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Case Study – Methods, Examples and Guide

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

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

Types of Case Study

Types and Methods of Case Study are as follows:

Single-Case Study

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

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

Multiple-Case Study

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

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

Exploratory Case Study

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

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

Descriptive Case Study

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

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

Instrumental Case Study

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

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

Case Study Data Collection Methods

Here are some common data collection methods for case studies:

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

Observations

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

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

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

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

How to conduct Case Study Research

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

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

Examples of Case Study

Here are some examples of case study research:

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

Application of Case Study

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

Business and Management

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

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

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

Social Sciences

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

Law and Ethics

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

Purpose of Case Study

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

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

Case studies can also serve other purposes, including:

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

Advantages of Case Study Research

There are several advantages of case study research, including:

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

Limitations of Case Study Research

There are several limitations of case study research, including:

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

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Assessment by Case Studies and Scenarios

Case studies depict real-life situations in which problems need to be solved. Scenario-based teaching may be similar to case studies, or may be oriented toward developing communication or teamwork skills. Both case studies and scenarios are commonly used methods of problem-based learning. Typically, using these methods, teachers aim to develop student reasoning, problem-solving and decision-making skills. Case studies differ from role plays in that in the former, learning takes place largely through discussion and analysis, whereas in the latter, students assume a character or role and "act out" what that character would do in the scenario (The Teaching Gateway page Assessing with Role Plays and Simulations contains more information on using role plays for assessments.) Like role plays and simulations, case studies and scenarios aim for authenticity:  allowing students to get a sense of the situations they might face in the real world upon graduation. Students can see how their learning and skills can be applied in a real-world situation, without the pressure of being actually involved in that situation with the associated constraints on research, discussion and reflection time.

Case studies and scenarios are particularly useful when they present situations are complex and solutions are uncertain. Ideally, their complexity requires group members to draw from and share their experiences, work together, and learn by doing to understand and help solve the case-study problem.

You can present a single case to several groups in a class and require each group to offer its solutions, or you can give a different case to each group or individual.

Case studies' effectiveness comes from their abiliity to:

• engage students in research and reflective discussion
• encourage clinical and professional reasoning in a safe environment
• encourage higher-order thinking
• facilitate creative problem solving and the application of different problem-solving theories without risk to third parties or projects
• allow students to develop realistic solutions to complex problems
• develop students' ability to identify and distinguish between critical and extraneous factors
• enable students to apply previously acquired skills
• allow students to learn from one another
• provide an effective simulated learning environment
• encourage practical reasoning
• allow you to assess individuals or teams.

You can use case studies to bridge the gap between teacher-centred lectures and pure problem-based learning. They leave room for you to guide students directly, while the scenarios themselves suggest how students should operate, and provide parameters for their work.

Although some students have reported greater satisfaction with simulations as learning tools than with case studies (Maamari & El-Nakla, 2023), case studies generally require less up-front preparation time, and can be less intimidating for students.

To make case studies an effective form of assessment, instructors and tutors need to be familiar with their use in both teaching and assessment. This applies whether teachers are developing the case studies for their courses themselves or using those developed by others.

Case studies reach their highest effectiveness as a teaching and assessment tool when they are authentic; ensuring that case studies accurately reflect the circumstances in which a student will eventually be practising professionally can require a considerable amount of research, as well as the potential involvement of industry professionals.

Students may need scaffolding as they learn how to problem-solve in the context of case studies; using case studies as low-stakes, formative assessments can prepare them for summative assessment by case study at the end of the course.

Learning outcomes, course outlines, and marking rubrics need to be entirely clear about how case studies will be used in the course and how students will be expected to demonstrate their learning through thee way they analyse and problem-solve in the context of case studies.

Assessment preparation

Typically, the product assessed after case study or scenario work is a verbal presentation or a written submission. Decide who will take part in the assessment: the tutor, an industry specialist, a panel, peer groups or students themselves by self-evaluation? Choose whether to give a class or group mark or to assess individual performance; and whether to assess the product yourself or have it assessed by peers.

Assessment strategies

You can assess students’ interaction with other members of a group by asking open-ended questions, and setting tasks that require teamwork and sharing resources.

Assess the process of analysis

Case studies allow you to assess a student’s demonstration of deeper understanding and cognitive skills as they address the case.  These skills include, for example:

• identification of a problem
• hypotheses generation
• construction of an enquiry plan
• interpretation of findings
• investigation of results collected for evidence to refine a hypothesis and construction of a management plan.

During the problem-solving process, you can also observe and evaluate:

• quality of research
• structural issues in written material
• organisation of arguments
• feasibility of solutions presented
• intra-group dynamics
• evidence of consideration of all case factors
• multiple resolutions of the same scenario issue.

Use a variety of questions in case analysis

The Questioning page discusses in detail various ways to use questions in teaching . If your students are using the Harvard Business School case study method for their analysis, use a range of question types to enable the class to move through the stages of analysis:

• clarification/information seeking ( What? )
• analysis/diagnosis ( Why? )
• conclusion/recommendation ( What now? )
• implementation ( How? ) and
• application/reflection ( So what? What does it mean to you?)

Use technology

Learning-management systems such as Moodle can help you track contributions to case discussions . You can assess students' interactions with other members of a group by viewing their responses to open-ended questions or observing their teamwork and sharing of resources as part of the discussion.  You can incorporate the use of various tools in these systems, or others such as Survey Monkey, into students' assessment of their peers, or of their group members' contribution to exploring and presenting case studies. You can also set this peer assessment up so that it takes place anonymously.

Assessing by Case Studies: UNSW examples

These videos show examples of how UNSW faculty have implemented case studies in their own courses.

• Boston University. Using Case Studies to Teach
• Columbia University. Case Method Teaching and Learning
• Science Education Resource Center, Carleton College. Starting Point: What is Investigative Case-Based Learning?

Maamari, B. E., & El-Nakla, D. (2023). From case studies to experiential learning. Is simulation an effective tool for student assessment? Arab Economic and Business Journal, 15(1), Article 2. https://doi.org/10.38039/2214-4625.1023

Merret, C. (2020). Using case studies and build projects as authentic assessments in cornerstone courses. International Journal of Mechanical Engineering Education , 50 (1), 20-50. https://doi.org/10.1177/0306419020913286

Porzecanski, A. L., Bravo, A., Groom, M. J., Dávalos, L. M., Bynum, N., Abraham, B. J., Cigliano, J. A., Griffiths, C., Stokes, D. L., Cawthorn, M., Fernandez, D. S., Freeman,  L., Leslie, T., Theodose, T., Vogler, D., & Sterling, E. J. (2021). Using case studies to improve the critical thinking skills of undergraduate conservation biology students. Case Studies in the Environment , 5 (1), 1536396. https://doi.org/10.1525/cse.2021.1536396

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A case study focuses on a particular unit - a person, a site, a project. It often uses a combination of quantitative and qualitative data.

Case studies can be particularly useful for understanding how different elements fit together and how different elements (implementation, context and other factors) have produced the observed impacts.

There are different types of case studies, which can be used for different purposes in evaluation. The GAO (Government Accountability Office) has described six different types of case study:

1.  Illustrative : This is descriptive in character and intended to add realism and in-depth examples to other information about a program or policy. (These are often used to complement quantitative data by providing examples of the overall findings).

2.  Exploratory : This is also descriptive but is aimed at generating hypotheses for later investigation rather than simply providing illustration.

3.  Critical instance : This examines a single instance of unique interest, or serves as a critical test of an assertion about a program, problem or strategy.

4.  Program implementation . This  investigates operations, often at several sites, and often with reference to a set of norms or standards about implementation processes.

5.  Program effects . This examines the causal links between the program and observed effects (outputs, outcomes or impacts, depending on the timing of the evaluation) and usually involves multisite, multimethod evaluations.

6.  Cumulative . This brings together findings from many case studies to answer evaluative questions. 

The following guides are particularly recommended because they distinguish between the research design (case study) and the type of data (qualitative or quantitative), and provide guidance on selecting cases, addressing causal inference, and generalizing from cases.

This guide from the US General Accounting Office outlines good practice in case study evaluation and establishes a set of principles for applying case studies to evaluations.

This paper, authored by Edith D. Balbach for the California Department of Health Services is designed to help evaluators decide whether to use a case study evaluation approach.

This guide, written by Linda G. Morra and Amy C. Friedlander for the World Bank, provides guidance and advice on the use of case studies.

Expand to view all resources related to 'Case study'

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• Case study evaluations - World Bank
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• Designing and facilitating creative conversations & learning activities
• Estudo de caso: a avaliação externa de um programa
• Evaluation tools
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• Reflections on innovation, assessment and social change processes: A SPARC case study, India
• Toward a listening bank: A review of best practices and the efficacy of beneficiary assessment
• UNICEF webinar: Comparative case studies
• Using case studies to do program evaluation

'Case study' is referenced in:

• Week 32: Better use of case studies in evaluation

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

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

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

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

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

Definitions of qualitative case study research

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

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

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

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

Current methodological issues in qualitative case study research

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

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

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

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

Assessment of rigour

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

Framework for assessing quality in qualitative case study research.

Adapted from Stake ( 1995 , p. 131).

Study design

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

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

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

Search strategy

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

Outcomes of search of qualitative methods journals.

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

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

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

Case study methodology or method

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

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

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

Case study of something particular and case selection

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

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

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

Contextually bound case study

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

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

Article synopsis of case study research using Stake's tradition

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

Article synopsis of case study research using Yin's tradition

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

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

Researcher and case interactions and triangulation

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

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

Study design inconsistent with methodology

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

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

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

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

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

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

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

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

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

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

Limitations of the review

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

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

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

Conflict of interest and funding

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

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• Open access
• Published: 27 June 2011

The case study approach

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

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

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

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Introduction

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

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

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

What is a case study?

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

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

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

What are case studies used for?

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

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

How are case studies conducted?

