the overall purpose of the evaluation and basic data collection procedures were provided prior to data collection. Then, both quantitative and qualitative data were gathered at the same time. The quantitative data were gathered from program documentation, charts of ICCM program visitors and, exit interview. Interviews with 21 KIIs and non-participatory observations of patient-provider interactions were used to acquire qualitative data. Key informant interviews were conducted to investigate the gaps and best practices in the implementation of the ICCM program.

A pretest was conducted to 26 mothers/caregivers/ at Maksegnit health post and appropriate modifications were made based on the pretest results. The data collectors were supervised and principal evaluator examined the completeness and consistency of the data on a daily basis.

Data management and analysis

For analysis, quantitative data were entered into epi-data version 4.6 and exported to Stata 14 software for analysis. Narration and tabular statistics were used to present descriptive statistics. Based on established judgment criteria, the total program implementation was examined and interpreted as a mix of the availability, compliance, and acceptability dimensions. To investigate the factors associated with ICCM acceptance, a binary logistic regression analysis was performed. During bivariable analysis, variables with p-values less than 0.25 were included in multivariable analysis. Finally, variables having a p-value less than 0.05 and an adjusted odds ratio (AOR) with a 95% confidence interval (CI) were judged statistically significant. Qualitative data were collected recorded, transcribed into Amharic, then translated into English and finally coded and thematically analyzed.

Judgment matrix analysis

The weighted values of availability, compliance, and acceptability dimensions were 35, 40, and 25 based on the stakeholder and investigator agreement on each indicator, respectively. The judgment parameters for each dimension and the overall implementation of the program were categorized as poor (< 60%), fair (60–74.9%), good (75-84.9%), and very good (85–100%).

Availability of resources

A total of 26 HEWs were assigned within the fourteen health posts, and 72.7% of them were trained on ICCM to manage common childhood illnesses in under-five children. However, the training was given before four years, and they didn’t get even refreshment training about ICCM. The KII responses also supported that the shortage of HEWs at the HPs was the problem in implementing the program properly.

I am the only HEW in this health post and I have not been trained on ICCM program. So, this may compromise the quality of service and client satisfaction.(25 years old HEW with two years’ experience)

All observed health posts had ICCM registration books, monthly report and referral formats, functional thermometer, weighting scale and MUAC tape meter. However, timer and resuscitation bag was not available in all HPs. Most of the key informant finding showed that, in all HPs there was no shortage of guideline, registration book and recording tool; however, there was no OTP card in some health posts.

“Guideline, ICCM registration book for 2–59 months of age, and other different recording and reporting formats and booklet charts are available since September/2016. However, OTP card is not available in most HPs.”. (A 30 years male health center director)

Only one-fifth (21%) of HPs had a clean water source for drinking and washing of equipment. Most of Key-informant interview findings showed that the availability of infrastructures like water was not available in most HPs. Poor linkage between HPs, HCs, town health department, and local Kebele administer were the reason for unavailability.

Since there is no water for hand washing, or drinking, we obligated to bring water from our home for daily consumptions. This increases the burden for us in our daily activity. (35 years old HEW)

Most medicines, such as anti-malaria drugs with RDT, Quartem, Albendazole, Amoxicillin, vitamin A capsules, ORS, and gloves, were available in all the health posts. Drugs like zinc, paracetamol, TTC eye ointment, and folic acid were available in some HPs. However, cotrimoxazole and vitamin K capsules were stocked-out in all health posts for the last six months. The key informant also revealed that: “Vitamin K was not available starting from the beginning of this program and Cotrimoxazole was not available for the past one year and they told us they would avail it soon but still not availed. Some essential ICCM drugs like anti malaria drugs, De-worming, Amoxicillin, vitamin A capsules, ORS and medical supplies were also not available in HCs regularly.”(28 years’ Female PHCU focal)

The overall availability of resources for ICCM implementation was 84.2% which was good based on our presetting judgment parameter (Table  1 ).