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

Defining the case

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

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

Selecting the case(s)

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

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

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

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

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

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

Collecting the data

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

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

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

Analysing, interpreting and reporting case studies

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

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

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

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

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

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

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

Conclusions

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

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Acknowledgements

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

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Sarah Crowe & Anthony Avery

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

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

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

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Crowe, S., Cresswell, K., Robertson, A. et al. The case study approach. BMC Med Res Methodol 11 , 100 (2011). https://doi.org/10.1186/1471-2288-11-100

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DOI : https://doi.org/10.1186/1471-2288-11-100

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What the Case Study Method Really Teaches

• Nitin Nohria

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

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

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

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

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Case studies

Case studies usually involve real-life situations and often take the form of a problem-based inquiry approach; in other words students are presented with a complex real life situation that they are asked to find a solution to. “The benefits of utilizing case studies in instruction include the way that cases model how to think professionally about real problems and situations, helping candidates to think productively about concrete experiences” (Kleinfeld, 1990 in Ulanoff, Fingon and Beltran, 2009). The case study method involves placing students in the role of decision-makers and asking them to address a challenge that may confront a company, non-profit organisation or government department. In the absence of a single straightforward answer students are expected to exchange ideas, consider possible theoretical explanations and data, and weigh up possible solutions. Based on this exchange and evaluation of mixed data they are expected to come up with a decision, and choose a solution to the particular challenge. Though case study learning and assessment may take many forms the common thread is that the case study involves a real-life situation and finding solutions is the focus of the assessment.

Advantages of case studies

• Enables students to apply their knowledge and skills to real life situations.
• Can be undertaken individually or as a group assessment.
• Generally designed to assess the higher levels of Bloom’s taxonomy of educational objectives (application, analysis and evaluation).
• Well adapted to multi- or inter-disciplinary learning.
• Calls on students to demonstrate a range of different skills such as the selection on information, analysis, decision-making problem-solving and presentation.
• In the case of a group-based approach students are given the opportunity to demonstrate their ability to collaborate and communicate effectively.
• Supports the development of a range of valuable employability skills which are likely to be attractive to employers and students alike.

Challenges of case studies

• Case studies can be used in time-constrained examinations but this method of assessment really lends itself better to a coursework approach.
• Can be a complex activity that involves negotiating a range of media that may be hard to contain in a controlled environment.
• It is important to have realistic expectations of what actually can be achieved.
• Planning and preparing for case study work can be time-consuming for teachers.

How students might experience case studies

There is some evidence to suggest that case studies increase students’ motivation. Students are often very interested in working on real life situations. It brings their learning alive and enables them not only to develop solutions to actual situations/problems but also to understand in new ways the valuable role that theory and relevant concepts can play as part of this process. In addition as part of their work on the case study they are clearly developing valuable transferable skills that they can take forward into the workplace and society at large. Students may not be used to this form of assessment so they will need clear guidance as to what is expected (length, format, main elements), a clear explanation of marking criteria as well as development in the different skills they will need to acquire in order to successfully complete the case study. These will in part depend on the nature of the case study - is data analysis involved?; where and how will students find relevant qualitative and quantitative data?; what is the appropriate way of citing and referencing?

Reliability, validity, fairness and inclusivity of case studies

Teaching and learning activities should be carefully designed to support the work on the case study or the development of the relevant skills and knowledge bases. From an inclusive design perspective case studies are an attractive form of learning and assessment.  Depending on the nature of the inquiry students may be given a degree of choice over their case study and thus be in a position to bring their different backgrounds and experience to bear. In any case, it is important to ensure that the chosen case studies are accessible to all students taking the course. In the case of first year students the teacher may want to provide all the relevant materials to the students. For more advanced students, they may be expected to do some research and to identify relevant supporting materials for the case study inquiry. Where group work is involved a number of options may be considered to ensure fairness. The students may complete some elements of both formative and summative work as a group as well as others individually. For example, students may complete various tasks or give a presentation on the case study as a group but write up part of the final case study individually. In addition, it is relatively common practice to ask students engaged in groupwork to write a short reflective piece discussing their experience of group work. Students can also be asked to rate their contribution and the contribution of other members of the group using one of a number of online group assessment tools such as WebPA and Teammates.

How to maintain and ensure rigour in case studies

Critical to ensuring rigour is having clarity about the different parts of the case study or, in the case of a single assessment task, the criteria against which the assessment will be marked; the weight that will be attached to different parts of the assignment, and the marking scheme.  Marking and moderation should follow departmental practice.

How to limit possible misconduct in case studies

Whether the students are working in groups or individually teachers can check that the work is the work of particular students by designing in opportunities to assess (formatively or summatively) work at several points in the assessment process. This can be done by asking students to present work in written or oral form – either by submitting assignment tasks via Moodle or making short presentations in class. In addition to serving as a check for misconduct this also provides an opportunity for teachers and peers to give constructive feedback on the development of the case study and as such constitutes good practice.

LSE examples

Daniel Ferreira discussed his use of case studies in teaching Master’s level Finance students for many years, and, starting in 2016/17 undergraduates with the introduction of the Finance department’s new BSc programme

http://lti.lse.ac.uk/lse-innovators/irene-papanicolas-healthy-collaboration/

Further resources

University of New South Wales, Sydney: Assessment by Case Studies and Scenarios https://teaching.unsw.edu.au/assessment-case-studies-and-scenarios

Assessment Resources at Hong Kong University: Types of Assessment Methods: Case Study http://ar.cetl.hku.hk/am_case_study.htm

Bonney, K.M. (2015) Case Study Teaching Method Improves Student Performance and Perceptions of Learning Gains.  Journal of Microbiological Education , 16(1): 21–28

Ulanoff, S.H., Fingon, J.C. and Beltrán, D. (2009) Using Case Studies To Assess Candidates’ Knowledge and Skills in a Graduate Reading Program,  Teacher Education Quarterly,  6(2): 125-142

Fry, H., Ketteridge, S. and Marshall, S. (1999)  A Handbook for Teaching and Learning in Higher Education,  Routledge, UK

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What Is a Case Study?

Weighing the pros and cons of this method of research

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

Cara Lustik is a fact-checker and copywriter.

Verywell / Colleen Tighe

• Pros and Cons

What Types of Case Studies Are Out There?

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

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

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

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

At a Glance

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

What Are the Benefits and Limitations of Case Studies?

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

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

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

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

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

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

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

Case Study Examples

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

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

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

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

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

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

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

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

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

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

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

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

Section 1: A Case History

This section will have the following structure and content:

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

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

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

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

Section 2: Treatment Plan

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

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

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

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

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

Need More Tips?

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

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

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

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

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

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

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

Case Study Research Method in Psychology

Saul Mcleod, PhD

Editor-in-Chief for Simply Psychology

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

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

Learn about our Editorial Process

Olivia Guy-Evans, MSc

Associate Editor for Simply Psychology

BSc (Hons) Psychology, MSc Psychology of Education

Olivia Guy-Evans is a writer and associate editor for Simply Psychology. She has previously worked in healthcare and educational sectors.

On This Page:

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

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

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

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

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

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

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

 Famous Case Studies

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

Clinical Case Studies

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

Child Psychology Case Studies

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

Types of Case Studies

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

Where Do You Find Data for a Case Study?

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

1. Primary sources

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

2. Secondary sources

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

3. Archival records

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

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

4. Organizational records

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

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

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

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

How do I Write a Case Study in Psychology?

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

1. Introduction

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

2. Case Presentation

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

3. Management and Outcome

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

4. Discussion

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

5. Additional Items

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

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

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

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

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

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

Limitations

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Further Information

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

Related Articles

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What Is a Focus Group?

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Criterion Validity: Definition & Examples

• Open access
• Published: 18 March 2015

A narrative review of research impact assessment models and methods

• Andrew J Milat 1 , 2 ,
• Adrian E Bauman 2 &
• Sally Redman 2 , 3  

Health Research Policy and Systems volume  13 , Article number:  18 ( 2015 ) Cite this article

Research funding agencies continue to grapple with assessing research impact. Theoretical frameworks are useful tools for describing and understanding research impact. The purpose of this narrative literature review was to synthesize evidence that describes processes and conceptual models for assessing policy and practice impacts of public health research.

The review involved keyword searches of electronic databases, including MEDLINE, CINAHL, PsycINFO, EBM Reviews, and Google Scholar in July/August 2013. Review search terms included ‘research impact’, ‘policy and practice’, ‘intervention research’, ‘translational research’, ‘health promotion’, and ‘public health’. The review included theoretical and opinion pieces, case studies, descriptive studies, frameworks and systematic reviews describing processes, and conceptual models for assessing research impact. The review was conducted in two phases: initially, abstracts were retrieved and assessed against the review criteria followed by the retrieval and assessment of full papers against review criteria.

Thirty one primary studies and one systematic review met the review criteria, with 88% of studies published since 2006. Studies comprised assessments of the impacts of a wide range of health-related research, including basic and biomedical research, clinical trials, health service research, as well as public health research. Six studies had an explicit focus on assessing impacts of health promotion or public health research and one had a specific focus on intervention research impact assessment. A total of 16 different impact assessment models were identified, with the ‘payback model’ the most frequently used conceptual framework. Typically, impacts were assessed across multiple dimensions using mixed methodologies, including publication and citation analysis, interviews with principal investigators, peer assessment, case studies, and document analysis. The vast majority of studies relied on principal investigator interviews and/or peer review to assess impacts, instead of interviewing policymakers and end-users of research.

Conclusions

Research impact assessment is a new field of scientific endeavour and there are a growing number of conceptual frameworks applied to assess the impacts of research.

Peer Review reports

There is increasing recognition that health research investment should lead to improvements in policy [ 1 - 3 ], practice, resource allocation, and, ultimately, the health of the community [ 4 , 5 ]. However, research impacts are complex, non-linear, and unpredictable in nature and there is a propensity to ‘count what can be easily measured’, rather than measuring what ‘counts’ in terms of significant, enduring changes [ 6 ].

Traditional academic-oriented indices of research productivity, such as number of papers, impact factors of journals, citations, research funding, and esteem measures, are well established and widely used by research granting bodies and academic institutions [ 7 ], but they do not always relate well to the ultimate goals of applied health research [ 6 , 8 , 9 ]. Governments are signaling that research metrics of research quality and productivity are insufficient to determine research value because they say little about the real world benefits of research [ 10 - 12 ]. At the same time, research funders continue to grapple with the fundamental problem of assessing broader impacts of research. This task is made more challenging because there are currently no agreed systematic approaches to measuring broader research impacts, particularly impacts on health policy and practice [ 13 , 14 ].

Recent years have seen the development of a number of frameworks that can assist in better describing and understanding the impact of research. Conceptual frameworks can help organize data collection, analysis, and reporting to promote clarity and consistency in the impact assessments made. In the context of this review, research impact is defined as: “… any type of output of research activities which can be considered a ‘positive return’ for the scientific community, health systems, patients, and the society in general ” [ 13 ], p. 2.

In light of these gaps in the literature, the purpose of this narrative literature review was to synthesize evidence that describes processes and conceptual models for assessing research impacts, with a focus on policy and practice impacts of public health research.

Literature review search strategy

The review involved keyword searches of electronic databases including MEDLINE (general medicine), CINAHL (nursing and allied health), PsycINFO (psychology and related behavioural and social sciences), EBM Reviews, Cochrane Database of Systematic Reviews 2005 to May 2013, and Google Scholar. Review search terms included ‘research impact’ OR ‘policy and practice’ AND ‘intervention research’ AND ‘translational research’ AND ‘health promotion’ AND ‘public health’.

The review included theoretical and opinion pieces, case studies, descriptive studies, frameworks and systematic reviews describing processes, and conceptual models for assessing research impact.

The review was conducted in two phases in July/August 2013. In phase 1, abstracts were retrieved and assessed against the review criteria. For abstracts that met the review criteria in phase 1, full papers were retrieved and were assessed for inclusion in the final review. Studies included in the review met the following criteria: i) published in English from January 1990 to June 2013; ii) described processes, theories, or frameworks associated with the assessment of research impact; and iii) were theoretical and opinion pieces, case studies, descriptive studies, frameworks, or systematic reviews.

Due the dearth of public health and health promotion-specific research impact assessment, papers with a focus on clinical or health services research impact assessment were included. The reference lists of the final papers were checked to ensure inclusion of further relevant papers; where such articles were considered relevant, they were included in the review. The search process is shown in Figure  1 .

Literature search process and numbers of papers identified, excluded, and included in the review of research impact assessment.

Findings of the literature review

An initial review of abstracts in electronic databases against the inclusion criteria yielded 431 abstracts and searches of reference lists and the grey literature identified a further 9 documents. Of the 434 abstracts and documents reviewed, 39 met the inclusion criteria and full papers were retrieved. Upon review of the full publications against the review criteria, a further 7 papers were excluded as they did not meet the review criteria, leaving 32 publications in the review [ 8 , 9 , 13 , 15 - 44 ]. A summary of characteristics of studies included in the review that have a focus on processes, theories, or frameworks associated with the assessment of research impact including reference details, study type, domains of impact, methods and indicators, frameworks applied or proposed, and key lessons learned is provided in Additional file 1 : Table S1.

Study characteristics

The review identified 31 primary studies and 1 systematic review that met the review criteria. Six of the studies were reports found in the grey literature. Interestingly, 88% of studies that met the review criteria were published since 2006. The studies in the review included assessments of the impacts of a wide range of health-related research, including basic and biomedical research, clinical trials, health service research, as well as public health research. Six studies [ 22 , 23 , 34 , 36 , 40 , 43 ] had an explicit focus on assessing impacts of health promotion or public health research and 1 had a specific focus on intervention research impact assessment [ 36 ].

The majority of studies were conducted in Australia, United Kingdom, and North America, noting that the review was limited to studies published in English. The unit of assessment varied greatly from researchers (research teams [ 22 ] to whole institutions [ 15 ]) to research disciplines (e.g., prevention research [ 23 ], cancer research [ 41 ], tobacco control research [ 43 ]) or type of grants, for example, from public funding bodies [ 17 , 24 ]. The most frequently applied research methods across studies in rank order were publication and citation analysis, interviews with principal investigators, peer assessment, case studies, and document analysis. The nature of frameworks and methods used to measure research impacts will now be examined in greater detail.

Frameworks and methods for measuring research impacts

Indices of traditional research productivity such as number of papers, impact factors of journals, and citations figured prominently in studies in the literature review [ 18 , 23 , 41 ].

Across the majority of studies in this review, research impact was assessed using multiple dimensions and methodological approaches. A total of 16 different impact assessment models were identified, with the ‘payback model’ being the most frequently used conceptual framework [ 15 , 24 , 29 , 31 , 44 ]. Other frequently used models included health economics frameworks [ 19 , 21 , 37 ], variants of Research Program Logic Models [ 9 , 35 , 42 ], and the Research Impact Framework [ 8 , 30 ]. A number of recent frameworks, including the Health Services Research Impact Framework [ 20 ] and the Banzi Health Research Impact Framework [ 13 , 34 , 36 ], are hybrids of previous conceptual approaches and categorize impacts and benefits in many dimensions, trying to integrate them. Commonly applied frameworks identified in the review, including the Payback model, Research Impact Framework, health economics models, and the new hybrid Health Research Impact Framework, will now be examined in greater detail.

The payback model was developed by Buxton and Hanney [ 45 ] and takes into account resources, research processes, primary outputs, dissemination, secondary outputs and applications, and benefits or final outcomes provided by the research. Categories of outcome in the ‘payback’ framework include i) knowledge production (journal articles, books/book chapters, conference proceeding, reports); ii) use of research in the research system (acquisition of formal qualifications by members of the research team, career advancement, and use of project findings for methodology in subsequent research); iii) use of research project findings in health system policy/decision making (findings used in policy/decision making at any level of the health service such as geographic level and organisation level); iv) application of the research findings through changed behaviour (changes in behaviour observed or expected through the application of findings to research-informed policies at a geographical, organisation and population level); v) factors influencing the utilization of research (impact of research dissemination in terms of policy/decision making/behavioural change); and vi) health/health service/economic benefits (improved service delivery, cost savings, improved health, or increased equity).

The model is usually applied as a semi-structured interview guide for researchers to identify the impact of their research and is often accompanied by bibliometric analysis and verification processes. The payback categories have been found to be applicable to assessing impact of research [ 15 , 24 , 29 ], especially the more proximal impacts on knowledge production, research targeting, capacity building and absorption, and informing practice, policy, and product development. The model has been found to be less effective in eliciting information about the longer term categories of impact on health and health sector benefits and economics [ 29 ].

The Research Impact Framework was developed in the UK by Kuruvilla et al. [ 8 , 30 ], and draws upon both the research impact literature and UK research assessment criteria for publically funded research, and was validated through empirical analysis of research projects at the London School of Hygiene & Tropical Medicine. The framework is built around four categories of impact, namely i) research related, ii) policy, iii) service, and iv) societal. Within each of these areas, further descriptive categories are identified. For example, the nature of research impact on policy can be described using the Weiss categorisation of ‘instrumental use’, where research findings drive policy-making; ‘mobilisation of support’, where research provides support for policy proposals; ‘conceptual use’, where research influences the concepts and language of policy deliberations; and ‘redefining/wider influence’, where research leads to rethinking and changing established practices and beliefs [ 30 ]. The framework is applied as a semi-structured interview guide for researchers to identify the impact of their research. Users of the framework have reported that it enables the systematic identification of a range of specific and verifiable impacts and allows consideration of the unintended effects of research [ 30 ].

The framework proposed by Banzi et al. [ 13 ] is an adaption of the Canadian Academy of Health Science impact model [ 25 ] in light of a systematic review and includes five broad categories of research impact, namely i) advancing knowledge, ii) capacity building, iii) informing decision-making, iv) health and other sector benefits, and v) broad socio-economic benefits. The Banzi framework proposes a set of indicators for each domain. To illustrate, indicators for informing decision making include citation in guidelines, policy documents, and plans; references used as background for successful funding proposals; consulting, support activity, and contributing to advisory committees; patents and industrial collaboration; packages of material and communication to key target audiences about findings. This multidimensional framework takes into account several aspects of research impact and use, as well as comprehensive analytical approaches including bibliometric analysis, surveys, audit, document review, case studies, and panel assessment. Panel assessments generally involve a process asking experts to assess the merits of research against impact criteria.

Economic models used to assess impacts of research varied from cost benefit analysis to return on investment and employed a variety of methods for determining economic benefits of research. The National Institutes of Medicine study in 1993 was among the first studies to attempt to systematically monetize the benefits of medical research. It provided estimates of savings for health care systems (direct costs) and savings for the community as a whole (indirect costs), and quantified benefits in terms of quality adjusted life years. On the other hand, the Deloitte Access Economics study [ 21 ] built on the foundations of the 1993 analysis to estimate the returns on investment in research in Australia for the main disease areas and employed of health system expenditure modelling and monetised total quality adjusted life years gained. According to Buxton et al. [ 19 ], measuring only health care savings is generally seen as too narrow a focus, and their analysis considered the benefits, or indirect cost savings, in avoiding lost production and the further activity stimulated by research.

The aforementioned models all attempted to quantify a mix of more proximal research and policy and practice impacts, as well as more distal societal and economic benefits of research. It is also interesting to note that across the studies in this review, only four [ 16 , 29 , 34 , 36 ] interviewed non-academic end-users of research in impact assessment processes, with the vast majority of studies relying on principal investigator interviews and/or peer review processes to assess impacts.

Comprehensive monitoring and measurement of research impact is a complex undertaking requiring the involvement of many actors within the research pipeline [ 13 ]. Interestingly, 90% of studies that met the review criteria were published since 2006, indicating that this is a new field of research. Given the dearth of literature on public health research impact assessment, this review included assessments of the impacts of a wide range of health-related research, including basic and biomedical research, clinical trials, and health service research as well as public health research.

The review of both the published and grey literature also revealed that there are a number of conceptual frameworks currently being applied that describe processes of assessing research impact. These frameworks differ in their terminology and approaches. The lack of a common understanding of terminology and metrics makes the task of quantifying research efforts, outputs, and, ultimately, performance in this area more difficult.

Most of the models identified in the review used multidimensional conceptualization and categorization of research impact. These multidimensional models, such as the Payback model, Research Impact Framework, and Banzi Health Research Impact Framework, shared common features including assessment of traditional research outputs, such as publication and research funding, but also a broader range of potential benefits, including capacity, building, policy and product development, and service development, as well as broader societal and economic impacts. Assessments that considered more than one category were valued for their ability to capture multifaceted impact processes [ 13 , 36 , 44 ]. Interestingly, these frameworks recognised that research often impacts not only in the country within which research is conducted, but also internationally. However, for practical reasons, most studies limited assessment and verification of impacts to a single country [ 19 , 34 , 36 ].

Several methods were used to practically assess research impact, including desk analysis, bibliometrics, panel assessments, interviews, and case studies. A number of studies highlighted the utility of case study methods noting that a considerable range of research paybacks and perspectives would not have been identified without employing a structured case study approach [ 13 , 36 , 44 ]. However, it was noted that case studies can be at risk of ‘conceptualization bias’ and ‘reporting bias’ especially when they are designed or carried out retrospectively [ 13 ]. The costs of conducting case studies can also be a barrier when assessing large volumes of research [ 13 , 36 ].

Despite recent efforts, little is known about the nature and mechanisms that underpin the influence that health research has on health policy or practice. This review suggests that, to date, most primary studies of health research impacts have been small scale case studies or reviews of medical and health services research funding [ 27 , 31 , 35 , 39 , 41 ], with only two studies offering comprehensive assessments of the policy and practice impacts of public health research, with both focusing on prevention research in Australia.