Health extension worker’s compliance

From the 42 patient-provider interactions, we found that 85.7%, 71.4%, 76.2%, and 95.2% of the children were checked for body temperature, weight, general danger signs, and immunization status respectively. Out of total (42) observation, 33(78.6%) of sick children were classified for their nutritional status. During observation time 29 (69.1%) of caregivers were counseled by HEWs on food, fluid and when to return back and 35 (83.3%) of children were appointed for next follow-up visit. Key informant interviews also affirmed that;

“Most of our health extension workers were trained on ICCM program guidelines but still there are problems on assessment classification and treatment of disease based on guidelines and standards this is mainly due to lack refreshment training on the program and lack of continuous supportive supervision from the respective body.” (27years’ Male health center head)

From 10 clients classified as having severe pneumonia cases, all of them were referred to a health center (with pre-referral treatment), and from those 57 pneumonia cases, 50 (87.7%) were treated at the HP with amoxicillin or cotrimoxazole. All children with severe diarrhea, very severe disease, and severe complicated malnutrition cases were referred to health centers with a pre-referral treatment for severe dehydration, very severe febrile disease, and severe complicated malnutrition, respectively. From those with some dehydration and no dehydration cases, (82.4%) and (86.8%) were treated at the HPs for some dehydration (ORS; plan B) and for no dehydration (ORS; plan A), respectively. Moreover, zinc sulfate was prescribed for 63 (90%) of under-five children with some dehydration or no dehydration. From 26 malaria cases and 32 severe uncomplicated malnutrition and moderate acute malnutrition cases, 20 (76.9%) and 25 (78.1%) were treated at the HPs, respectively. Of the total reviewed documents, 56 (93.3%), 66 (94.3%), 38 (84.4%), and 25 (78.1%) of them were given a follow-up date for pneumonia, diarrhea, malaria, and malnutrition, respectively.

Supportive supervision and performance review meetings were conducted only in 10 (71.4%) HPs, but all (100%) HPs sent timely reports to the next supervisory body.

Most of the key informants’ interview findings showed that supportive supervision was not conducted regularly and for all HPs.

I had mentored and supervised by supportive supervision teams who came to our health post at different times from health center, town health office and zonal health department. I received this integrated supervision from town health office irregularly, but every month from catchment health center and last integrated supportive supervision from HC was on January. The problem is the supervision was conducted for all programs.(32 years’ old and nine years experienced female HEW)

Moreover, the result showed that there was poor compliance of HEWs for the program mainly due to weak supportive supervision system of managerial and technical health workers. It was also supported by key informants as:

We conducted supportive supervision and performance review meeting at different time, but still there was not regular and not addressed all HPs. In addition to this the supervision and review meeting was conducted as integration of ICCM program with other services. The other problem is that most of the time we didn’t used checklist during supportive supervision. (Mid 30 years old male HC director)

Based on our observation and ICCM document review, 83.1% of the HEWs were complied with the ICCM guidelines and judged as fair (Table  2 ).

Acceptability of ICCM program

Sociodemographic and obstetric characteristics of participants.

A total of 484 study participants responded to the interviewer-administered questionnaire with a response rate of 95.3%. The mean age of study participants was 30.7 (SD ± 5.5) years. Of the total caregivers, the majority (38.6%) were categorized under the age group of 26–30 years. Among the total respondents, 89.3% were married, and regarding religion, the majorities (84.5%) were Orthodox Christian followers. Regarding educational status, over half of caregivers (52.1%) were illiterate (unable to read or write). Nearly two-thirds of the caregivers (62.6%) were housewives (Table  3 ).

All the caregivers came to the health post on foot, and most of them 418 (86.4%) arrived within one hour. The majority of 452 (93.4%) caregivers responded that the waiting time to get the service was less than 30 min. Caregivers who got the prescribed drugs at the health post were 409 (84.5%). Most of the respondents, 429 (88.6%) and 438 (90.5%), received counseling services on providing extra fluid and feeding for their sick child and were given a follow-up date.

Most 298 (61.6%) of the caregivers were satisfied with the convenience of the working hours of HPs, and more than three-fourths (80.8%) were satisfied with the counseling services they received. Most of the respondents, 366 (75.6%), were satisfied with the appropriateness of waiting time and 431 (89%) with the appropriateness of consultation time. The majority (448 (92.6%) of caregivers were satisfied with the way of communicating with HEWs, and 269 (55.6%) were satisfied with the knowledge and competence of HEWs. Nearly half of the caregivers (240, or 49.6%) were satisfied with the availability of drugs at health posts.