The first of these aforementioned studies examined impact of population health surveillance studies on obesity prevention policy and practice [ 34 ], while the second [ 36 ] examined the policy and practice impacts of intervention research funded through the NSW Health Promotion Demonstration Research Grants Scheme 2000–2006. Both of these studies utilised comprehensive mixed methods to assess impacts that included semi-structured interviews with both investigators and end-users, bibliometric analysis, document review, verification processes, and case studies. These studies concluded that research projects can achieve the greatest policy and practice impacts if they address proximal needs of the policy context by engaging end-users from the inception of research projects and utilizing existing policy networks and structures, as well as using a range of strategies to disseminate findings that go beyond traditional peer review publications.

This review suggests that the research sector often still uses bibliometric indices to assess research impacts, rather than measuring more enduring and arguably more important policy and practice outcomes [ 6 ]. However, governments are increasingly signaling that research metrics of research quality are insufficient to determine research value because they say little about real world benefits of research [ 10 - 12 ]. The Australian Excellence in Innovation trial [ 26 ] and the UK’s Research Excellence Framework trials [ 28 , 46 ] were commissioned by governments to determine the public benefit from research spending [ 10 , 16 , 47 ].

These attempts raise an important question of how to construct an impact assessment process that can assess multi-dimensional impacts while being feasible to implement on a system level. For example, can 28 indicators across 4 domains of Research Impact Framework be realistically measured in practice? This could also be said of the Research Impact Model [ 13 ], which has 26 indicators, and the Research Excellent Framework by Ovseiko et al. [ 38 ], which has a total of 20 impact indicators. If such methods are to be widely used in practice by research funders and academic institutions to assess research impacts, the right balance between comprehensiveness and feasibility must be struck.

Though a number of studies suggest it is difficult to determine longer-term societal and economic benefits of research as part of multi-dimensional research impact assessment processes [ 13 , 36 , 44 ], the health economic impact models presented in this review and the broader literature demonstrate that it is feasible to undertake these analyses, particularly if the right methods are used [ 19 , 21 , 37 , 48 ].

The review revealed that, where broader policy and practice impacts of research have been assessed in the literature, the vast majority of studies have relied on principal investigator interviews and/or peer review to assess impacts, instead of interviewing policymakers and other important end-users of research. This would seem to be a methodological weakness of previous research, as solely relying on principal investigator assessments, particularly of impacts of their own research, has an inherent bias, leaving the research impact assessment process open to ‘gilding the lily’. In light of this, future impact assessment processes should routinely engage end-users of research in interviews and assessment processes, but also include independent documentary verification, thus addressing methodological limitations of previous research.

One of the greatest practical issues in measuring research impact, including the impact of public health research, are the long lag times before impacts manifest. It has been observed that, on average, it takes over 6 years for research evidence to reach reviews, papers, and textbooks, and a further 9 years for this evidence to be implemented into practice [ 49 ]. In light of this, it is important to allow sufficient time for impacts to manifest, while not waiting so long that these impacts cannot be verified by stakeholders involved in the production and use of the research. Studies in this review have addressed this issue by only assessing studies that had been completed for at least 24 months [ 36 ].

As identified in previous research [ 13 ], a major challenge is attribution of impacts and understanding what would have happened without individual research activity or what some describe as the ‘counterfactual’. Creating a control situation for this type of research is difficult, but, where possible, identification of baseline measures and contextual factors is important in understanding what counterfactual situations may have arisen. Confidence in attribution of effects can be improved by undertaking independent verification of processes and engaging end-users in assessments instead of solely relying on investigators accounts of impacts [ 36 ].

The research described in this review has some limitations that merit closer examination. Given the paucity of research in this area, review criteria had to be adjusted to include assessment of impacts beyond public health research to include all health research. It was also challenging to make direct comparisons across studies mostly due to the heterogeneity of studies and the lack of a standard terminology, hence the broad definition of ‘research impact’ finally applied in the review criteria. Although the majority of studies were found in the traditional biomedical databases (i.e., Medline, etc.), 18% were found in the grey literature highlighting the importance of using multiple data sources in future review processes. Another methodological limitation also identified in previous reviews [ 13 ], is that we did not estimate the level of publication bias and selective publication in this emerging field. Finally, as our analysis included studies published up to June 2013, we may not have captured more recent approaches to impact assessment.

Research impact assessment is a new field of scientific endeavour and typically impacts are assessed using mixed methodologies, including publication and citation analysis, interviews with principal investigators, peer assessment, case studies, and document analysis. The literature is characterised by an over reliance on bibliometric methods to assess research impact. Future impact assessment processes could be strengthened by routinely engaging the end-users of research in interviews and assessment processes. If multidimensional research impact assessment methods are to be widely used in practice by research funders and academic institutions, the right balance between comprehensiveness and feasibility must be determined.

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Characteristics of studies focusing on processes, theories, or frameworks assessing research impact.

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Milat, A.J., Bauman, A.E. & Redman, S. A narrative review of research impact assessment models and methods. Health Res Policy Sys 13 , 18 (2015). https://doi.org/10.1186/s12961-015-0003-1

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Blog Business How to Present a Case Study like a Pro (With Examples)

How to Present a Case Study like a Pro (With Examples)

Written by: Danesh Ramuthi Sep 07, 2023

Okay, let’s get real: case studies can be kinda snooze-worthy. But guess what? They don’t have to be!

In this article, I will cover every element that transforms a mere report into a compelling case study, from selecting the right metrics to using persuasive narrative techniques.

And if you’re feeling a little lost, don’t worry! There are cool tools like Venngage’s Case Study Creator to help you whip up something awesome, even if you’re short on time. Plus, the pre-designed case study templates are like instant polish because let’s be honest, everyone loves a shortcut.

Click to jump ahead: 

What is a case study presentation?

What is the purpose of presenting a case study, how to structure a case study presentation, how long should a case study presentation be, 5 case study presentation examples with templates, 6 tips for delivering an effective case study presentation, 5 common mistakes to avoid in a case study presentation, how to present a case study faqs.

A case study presentation involves a comprehensive examination of a specific subject, which could range from an individual, group, location, event, organization or phenomenon.

They’re like puzzles you get to solve with the audience, all while making you think outside the box.

Unlike a basic report or whitepaper, the purpose of a case study presentation is to stimulate critical thinking among the viewers. 

The primary objective of a case study is to provide an extensive and profound comprehension of the chosen topic. You don’t just throw numbers at your audience. You use examples and real-life cases to make you think and see things from different angles.

The primary purpose of presenting a case study is to offer a comprehensive, evidence-based argument that informs, persuades and engages your audience.

Here’s the juicy part: presenting that case study can be your secret weapon. Whether you’re pitching a groundbreaking idea to a room full of suits or trying to impress your professor with your A-game, a well-crafted case study can be the magic dust that sprinkles brilliance over your words.

Think of it like digging into a puzzle you can’t quite crack . A case study lets you explore every piece, turn it over and see how it fits together. This close-up look helps you understand the whole picture, not just a blurry snapshot.

It’s also your chance to showcase how you analyze things, step by step, until you reach a conclusion. It’s all about being open and honest about how you got there.

Besides, presenting a case study gives you an opportunity to connect data and real-world scenarios in a compelling narrative. It helps to make your argument more relatable and accessible, increasing its impact on your audience.

One of the contexts where case studies can be very helpful is during the job interview. In some job interviews, you as candidates may be asked to present a case study as part of the selection process.

Having a case study presentation prepared allows the candidate to demonstrate their ability to understand complex issues, formulate strategies and communicate their ideas effectively.

The way you present a case study can make all the difference in how it’s received. A well-structured presentation not only holds the attention of your audience but also ensures that your key points are communicated clearly and effectively.

In this section, let’s go through the key steps that’ll help you structure your case study presentation for maximum impact.

Let’s get into it. 

Open with an introductory overview 

Start by introducing the subject of your case study and its relevance. Explain why this case study is important and who would benefit from the insights gained. This is your opportunity to grab your audience’s attention.

Explain the problem in question

Dive into the problem or challenge that the case study focuses on. Provide enough background information for the audience to understand the issue. If possible, quantify the problem using data or metrics to show the magnitude or severity.

Detail the solutions to solve the problem

After outlining the problem, describe the steps taken to find a solution. This could include the methodology, any experiments or tests performed and the options that were considered. Make sure to elaborate on why the final solution was chosen over the others.

Key stakeholders Involved

Talk about the individuals, groups or organizations that were directly impacted by or involved in the problem and its solution. 

Stakeholders may experience a range of outcomes—some may benefit, while others could face setbacks.

For example, in a business transformation case study, employees could face job relocations or changes in work culture, while shareholders might be looking at potential gains or losses.

Discuss the key results & outcomes

Discuss the results of implementing the solution. Use data and metrics to back up your statements. Did the solution meet its objectives? What impact did it have on the stakeholders? Be honest about any setbacks or areas for improvement as well.

Include visuals to support your analysis

Visual aids can be incredibly effective in helping your audience grasp complex issues. Utilize charts, graphs, images or video clips to supplement your points. Make sure to explain each visual and how it contributes to your overall argument.

Pie charts illustrate the proportion of different components within a whole, useful for visualizing market share, budget allocation or user demographics.

This is particularly useful especially if you’re displaying survey results in your case study presentation.

Stacked charts on the other hand are perfect for visualizing composition and trends. This is great for analyzing things like customer demographics, product breakdowns or budget allocation in your case study.

Consider this example of a stacked bar chart template. It provides a straightforward summary of the top-selling cake flavors across various locations, offering a quick and comprehensive view of the data.

Not the chart you’re looking for? Browse Venngage’s gallery of chart templates to find the perfect one that’ll captivate your audience and level up your data storytelling.

Recommendations and next steps

Wrap up by providing recommendations based on the case study findings. Outline the next steps that stakeholders should take to either expand on the success of the project or address any remaining challenges.

Acknowledgments and references

Thank the people who contributed to the case study and helped in the problem-solving process. Cite any external resources, reports or data sets that contributed to your analysis.

Feedback & Q&A session

Open the floor for questions and feedback from your audience. This allows for further discussion and can provide additional insights that may not have been considered previously.

Closing remarks

Conclude the presentation by summarizing the key points and emphasizing the takeaways. Thank your audience for their time and participation and express your willingness to engage in further discussions or collaborations on the subject.

Well, the length of a case study presentation can vary depending on the complexity of the topic and the needs of your audience. However, a typical business or academic presentation often lasts between 15 to 30 minutes. 

This time frame usually allows for a thorough explanation of the case while maintaining audience engagement. However, always consider leaving a few minutes at the end for a Q&A session to address any questions or clarify points made during the presentation.

When it comes to presenting a compelling case study, having a well-structured template can be a game-changer. 

It helps you organize your thoughts, data and findings in a coherent and visually pleasing manner. 

Not all case studies are created equal and different scenarios require distinct approaches for maximum impact. 

To save you time and effort, I have curated a list of 5 versatile case study presentation templates, each designed for specific needs and audiences. 

Here are some best case study presentation examples that showcase effective strategies for engaging your audience and conveying complex information clearly.

1 . Lab report case study template

Ever feel like your research gets lost in a world of endless numbers and jargon? Lab case studies are your way out!

Think of it as building a bridge between your cool experiment and everyone else. It’s more than just reporting results – it’s explaining the “why” and “how” in a way that grabs attention and makes sense.

This lap report template acts as a blueprint for your report, guiding you through each essential section (introduction, methods, results, etc.) in a logical order.

Want to present your research like a pro? Browse our research presentation template gallery for creative inspiration!

2. Product case study template

It’s time you ditch those boring slideshows and bullet points because I’ve got a better way to win over clients: product case study templates.

Instead of just listing features and benefits, you get to create a clear and concise story that shows potential clients exactly what your product can do for them. It’s like painting a picture they can easily visualize, helping them understand the value your product brings to the table.

Grab the template below, fill in the details, and watch as your product’s impact comes to life!

3. Content marketing case study template

In digital marketing, showcasing your accomplishments is as vital as achieving them. 

A well-crafted case study not only acts as a testament to your successes but can also serve as an instructional tool for others. 

With this coral content marketing case study template—a perfect blend of vibrant design and structured documentation, you can narrate your marketing triumphs effectively.

4. Case study psychology template

Understanding how people tick is one of psychology’s biggest quests and case studies are like magnifying glasses for the mind. They offer in-depth looks at real-life behaviors, emotions and thought processes, revealing fascinating insights into what makes us human.

Writing a top-notch case study, though, can be a challenge. It requires careful organization, clear presentation and meticulous attention to detail. That’s where a good case study psychology template comes in handy.

Think of it as a helpful guide, taking care of formatting and structure while you focus on the juicy content. No more wrestling with layouts or margins – just pour your research magic into crafting a compelling narrative.

5. Lead generation case study template

Lead generation can be a real head-scratcher. But here’s a little help: a lead generation case study.

Think of it like a friendly handshake and a confident resume all rolled into one. It’s your chance to showcase your expertise, share real-world successes and offer valuable insights. Potential clients get to see your track record, understand your approach and decide if you’re the right fit.

No need to start from scratch, though. This lead generation case study template guides you step-by-step through crafting a clear, compelling narrative that highlights your wins and offers actionable tips for others. Fill in the gaps with your specific data and strategies, and voilà! You’ve got a powerful tool to attract new customers.

Related: 15+ Professional Case Study Examples [Design Tips + Templates]

So, you’ve spent hours crafting the perfect case study and are now tasked with presenting it. Crafting the case study is only half the battle; delivering it effectively is equally important. 

Whether you’re facing a room of executives, academics or potential clients, how you present your findings can make a significant difference in how your work is received. 

Forget boring reports and snooze-inducing presentations! Let’s make your case study sing. Here are some key pointers to turn information into an engaging and persuasive performance:

• Know your audience : Tailor your presentation to the knowledge level and interests of your audience. Remember to use language and examples that resonate with them.
• Rehearse : Rehearsing your case study presentation is the key to a smooth delivery and for ensuring that you stay within the allotted time. Practice helps you fine-tune your pacing, hone your speaking skills with good word pronunciations and become comfortable with the material, leading to a more confident, conversational and effective presentation.
• Start strong : Open with a compelling introduction that grabs your audience’s attention. You might want to use an interesting statistic, a provocative question or a brief story that sets the stage for your case study.
• Be clear and concise : Avoid jargon and overly complex sentences. Get to the point quickly and stay focused on your objectives.
• Use visual aids : Incorporate slides with graphics, charts or videos to supplement your verbal presentation. Make sure they are easy to read and understand.
• Tell a story : Use storytelling techniques to make the case study more engaging. A well-told narrative can help you make complex data more relatable and easier to digest.

Ditching the dry reports and slide decks? Venngage’s case study templates let you wow customers with your solutions and gain insights to improve your business plan. Pre-built templates, visual magic and customer captivation – all just a click away. Go tell your story and watch them say “wow!”

Nailed your case study, but want to make your presentation even stronger? Avoid these common mistakes to ensure your audience gets the most out of it:

Overloading with information

A case study is not an encyclopedia. Overloading your presentation with excessive data, text or jargon can make it cumbersome and difficult for the audience to digest the key points. Stick to what’s essential and impactful. Need help making your data clear and impactful? Our data presentation templates can help! Find clear and engaging visuals to showcase your findings.

Lack of structure

Jumping haphazardly between points or topics can confuse your audience. A well-structured presentation, with a logical flow from introduction to conclusion, is crucial for effective communication.

Ignoring the audience

Different audiences have different needs and levels of understanding. Failing to adapt your presentation to your audience can result in a disconnect and a less impactful presentation.

Poor visual elements

While content is king, poor design or lack of visual elements can make your case study dull or hard to follow. Make sure you use high-quality images, graphs and other visual aids to support your narrative.

Not focusing on results

A case study aims to showcase a problem and its solution, but what most people care about are the results. Failing to highlight or adequately explain the outcomes can make your presentation fall flat.

How to start a case study presentation?

Starting a case study presentation effectively involves a few key steps:

• Grab attention : Open with a hook—an intriguing statistic, a provocative question or a compelling visual—to engage your audience from the get-go.
• Set the stage : Briefly introduce the subject, context and relevance of the case study to give your audience an idea of what to expect.
• Outline objectives : Clearly state what the case study aims to achieve. Are you solving a problem, proving a point or showcasing a success?
• Agenda : Give a quick outline of the key sections or topics you’ll cover to help the audience follow along.
• Set expectations : Let your audience know what you want them to take away from the presentation, whether it’s knowledge, inspiration or a call to action.

How to present a case study on PowerPoint and on Google Slides?

Presenting a case study on PowerPoint and Google Slides involves a structured approach for clarity and impact using presentation slides :

• Title slide : Start with a title slide that includes the name of the case study, your name and any relevant institutional affiliations.
• Introduction : Follow with a slide that outlines the problem or situation your case study addresses. Include a hook to engage the audience.
• Objectives : Clearly state the goals of the case study in a dedicated slide.
• Findings : Use charts, graphs and bullet points to present your findings succinctly.
• Analysis : Discuss what the findings mean, drawing on supporting data or secondary research as necessary.
• Conclusion : Summarize key takeaways and results.
• Q&A : End with a slide inviting questions from the audience.

What’s the role of analysis in a case study presentation?

The role of analysis in a case study presentation is to interpret the data and findings, providing context and meaning to them. 

It helps your audience understand the implications of the case study, connects the dots between the problem and the solution and may offer recommendations for future action.

Is it important to include real data and results in the presentation?

Yes, including real data and results in a case study presentation is crucial to show experience,  credibility and impact. Authentic data lends weight to your findings and conclusions, enabling the audience to trust your analysis and take your recommendations more seriously

How do I conclude a case study presentation effectively?

To conclude a case study presentation effectively, summarize the key findings, insights and recommendations in a clear and concise manner. 

End with a strong call-to-action or a thought-provoking question to leave a lasting impression on your audience.

What’s the best way to showcase data in a case study presentation ?

The best way to showcase data in a case study presentation is through visual aids like charts, graphs and infographics which make complex information easily digestible, engaging and creative. 

Don’t just report results, visualize them! This template for example lets you transform your social media case study into a captivating infographic that sparks conversation.

Choose the type of visual that best represents the data you’re showing; for example, use bar charts for comparisons or pie charts for parts of a whole. 

Ensure that the visuals are high-quality and clearly labeled, so the audience can quickly grasp the key points. 

Keep the design consistent and simple, avoiding clutter or overly complex visuals that could distract from the message.

Choose a template that perfectly suits your case study where you can utilize different visual aids for maximum impact. 

Need more inspiration on how to turn numbers into impact with the help of infographics? Our ready-to-use infographic templates take the guesswork out of creating visual impact for your case studies with just a few clicks.

Related: 10+ Case Study Infographic Templates That Convert

Congrats on mastering the art of compelling case study presentations! This guide has equipped you with all the essentials, from structure and nuances to avoiding common pitfalls. You’re ready to impress any audience, whether in the boardroom, the classroom or beyond.

And remember, you’re not alone in this journey. Venngage’s Case Study Creator is your trusty companion, ready to elevate your presentations from ordinary to extraordinary. So, let your confidence shine, leverage your newly acquired skills and prepare to deliver presentations that truly resonate.

Go forth and make a lasting impact!

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• Open access
• Published: 27 May 2024

Multi-source remote sensing-based landslide investigation: the case of the August 7, 2020, Gokseong landslide in South Korea

• Shin-Kyu Choi 1 ,
• Ryan Angeles Ramirez   ORCID: orcid.org/0000-0003-1596-8295 2 ,
• Hwan-Hui Lim 3 &
• Tae-Hyuk Kwon   ORCID: orcid.org/0000-0002-1610-8281 3  

Scientific Reports volume  14 , Article number:  12048 ( 2024 ) Cite this article

Metrics details

• Engineering
• Natural hazards

Landslides pose a growing concern worldwide, emphasizing the need for accurate prediction and assessment to mitigate their impact. Recent advancements in remote sensing technology offer unprecedented datasets at various scales, yet practical applications demand further case studies to fully integrate these technologies into landslide analysis. This study presents a case study approach to fully leverage variety of multi-source remote sensing technologies for analyzing the characteristics of a landslide. The selected case is a landslide with a long runout debris flow that occurred in Gokseong County, South Korea, on August 7, 2020. The chosen multi-source technologies encompass digital photogrammetry using RGB and multi-spectral imageries, 3D point clouds acquired by light detection and ranging (LiDAR) mounted on an unmanned aerial vehicle (UAV), and satellite interferometric synthetic aperture radar (InSAR). The satellite InSAR analysis identifies the initial displacement, triggered by rainfall and later transforming into a debris flow. The utilization of digital photogrammetry, employing UAV-RGB and multi-spectral image data, precisely delineates the extent affected by the landslide. The landslide encompassed a runout distance of 678 m, featuring an initiation zone characterized by an average slope of 35°. Notably, the eroded and deposited areas measured 2.55 × 10 4  m 2 and 1.72 × 10 4  m 2 , respectively. The acquired UAV-LiDAR data further reveal the eroded and deposited landslide volumes approximately measuring 5.60 × 10 4  m 3 and 1.58 × 10 4  m 3 , respectively. This study contributes a valuable dataset on a rainfall-induced landslide with a long runout debris flow, underscoring the effectiveness of multi-source remote sensing technology in monitoring and comprehending complex landslide events.