The overall acceptability of the ICCM program was 75.3%, which was judged as good. A low proportion of acceptability was measured on the cleanliness of the health posts, the appropriateness of the waiting area, and the competence and knowledge of the HEWs. On the other hand, high proportion of acceptability was measured on appropriateness of waiting time, way of communication with HEWs, and the availability of drugs (Table  4 ).

Factors associated with acceptability of ICCM program

In the final multivariable logistic regression analysis, educational status of caregivers, availability of prescribed drugs, time to arrive, and waiting time were factors significantly associated with the satisfaction of caregivers with the ICCM program.

Accordingly, the odds of caregivers with primary education, secondary education, and college and above were 73% (AOR = 0.27, 95% CI: 0.11–0.52), 84% (AOR = 0.16, 95% CI: 0.07–0.39), and 92% (AOR = 0.08, 95% CI: 0.07–0.40) less likely to accept the program as compared to mothers or caregivers who were not able to read and write, respectively. The odds of caregivers or mothers who received prescribed drugs were 2.17 times more likely to accept the program as compared to their counters (AOR = 2.17, 95% CI: 1.14–4.10). The odds of caregivers or mothers who waited for services for less than 30 min were 2.8 times more likely to accept the program as compared to those who waited for more than 30 min (AOR = 2.80, 95% CI: 1.16–6.79). Moreover, the odds of caregivers/mothers who traveled an hour or less for service were 3.8 times more likely to accept the ICCM program as compared to their counters (AOR = 3.82, 95% CI:1.99–7.35) (Table  5 ).

Overall ICCM program implementation and judgment

The implementation of the ICCM program in Gondar city administration was measured in terms of availability (84.2%), compliance (83.1%), and acceptability (75.3%) dimensions. In the availability dimension, amoxicillin, antimalarial drugs, albendazole, Vit. A, and ORS were available in all health posts, but only six HPs had Ready-to-Use Therapeutic Feedings, three HPs had ORT Corners, and none of the HPs had functional timers. In all health posts, the health extension workers asked the chief to complain, correctly assessed for pneumonia, diarrhea, malaria, and malnutrition, and sent reports based on the national schedule. However, only 70% of caretakers counseled about food, fluids, and when to return, 66% and 76% of the sick children were checked for anemia and other danger signs, respectively. The acceptability level of the program by caretakers and caretakers’/mothers’ educational status, waiting time to get the service and travel time ICCM sites were the factors affecting its acceptability. The overall ICCM program in Gondar city administration was 81.5% and judged as good (Fig.  2 ).

Overall ICCM program implementation and the evaluation dimensions in Gondar city administration, 2022

The implementation status of ICCM was judged by using three dimensions including availability, compliance and acceptability of the program. The judgment cut of points was determined during evaluability assessment (EA) along with the stakeholders. As a result, we found that the overall implementation status of ICCM program was good as per the presetting judgment parameter. Availability of resources for the program implementation, compliance of HEWs to the treatment guideline and acceptability of the program services by users were also judged as good as per the judgment parameter.

This evaluation showed that most medications, equipment and recording and reporting materials available. This finding was comparable with the standard ICCM treatment guide line [ 10 ]. On the other hand trained health care providers, some medications like Zink, Paracetamol and TTC eye ointment, folic acid and syringes were not found in some HPs. However the finding was higher than the study conducted in SNNPR on selected health posts [ 33 ] and a study conducted in Soro district, southern Ethiopia [ 24 ]. The possible reason might be due to low interruption of drugs at town health office or regional health department stores, regular supplies of essential drugs and good supply management and distribution of drug from health centers to health post.

The result of this evaluation showed that only one fourth of health posts had functional ORT Corner which was lower compared to the study conducted in SNNPR [ 34 ]. This might be due poor coverage of functional pipe water in the kebeles and the installation was not set at the beginning of health post construction as reported from one of ICCM program coordinator.

Compliance of HEWs to the treatment guidelines in this evaluation was higher than the study done in southern Ethiopia (65.6%) [ 24 ]. This might be due to availability of essential drugs educational level of HEWs and good utilization of ICCM guideline and chart booklet by HEWs. The observations showed most of the sick children were assessed for danger sign, weight, and temperature respectively. This finding is lower than the study conducted in Rwanda [ 35 ]. This difference might be due to lack of refreshment training and regular supportive supervision for HEWs. This also higher compared to the study done in three regions of Ethiopia indicates that 88%, 92% and 93% of children classified as per standard for Pneumonia, diarrhea and malaria respectively [ 36 ]. The reason for this difference may be due to the presence of medical equipment and supplies including RDT kit for malaria, and good educational level of HEWs.

Moreover most HPs received supportive supervision and performance review meeting was conducted and all of them send reports timely to next level. The finding of this evaluation was lower than the study conducted on implementation evaluation of ICCM program southern Ethiopia [ 24 ] and study done in three regions of Ethiopia (Amhara, Tigray and SNNPR) [ 37 ]. This difference might be due sample size variation.

The overall acceptability of the ICCM program was less than the presetting judgment parameter but slightly higher compared to the study in southern Ethiopia [ 24 ]. This might be due to presence of essential drugs for treating children, reasonable waiting and counseling time provided by HEWs, and smooth communication between HEWs and caregivers. In contrast, this was lower than similar studies conducted in Wakiso district, Uganda [ 38 ]. The reason for this might be due to contextual difference between the two countries, inappropriate waiting area to receive the service and poor cleanness of the HPs in our study area. Low acceptability of caregivers to ICCM service was observed in the appropriateness of waiting area, availability of drugs, cleanness of health post, and competence of HEWs while high level of caregiver’s acceptability was consultation time, counseling service they received, communication with HEWs, treatment given for their sick children and interest to return back for ICCM service.

Caregivers who achieved primary, secondary, and college and above were more likely accept the program services than those who were illiterate. This may more educated mothers know about their child health condition and expect quality service from healthcare providers which is more likely reduce the acceptability of the service. The finding is congruent with a study done on implementation evaluation of ICCM program in southern Ethiopia [ 24 ]. However, inconsistent with a study conducted in wakiso district in Uganda [ 38 ]. The possible reason for this might be due to contextual differences between the two countries. The ICCM program acceptability was high in caregivers who received all prescribed drugs than those did not. Caregivers those waited less than 30 min for service were more accepted ICCM services compared to those more than 30 minutes’ waiting time. This finding is similar compared with the study conducted on implementation evaluation of ICCM program in southern Ethiopia [ 24 ]. In contrary, the result was incongruent with a survey result conducted by Ethiopian public health institute in all regions and two administrative cities of Ethiopia [ 39 ]. This variation might be due to smaller sample size in our study the previous one. Moreover, caregivers who traveled to HPs less than 60 min were more likely accepted the program than who traveled more and the finding was similar with the study finding in Jimma zone [ 40 ].

Strengths and limitations

This evaluation used three evaluation dimensions, mixed method and different data sources that would enhance the reliability and credibility of the findings. However, the study might have limitations like social desirability bias, recall bias and Hawthorne effect.

The implementation of the ICCM program in Gondar city administration was measured in terms of availability (84.2%), compliance (83.1%), and acceptability (75.3%) dimensions. In the availability dimension, amoxicillin, antimalarial drugs, albendazole, Vit. A, and ORS were available in all health posts, but only six HPs had Ready-to-Use Therapeutic Feedings, three HPs had ORT Corners, and none of the HPs had functional timers.

This evaluation assessed the implementation status of the ICCM program, focusing mainly on availability, compliance, and acceptability dimensions. The overall implementation status of the program was judged as good. The availability dimension is compromised due to stock-outs of chloroquine syrup, cotrimoxazole, and vitamin K and the inaccessibility of clean water supply in some health posts. Educational statuses of caregivers, availability of prescribed drugs at the HPs, time to arrive to HPs, and waiting time to receive the service were the factors associated with the acceptability of the ICCM program.