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Landslide detection, monitoring and prediction with remote-sensing techniques

Introduction.

Landslides refer to sudden collapse and rapid downstream movement of destabilized earth ground, which can be primed or triggered by various factors, including rainfall, earthquakes, and human activities. These events are highly unpredictable, and they carry immense velocity and impact force, posing significant hazards. Several catastrophic landslide-related damages have been reported around the world, such as the Woomyeon landslide in Seoul 1 , 2 , 3 , the Montecito landslide in California 4 , 5 , the Mabian landslide in Mabian County 6 , the Livadea landslide in Livadea village 7 , the Jichang landslide in Shuicheng County 8 , and the Aniangzhia landslide in Danba County 9 . As heavy rains become more concentrated in localized regions, the frequency and severity of landslide hazards are becoming increasingly pronounced in numerous countries.

Records on past landslide events are one of the critical ingredients to build a capacity for accurate prediction of potential landslides. The landslide record or landslide inventory needs to include the volumes of initial source and final deposited mass, and landslide characteristics (e.g., rheology, soil properties, erosion rate) as well as the geographic, geologic and topographic data. Hence, conducting a comprehensive investigation of landslide events becomes crucial, involving a quantitative assessment of their geometry, such as area, volume, and runout distance, along with other relevant landslide-related characteristics. In general, walk-in field surveys immediately after a landslide event can provide valuable information 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 . However, field visits are often restricted due to the safety concern, such as a potential danger of progressive collapse as an example.

Recently, remote sensing technology has emerged as a valuable tool to overcome this limitation as it can effectively monitor hard-to-reach areas and conduct prolonged and periodic observations. Additionally, it is cost-effective, time-saving, and portable. The types of remote sensing technology are classified according to the sensors (or cameras) mounted on UAVs (i.e., optical camera, LiDAR sensor, and radar sensor). Optical data typically includes visible radiation (red, green, and blue bands; RGB data) as well as infrared radiation (IR) range. In addition, monitoring using satellite radio detection and ranging (radar) enables observation of tiny displacements at the millimeter scale and can also observe past displacement histories. Therefore, the remote sensing techniques are widely utilized not only in the field of landslide disasters but also in various geo-science fields which requires long-term monitoring over a large area 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 .

Use of a single technique often poses a challenge in landslide surveys. For example, the optical imaging, as a passive method, is difficult to acquire topographic information in densely forested areas due to the occlusion effect 27 , 28 , 29 . Although the 3D point clouds gathered from LiDAR can provide topographic information, its lack of RGB information limits the object identification. The satellite radar is highly effective in detecting tiny displacements before a landslide occurs. However, its capability to observe meter-scale displacements with massive earth movements is limited. Rather than using a single technique, integration of multiple remote sensing technologies offers a promising approach to effective landslide monitoring 8 , 30 , 31 , 32 , 33 , 34 , 35 .

This study presents a comprehensive investigation on a landslide, focusing on the detailed analysis of its characteristics through the integration of diverse remote sensing technologies. The chosen case pertains to a landslide with a long runout debris flow that occurred in Gokseong County, South Korea, on August 7, 2020. A suite of multi-source technologies was strategically employed, including digital photogrammetry utilizing RGB and multi-spectral imagery, 3D point clouds derived from light detection and ranging (LiDAR) mounted on an unmanned aerial vehicle (UAV), and satellite interferometric synthetic aperture radar (InSAR). In particular, InSAR technology facilitated the detection of landslide initiation, while RGB and multi-spectral information aided in delineating the extent of the affected areas. Additionally, for precise quantification of landslide magnitude, 3D LiDAR point clouds were utilized to compute the volumes involved. Through the synergistic utilization of these diverse remote sensing technologies, this study aims to elevate the precision and efficacy of landslide investigations.

On August 7, 2020, a catastrophic landslide occurred at approximately 8:30 p.m. on a mountain behind a village in Osan town, Gokseong County, South Jeolla Province, South Korea (35°11′40″ N, 127°8′10″ E; Fig. 1 ), referred to as the Gokseong landslide. Figure 1 d represents the elevation profiles of the landslide channel before and after the event. It is a typical form of debris flows where eroded (or collapsed) sediment from the upstream area travels a long distance and accumulates in the downstream area. The primary trigger for this landslide was three consecutive days of heavy rainfall. The event caused extensive devastation to the downstream village as a significant volume of debris traveled a considerable distance, resulting in five fatalities, five houses buried, and a section of road collapsed (Fig. 2 ). Approximately 30 residents residing near the landslide site were evacuated. Five days post the landslide event, this study conducted a UAV field survey.

Optical images of the Gokseong landslide site: ( a ) Sentinel-2 image after the event in Sites 1 and 2, ( b ) before the event in Site 1 (captured by Korea National Geographic Information Institute, KNGII in 2019), ( c ) The image representing the location of Gokseong County in South Korea and ( d ) the profiles before and after the occurrence of the landslide event. Note that the areas highlighted by the red polygons indicate the landslide areas.

Digital photographs of the Gokseong landslide: ( a ) Overview of the landslide (Site 1), ( b ) the initiation zone of Site 1, ( c ) the deposition zone of Site 1, and ( d ) overview of the landslide (Site 2).

South Korea exhibits intricate climatic patterns arising from the interplay of continental and oceanic influences, featuring an average annual precipitation of 1,190 mm. The monsoon season, extending from July to September, contributes to over 50% of the total annual rainfall. Figure 3 presents rainfall data from a local meteorological station located 6 km from the landslide site, sourced from the Korea Meteorological Administration (KMA). The precipitation graph highlights the commencement of intense rainfall around 8:30 a.m. on August 5, 2020, two days before the landslide event. Approximately 7.5 h before the landslide occurrence, cumulative rainfall had surpassed 150 mm, with the maximum hourly rainfall recorded at 51.5 mm. The antecedent cumulative rainfall in the three days leading up to the landslide event amounted to 290 mm (Fig. 3 ). Additionally, on August 5, 2020, Typhoon Hagupit induced heavy rainfall in the region.

Hourly and cumulative rainfalls before the Gokseong landslide (at approximately 8:30 p.m. on August 7th).

Materials and methods

Landslide monitoring involves distinct phases before and after the occurrence. Before a landslide event, it is important to conduct ongoing monitoring by regularly measuring displacement in areas prone to such risks. Employing UAVs for this purpose proves to be inefficient. However, utilizing satellites, despite longer monitoring intervals, offers an effective alternative. After a landslide, quantitative assessments to area, volume, changes in elevation are required to identify triggers and formulate an effective recovery plan. Given that landslides typically occur within a range of several meters to hundreds of meters, the use of LiDAR data is more appropriate than radar data. Prior to the landslide, the satellite InSAR technology was utilized to detect any indications of pre-failure movement. Subsequent to the landslide event, the volumes of eroded and deposited materials were calculated using topographic data obtained from the 3D LiDAR sensor. Additionally, RGB and multi-spectral data were used to estimate the extent of the landslide damage area.

Pre-failure monitoring using satellite SAR data

This study involved the collection and processing of 32 satellite SAR data from the ascending Sentinel-1 mission, as shown in Fig.  4 . The dataset covered the period from August 1, 2019 to August 7, 2020, including the pre-failure state. The InSAR stack overview operator of the Sentinel Application Platform (SNAP) automatically selected the master image (January 1, 2020 in this analysis). Subsequently, the remaining images were co-registered as slave images to match the geometry of the master image. Figure  4 illustrates the spatiotemporal distribution of the Sentinel-1 SAR data stack and the interferometric pairs used in this study. The satellite InSAR method is capable of providing near-real-time monitoring of ground displacement, overcoming temporal, spatial, and meteorological constraints. Time-series InSAR analysis using multi-temporal satellite SAR effectively detects tiny displacements over a long period. In particular, we employed the permanent scatterer InSAR (PS-InSAR) method 36 , which is one of reliable and thus widely used time-series InSAR analysis methods. The PS-InSAR observes temporal deformation by using ground targets that exhibit stable phase behavior over the satellite radar data stack. The targets are primarily observed in in urban areas such as buildings, maintaining stable coherence and experiencing minimal noise interference. Compared to other InSAR analysis methods, it exhibits fewer atmospheric errors, enabling more precise estimation of ground displacement. Furthermore, it facilitates the analysis of long-term temporal deformation. The PS-InSAR analysis was carried out through a semi-automated processing chain with a two-stage workflow, consisting of the single master differential InSAR processing and the time series analysis.

Pairing of master and slave synthetic aperture radar (SAR) images.

Landslide area mapping using optical data

RGB and multi-spectral images were acquired for digital photogrammetry to examine the geometric characteristics of the landslide and analyze the affected area. The RGB images were captured using an optical digital camera (X5S, DJI) mounted on the DJI Inspire 2 UAV. Additionally, a multi-spectral digital camera (RedEdge-MX, MicaSense), capable of capturing five bands (i.e., 475 nm ± 32 nm for the blue band, 560 nm ± 27 nm for the green band, 668 nm ± 14 nm for the red band, 717 nm ± 12 nm for red edge band, and 842 nm ± 57 nm for near-infrared (NIR) band), was installed on the DJI Inspire 2 UAV to obtain multi-spectral images. For data analysis, 3D point clouds were generated from overlapped images taken from various locations using the structure from motion algorithm (SfM) with the Agisoft Metashape program (v.1.5.5). Ground control points (GCP) were employed to ensure high accuracy in obtaining point clouds, as the global navigation satellite system (GNSS) sensor mounted on the UAV had limited accuracy.

In particular, this study employed the normalized difference vegetation index (NDVI) to delineate landslide-affected areas 37 , 38 , and it is calculated using the NIR and red band reflectance, as follows:

where R NIR is the reflectance of the NIR band and R red is the reflectance of the red band. The NDVI proves more accurate than results derived from RGB images, particularly in forested and vegetated areas, common locations for landslides. Its application extends to extracting landslide-affected areas, considering diverse characteristics contingent on land cover types. In this study, the NDVI was used to differentiate various land-cover types, with vegetated areas exhibiting higher NDVI values, while non-vegetated regions, such as soil or concrete, showed lower values. Therefore, when a landslide occurs, the NDVI decreases significantly as trees and vegetation are uprooted, leaving only exposed soil behind 38 . Leveraging these distinctive features, the occurrence of landslides was analyzed using multi-spectral data at the Gokseong landslide site.