Therefore, continuous supportive supervision for health facilities, and refreshment training for HEW’s to maximize compliance are recommended. Materials and supplies shall be delivered directly to the health centers or health posts to solve the transportation problem. HEWs shall document the assessment findings and the services provided using the registration format to identify their gaps, limitations, and better performances. The health facilities and local administrations should construct clean water sources for health facilities. Furthermore, we recommend for future researchers and program evaluators to conduct longitudinal studies to know the causal relationship of the program interventions and the outcomes.

Data availability

Data will be available upon reasonable request from the corresponding author.

Abbreviations

Ethiopian Demographic and Health Survey

Health Center/Health Facility

Health Extension Program

Health Extension Workers

Health Post

Health Sector Development Plan

Integrated Community Case Management of Common Childhood Illnesses

Information Communication and Education

Integrated Family Health Program

Integrated Management of Neonatal and Childhood Illness

Integrated Supportive Supervision

Maternal and Child Health

Mid Upper Arm Circumference

Non-Government Organization

Oral Rehydration Salts

Outpatient Therapeutic program

Primary health care unit

Rapid Diagnostics Test

Ready to Use Therapeutic Foods

Sever Acute Malnutrition

South Nation Nationalities People Region

United Nations International Child Emergency Fund

World Health Organization

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Acknowledgements

We are very grateful to University of Gondar and Gondar town health office for its welcoming approaches. We would also like to thank all of the study participants of this evaluation for their information and commitment. Our appreciation also goes to the data collectors and supervisors for their unreserved contribution.

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Mekides Geta

Department of Health Systems and Policy, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, P.O. Box 196, Gondar, Ethiopia

Geta Asrade Alemayehu, Wubshet Debebe Negash, Tadele Biresaw Belachew, Chalie Tadie Tsehay & Getachew Teshale

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All authors contributed to the preparation of the manuscript. M.G. conceived and designed the evaluation and performed the analysis then T.B.B., W.D.N., G.A.A., C.T.T. and G.T. revised the analysis. G.T. prepared the manuscript and all the authors revised and approved the final manuscript.

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Geta, M., Alemayehu, G.A., Negash, W.D. et al. Evaluation of integrated community case management of the common childhood illness program in Gondar city, northwest Ethiopia: a case study evaluation design. BMC Pediatr 24 , 310 (2024). https://doi.org/10.1186/s12887-024-04785-0

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Opinion Haiti’s plight is a case study in the ‘responsibility to protect’

Civilians at risk need protection, but when is humanitarian intervention justified?

After months of delay, a transitional council for Haiti has picked a president and prime minister. The interim appointments pave the way for deployment of an international security force, led by Kenyan police. Its job is to restore order and retake the capital, Port-au-Prince, from armed criminal gangs that control most of it and have already killed thousands . The ultimate goal is an election for a permanent government.

The mission faces a raft of challenges. Though authorized by the United Nations and funded by the United States, the deployment is unpopular in Kenya, where police have a reputation for human rights abuses. It’s unclear that the planned 1,100-man force is large and capable enough to take on hundreds of heavily armed gangs. Will the Kenyans be expected to disarm them? Or just provide a “static” presence at key buildings and infrastructure?

The Haiti deployment represents a comeback for the “ responsibility to protect .” This is the principle, born two decades ago — amid bloody wars in the Balkans, famine and anarchy in Somalia, and genocide in Rwanda — that the international community can, and should, intervene to save civilian populations in failed states. Since the United Nations General Assembly endorsed “R2P” in 2005, however, it has only been invoked once: the NATO-led military mission in Libya in 2011, which began with the goal of preventing massacres and ended with the toppling of Moammar Gaddafi amid anarchic factional fighting.

The Libya intervention not only went awry; it led China, Russia and nations of the Global South to denounce civilian protection as a pretext for the United States and Europe to engage in self-interested regime change. Yet even staunch proponents of R2P also looked at Libya and argued that it was, in hindsight, a misapplication of the concept. Libya helps explain why, in 2012, President Barack Obama hesitated to enforce his “red line” against the Syrian regime’s atrocities, despite urgings from R2P advocates in his administration. U.S. airstrikes might have toppled the regime — creating a power vacuum that the Islamic State could have exploited.