Topographic change estimation using LiDAR data

The landslide volume plays a crucial role in back-analyzing the flow characteristics of landslides. Additionally, post-disaster recovery planning necessitates volume information, which can be derived from changes in elevation obtained through remote sensing. This study estimated the landslide volume based on the change in topographic elevation before and after the landslide, where a UAV-LiDAR system was used to obtain the topographic information. The system was composed of a UAV (Matrice 600 Pro, DJI), GNSS, inertial measurement unit (IMU), LiDAR sensor (VLP-16, Velodyne), and other components. Detailed information on the UAV-LiDAR system used in this study can be found in Choi et al. 39 , including its configuration, calibration, and accuracy. The UAV-LiDAR system was flown at an altitude of 300 m with a velocity of 3 m/s to acquire a 3D LiDAR point cloud of the area after the landslide event. Then, the topographic change was quantified by using the multiscale model-to-model cloud comparison (M3C2) method, which calculates the distance between two point clouds even in cases where homologous parts are not explicitly defined 40 . When two point clouds are produced, the normal vector is determined by analyzing the points within the circle defined by the user. The normal vector indicates the direction of change between the two point clouds. Next, the average elevation is determined by analyzing the points within a cylinder defined by the user. This entire process is repeated for each point separated by the input distance, allowing for a comprehensive analysis of topographic changes between the two point clouds.

Landslide pre-failure analysis

Figure 5 represents the pre-failure annual mean velocity map along the line-of-sight (LOS) direction. Securing observation points in forested areas becomes challenging due to the scattering of radar signals caused by vegetation movement. Fortunately, observation points were obtained on the road near the landslide initiation zone in Site 1 (PS A1-to-A4; Fig. 5 b). Figure 6 shows the temporal variations of displacements in the LOS direction, superimposed with hourly precipitation data over time. The LOS displacements were negative, indicating movement away from the satellite along the LOS direction. Prior to the landslide event, the precipitation had continuously influenced the slope movement, specifically during Typhoon Hagupit on August 5, 2020. Similarly, Fig. 5 c shows the pre-failure annual mean velocity map and time-series displacement results of a landslide in Site 2, located 4 km away from the Gokseong landslide site. The observed pattern in Site 2 closely resembles that of Site 1 (PS A5-to-A7; Fig. 6 b). The displacement was attributed to continuous rainfall that commenced a few days earlier. These findings strongly suggest a significant correlation between landslide occurrences and rainfall patterns. Moreover, the study demonstrates that precise displacement monitoring through satellite InSAR technology can aid in identifying landslide-prone areas and monitoring displacement before major landslides occur.

Annual LOS mean velocity map. ( a ) Gokseong landslide site, ( b ) Site 1, and ( c ) Site 2. Note that the red and black rectangles in Fig. 5a indicate the locations of Sites 1 and 2, respectively. Note that the red polygons in Figs. 5b and 5c represent the landslide boundaries. The inset photos show the sites post-landslide.

Cumulative LOS displacement in ( a ) Site 1 and ( b ) Site 2. Note that the inset figures represent the results from April to August 2020.

Landslide area mapping

The trace of the landslide at Site 1 is illustrated in Fig. 2 a. The depth of the eroded channel was approximately 2.5 m. The initiation and deposition zones were located at elevations of 251 m and 160 m above sea level, respectively, with a total landslide runout distance of 678 m. The average slope of the landslide initiation zone was 35°. Additionally, the watershed widths of the initiation and transport zones ranged from approximately 40–60 m, while the maximum width of the deposition fan reached 140 m.

The NDVI estimated from the multi-spectral data delineated the landslide area (Site 1), as shown in Fig. 7 . The range of the NDVI value differed with land-cover types, and Fig. 7 c illustrates the NDVI distributions for road, landslide, and forest areas. In this study, the NDVI value of 0.04–0.70 was determined as the landslide area, and as a result, the landslide area was determined to be 4.26 × 10 4  m 2 . The delineated landslide area well matched with the actual landslide area, highlighting the accuracy of the method employing multi-spectral images, UAV and NDVI.

( a ) RGB composite image ( b ) Spatial distribution of NDVIs obtained from the UAV survey after the Gokseong landslide event and ( c ) NDVI distributions by land cover type. Polygons A, B, and C cover road, landslide, and forest, respectively. Note that the red polygon in Fig. 7a represents the area extracted by manual estimation, the black polygon in Fig. 7b represents the area extracted with an NDVI range 0.04 to 0.70, and the white polygons indicate the sample location to analyze the ranges of the NDVIs.

Elevation change post-landslide

The pre-landslide DEM data was constructed by using the source provided by Korea National Geographic Information Institute (KNGII), as illustrated in Fig. 8 a. Following the landslide event, a high-resolution digital elevation model (DEM) of the site was acquired using the UAV-LiDAR system (Fig. 8 b). Comparison of these two DEM allowed to identify terrain differences caused by the landslide (Fig. 8 c). The negative elevation change indicated the erosion and the positive elevation change means the deposition. The initiation zone of the landslide exhibited a substantial topographic change of more than 13 m. In the downstream area, it was confirmed that a significant amount of debris (5 m in thickness) was deposited as a result of the landslide. For the landslide area derived from the NDVI analysis, the volume of the landslide was calculated based on the changes in the terrain elevation. As a result, the eroded and deposited volumes were estimated to be approximately 5.37 × 10 4  m 3 and 1.58 × 10 4  m 3 , respectively.

Digital elevation information of the landslide region: ( a ) Before and ( b ) after the event. ( c ) Elevation difference map, which captures the source and deposition areas.

Effect of resolution of the NDVI data on the landslide area and volume

The Normalized Difference Vegetation Index (NDVI) can exhibit variations depending on the timing of data collection. Moreover, NDVI values are subject to change based on the specific characteristics of the area where a landslide has occurred 41 , 42 , 43 . Accurate estimation of the landslide occurrence area requires identifying the appropriate NDVI range. Incorrect selection may result in underestimation or overestimation of the landslide area. Meanwhile, it is worth noting that the resolution of the map heavily affects the determination of NDVI range and landslide areas. Herein, we further compare different data acquisition techniques and examine the effect of image resolution on the results.

This study uses optical and multi-spectral images with 10 m resolution acquired on August 20, 2020 from the Sentinel-2 satellite and obtains an NDVI map (Fig. 9 a,b). Herein, the NDVI of 0.08–0.53 is chosen to delineate the landslide area (Fig. 9 c). Figures 7 b and 9 b compare the landslide covers captured from the UAV-driven NDVI map and satellite-driven NDVI map, respectively. The distinction between the road and debris (landslide) boundaries is less clear, especially in the initiation zone, in the satellite-based result compared to the UAV-acquired result. While it is possible to distinguish between the landslide and forest covers, there is an overlapping section between the landslide and the road, as shown in Figure 9 c. The image resolution seems to have a minimal impact on the aerial estimates of the depositional area: 1.72 × 10 4  m 2 from the UAV-RGB map with the visual inspection method, 1.75 × 10 4  m 2 from the UAV-NDVI, and 1.83 × 10 4  m 2 from the satellite NDVI, respectively, as illustrated in Fig. 10 a. However, it exerts a more significant influence on the erosion area estimation: 2.55 × 10 4  m 2 from the UAV-RGB map, 2.49 × 10 4  m 2 from the UAV-NDVI map, and 3.01 × 10 4  m 2 from the satellite NDVI map (Fig. 10 b). These variations can be attributed to the lower resolution of the Sentinel-2 images, resulting in significant overestimation of the erosion area within the landslide region.

( a ) Optical image and ( b ) spatial distribution of NDVIs, which were obtained from the Sentinel-2 after the event. c Ranges of NDVI by region. Note that the black polygon in Fig. 9b represents the area extracted with an NDVI range 0.08 to 0.53. Note that the red circle indicates the soil sampling point.

Estimated areas and volumes related to the landslide. ( a ) Results in the deposition zone and ( b ) results in the erosion zone. Note that manual estimation indicates that the landslide area is delineated with visual inspection of the optical image.

Similarly, image resolution has a greater impact on the estimation of erosion volume compared to deposited volume. When the elevation changes acquired from UAV-LiDAR used, the erosion volume is estimated to be 5.60 × 10 4  m 3 from the UAV-RGB map, 5.37 × 10 4  m 3 from the UAV-NDVI map, and 6.21 × 10 4  m 3 from the satellite NDVI map (Fig. 10 b). By contrast, the deposited volume appears to be consistent, e.g., approximately 1.58 × 10 4  m 3 from the UAV-RGB map, 1.58 × 10 4  m 3 from the UAV-NDVI map, and 1.61 × 10 4  m 3 from the satellite NDVI map (Fig. 10 a).

These results clearly demonstrate that the spatial resolution of NDVI data plays a significant role in determining the area and volume of landslides, particularly in areas with notable topographic changes, i.e., the erosion zone in this study. Therefore, it is crucial to carefully consider and select an appropriate image resolution when conducting landslide investigations to ensure accurate and reliable results.

Effect of topographic information on the landslide volume

The elevation change can be determined by using two approaches: digital photogrammetry using UAV-RGB images (or UAV-RGB) and 3D LiDAR point cloud (or UAV-LiDAR). In this context, a comparison of these two approaches is conducted, focusing on erosion and deposition volume estimation, as illustrated in Fig. 10 . Overall, the UAV-LiDAR method yields a greater erosion volume but a lower deposition volume when compared to the UAV-RGB method. This discrepancy is attributed to the interference of the tree branches in the RGB images. The elevation change near wooded areas is not properly captured in the volume calculation, especially in the narrow upstream area where erosion is prevalent. By contrast, in the downstream area with a wider deposition fan and fewer trees, the difference in deposited volume between the UAV-RGB and UAV-LiDAR methods is relatively minimal (Fig. 10 b).

Distribution of soil water content

The moisture content (or water content) of soil undergoes changes during rainfall infiltration, and hence it is one of the important indicators to rainfall-triggered or rainfall-primed landslides. Specifically, in the event of a landslide and accompanying debris flow, the water contents in the various regions—such as the upslope landslide initiation area, eroded channel bed, and downstream deposition zone—reflects the characteristics of surface soils, including their density and looseness. In this section, the water content of soils at the Gokseong landslide site is estimated using UAV-acquired multi-spectral images. An artificial neural network (ANN) model developed by Lim and his co-workers 44 is employed for this purpose, which utilizes soil color and NIR reflectance characteristics as input parameters, extracted from the multi-spectral images, to predict the water content of soils.