Haiti’s predicament, however, shows that the problem R2P meant to address remains real and that discarding the concept altogether would be a mistake. It needs to be applied more carefully and consistently. Gareth Evans, a former Australian foreign minister and president of the International Crisis Group, has identified five criteria for doing that.

First, the threat of mass civilian casualties must be serious and imminent. Second, while an intervention can never be free of geopolitical motivations or consequences, its primary goal must be to save civilians. Third, opportunities for diplomatic and economic pressure must be exhausted first. Fourth, the military force used must be sufficient to deal with all threats on the ground. Fifth, and crucially, intervention must be reasonably certain to do more good than harm.

These standards can help the U.S. public sort through its inevitably competing impulses: the decent wish to do something — anything — to stop the suffering and the skeptical concern that a given crisis is too complicated, remote and, for a nation with problems of its own, costly.

Such doubts are understandable regarding Haiti, where the record of interventions is lengthy and mixed — from the Marine Corps’s often-abusive 1915-1934 occupation to the cholera epidemic and accusations of sex trafficking during a 2004-2017 U.N. peacekeeping mission .

Also understandable are questions about selectivity: Why a U.S.-backed mission to Haiti but not, say, Sudan, where a two-year battle between dueling warlords has killed at least 15,000 people , displaced 9 million more, left millions on the brink of famine and led to a likely genocide in Darfur? Or Myanmar, whose military, bent on crushing a popular insurgency, has killed more than 6,000 people in almost three years and displaced 3 million more ?

Mr. Evans’s criteria provide answers. The slaughter in Sudan and Myanmar is clear, but not the chances intervention could do more good than harm. Also, the Haiti mission meets a sixth criterion we would add to Mr. Evans’s list: If intervention is warranted, it is crucial to assemble the broadest possible coalition, including countries from the region. The proposed Haiti mission is backed by a U.N. Security Council resolution and Kenyan police; the Bahamas, Barbados, Benin, Chad and Bangladesh have offered additional personnel. It did not trigger Russian and Chinese vetoes at the U.N., as more geopolitically sensitive missions elsewhere might have.

The main lingering uncertainty relates to Mr. Evans’s fourth criterion: force sufficiency. Gen. Peter Cosgrove, who commanded Australian troops in a humanitarian intervention in East Timor in 1999, memorably attributed his success to telling local militias, “there’s only one military force allowed to posture here, and that’s my force.” If the Haiti operation cannot say the same to that country’s gangs, it could fail. With enough U.S. help, though, the mission could save Haitian lives and breathe much-needed new life into the responsibility to protect.

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Research: Negotiating Is Unlikely to Jeopardize Your Job Offer

• Einav Hart,
• Julia Bear,
• Zhiying (Bella) Ren

A series of seven studies found that candidates have more power than they assume.

Job seekers worry about negotiating an offer for many reasons, including the worst-case scenario that the offer will be rescinded. Across a series of seven studies, researchers found that these fears are consistently exaggerated: Candidates think they are much more likely to jeopardize a deal than managers report they are. This fear can lead candidates to avoid negotiating altogether. The authors explore two reasons driving this fear and offer research-backed advice on how anxious candidates can approach job negotiations.

Imagine that you just received a job offer for a position you are excited about. Now what? You might consider negotiating for a higher salary, job flexibility, or other benefits , but you’re apprehensive. You can’t help thinking: What if I don’t get what I ask for? Or, in the worst-case scenario, what if the hiring manager decides to withdraw the offer?

• Einav Hart is an assistant professor of management at George Mason University’s Costello College of Business, and a visiting scholar at the Wharton School. Her research interests include conflict management, negotiations, and organizational behavior.
• Julia Bear is a professor of organizational behavior at the College of Business at Stony Brook University (SUNY). Her research interests include the influence of gender on negotiation, as well as understanding gender gaps in organizations more broadly.
• Zhiying (Bella) Ren is a doctoral student at the Wharton School of the University of Pennsylvania. Her research focuses on conversational dynamics in organizations and negotiations.

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