Figure 11 illustrates the distribution of soil water content within the soil cover affected by the landslide. The result reveals that the soil in the landslide initiation (source) zone exhibits a low water content, measuring below 22%, while the downstream deposition zone features a higher water content, exceeding 26%. In the initiation zone, the top soil underwent erosion, leaving the exposed soil cover as the original ground. As a result, the soil in this area showed a high compacted density and thus a low water content when fully saturated. Furthermore, the multispectral imaging was carried out a few days after the precipitation ceased, potentially allowing for the drainage of pore water from the steep slope in this region. In contrast, the majority of the soil cover downstream consisted of freshly deposited soil. Consequently, this loosely deposited soil exhibited a higher water content. Along the curved debris flow path, a notable difference in water content is observed between the left and right-side channels due to the prevalence of erosion on one side and the dominance of deposition on the other. Particularly noteworthy is an area in the middle-stream where the estimated soil water content exceeds 41%. This heightened water content is presumed to be primarily a result of substantial soil deposition in this specific corner area. However, it is also worth noting that the shading in this particular region may have influenced the multi-spectral imaging, potentially contributing to this unusually high water content.

Distribution of soil water content at the landslide site.

To validate the water content estimation based on the ANN model, soil samples were collected from the deposition zone, given restricted access to the landslide site (Fig. 9 a). The water content of a sampled soil was measured at 27.8%, while the estimated water content for the corresponding location was 26.5%. Although further validation is required to fully validate the ANN model, the result suggests feasibility of using the multi-spectral images for estimating the water content across large-scale soil covers. The water content data enhances the accuracy of landslide predictions by accounting for the impact of preceding rainfall on landslide occurrence. Furthermore, post-landslide water content data can contribute to improved forecasts of potential collapses.

Implications of multi-source remote sensing

In this study, we present four remote sensing techniques: satellite-based InSAR, UAV-driven RGB imaging, UAV-driven multi-spectral imaging and UAV-driven LiDAR survey. Before the landslide event, the satellite InSAR technology detects occurrence and continuity of displacement over a wide area. After the landslide event, RGB and multi-spectral image data are used to estimate the extent of the landslide damage area. The eroded and deposited volumes are assessed using topographic data obtained from the UAV-LiDAR system. In addition, the UAV-driven multi-spectral images, in combination with a prediction model, allow estimation of water content of the soil cover. Integration of these valuable data advances our understanding of landslides, and it can facilitate not only prediction of landslide hazard but also planning of effective post-disaster recovery plans.

The satellite InSAR technology plays a crucial role in identifying landslide-prone areas and enables long-term pre-event monitoring, without the need for on-site visits. To ensure high accuracy, it is essential to carefully choose the optimal analysis method among various InSAR methods and related parameters based on the site conditions and type of landslides. In forested regions, the selection of an appropriate radar wavelength for acquiring coherent radar targets becomes especially critical. The radar wavelength directly influences the probability of radar waves being scattered from the crowns or stems of trees. Smaller radar wavelengths tend to increase the likelihood of such scattering occurrences 45 , 46 , 47 , 48 .

The UAV-acquiring RGB imaging offers numerous advantages in various applications. One significant benefit is the capability to acquire a digital surface model (DSM). Moreover, it facilitates visible inspections for landslide triggers without the need for on-site access. Additionally, the UAV-acquiring RGB imaging proves valuable in manually estimating the extent of landslides, providing a means to cross-verify results obtained from the NDVI method. Furthermore, this UAV-acquiring RGB imaging technology demonstrates remarkable efficiency and rapidity in monitoring areas with minimal vegetation or exposed terrain, such as rocky mountain, post-landslide sites, and bare soil. The simplicity of operating UAVs and processing data makes it an optimal choice for such monitoring tasks. However, it is important to note that in regions with dense vegetation, the UAV-LiDAR system becomes indispensable for acquiring accurate topographic information. The UAV-LiDAR technology offers a significant advantage by providing topographic information even in densely vegetated areas. However, LiDAR sensors using specific wavelengths may encounter limitations in data collection when the ground is saturated. In this study, the LiDAR points were not acquired for five days after the Gokseong landslide event, as the soil remained saturated after the event (the LiDAR sensor operated at a wavelength of 905 nm in this study). Fifteen days after the landslide event, the soil had dried sufficiently to obtain LiDAR points. The selection of appropriate LiDAR sensors is crucial, especially when dealing with monitoring tasks in areas with saturated ground shortly after a landslide event.

Conclusions

This study presents a comprehensive demonstration of the multi-source remote sensing technology employed to analyze the Gokseong landslide in South Korea. The novel approach involved utilizing UAV-mounted RGB, multi-spectral, and LiDAR sensors, and satellite SAR sensor. The key findings derived from this study are as follows:

The research employed satellite InSAR technology to monitor ground displacement before the occurrence of the landslide. The satellite InSAR technology can provide time-series displacement of the study area, which is critical in understanding the pre-landslide displacement patterns. The displacement persisted prior to the landslide, and its pattern exhibited a significant correlation with rainfall in the region. The selection of radar wavelength and InSAR analysis methods should be considered concerning the type of landslides and field characteristics.

The UAV equipped with RGB and multi-spectral sensors offer a valuable means of acquiring precise information regarding the topography and land-cover of the study area. The UAV-mounted RGB, multi-spectral sensors can help identify traces and erosion patterns of the landslide. The landslide area analyzed using the NDVI was consistent with the results obtained from the manual estimation.

The landslide volume was analyzed by acquiring topographic information through the UAV-LiDAR technology. Although the flight and processing procedures are relatively complex compared to the UAV-RGB technology, this method has the distinct advantage of collecting topographic information in forested areas. LiDAR data allows for precise capturing of the topography and provides high-resolution elevation information.

The multi-source remote sensing technology can provide a comprehensive understanding of landslide characteristics, significantly enhancing disaster risk assessment and aiding in the formulation of effective recovery plans.

Data availability

The data and materials used in this article are available upon request by the correspondence author.

Abbreviations

Light detection and ranging

Unmanned aerial vehicle

Interferometric synthetic aperture radar

Red, green, blue

Radio detection and ranging

Infrared radiation

Korea Meteorological Administration

Sentinel application platform

Permanent scatterer InSAR

Near-infrared

Structure from motion

Ground control point

Global navigation satellite system

Normalized difference vegetation index

Inertial measurement unit

Multiscale model-to-model cloud comparison

Line of sight

Korea National Geographic Information Institute

Digital elevation model

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Acknowledgements

This work was supported by Korea Electric Power Corporation (Grant number: R22XO05-05) and "Ministry of the Interior and Safety" R&D program (20018265).

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S.C.: Conceptualization, Methodology, Validation, Formal analysis, Investigation, Resources, Data Curation, Writing – Original Draft, Visualization. R.R.: Investigation, InSAR analysis, Writing. H.L.: Investigation, Multi-spectral data analysis, Laboratory experiment, Writing. T.K.: Writing – Review & Editing, Supervision, Project administration, Funding acquisition. All authors reviewed and contributed to the manuscript.

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Choi, SK., Ramirez, R.A., Lim, HH. et al. Multi-source remote sensing-based landslide investigation: the case of the August 7, 2020, Gokseong landslide in South Korea. Sci Rep 14 , 12048 (2024). https://doi.org/10.1038/s41598-024-59008-4

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EPA Transcriptomic Assessment Product (ETAP) and Value of Information (VOI) Case Study

EPA’s Safer Chemicals Research  aims to address the challenge of needing more chemical information to make informed, risk-based decisions. Less  than a quarter of the tens of thousands of chemicals in commerce--as well as those found in the environment, various waste streams, and the human body--have traditional toxicity or epidemiological data that can inform human health risk assessments. To address the challenge,  researchers developed the EPA Transcriptomic Assessment Product (ETAP). ETAP is a novel human health assessment approach targeting chemicals lacking traditional toxicity testing data. To accompany the ETAP, EPA also conducted a Value of Information (VOI) analysis to weigh the public health and economic trade-offs associated with the timeliness, uncertainty, and costs of the ETAP compared to traditional toxicity tests. 

EPA Transcriptomic Assessment Product (ETAP)

Value of information (voi) analysis.

• Expected Results

A human health assessment or science assessment is typically the hazard identification and dose-response analysis that produces a reference value for the chemical. This, along with exposure information, is foundational for a risk assessment . 

One reason for the limited number of human health assessments, and subsequent risk assessments, is traditional toxicity testing and human health assessments for a chemical are time and resource intensive--often taking eight or more years to complete. State agencies, the public, and various stakeholder organizations are in need of toxicity values for data poor chemicals in a shorter timeframe in order to take an informed action to protect human health.

The draft EPA Transcriptomic Assessment Product (ETAP) aims to help address chemicals lacking traditional toxicity testing data in a more timely way. The primary driver for this new assessment product is the lack of human health toxicity values for most chemicals under the EPA regulatory purview. The ETAP transcriptomic-based reference values can be developed and reported in a 6–9-month timeframe, providing key data to the Agency that may facilitate more timely regulatory decision-making. ETAP is currently undergoing a Board of Scientific Counselors (BOSC) and public comment review. 

" Transcriptomics " is the study of messenger RNA molecules expressed in a cell or tissue, and it takes advantage of technology from the human genome project   tha t allows for a comprehensive evaluation of changes in gene activity. Previous studies have demonstrated that doses of chemicals causing disruption of gene activity are highly correlated with doses causing toxicological responses in traditional animal toxicity tests. Costs associated with the RNA sequencing technology have fallen significantly, making it more accessible and enabling broad application to environmental issues.

Read the draft reports: 

• Standard Methods for Development of ETAPs (pdf) (3.1 MB)
• Scientific Studies Supporting Development of Transcriptomic Points of Departure for EPA Transcriptomic Assessment Products (ETAPs) (pdf) (2.3 MB)

EPA developed a Value of Information (VOI) decision frameworks to evaluate the ETAP compared to toxicity testing in traditional human health assessments. VOI analysis was listed as a recommendation in the 2009 NAS report Science and Decisions  to provide EPA a more objective decision framework in assessing the trade-offs of time, uncertainty, and cost for a variety of chemical exposure scenarios and decision contexts.

This socio-economic analysis compares the public health (i.e., societal health benefits) and economic trade-offs associated with the ETAP as compared to traditional toxicity testing and human health assessment.

The VOI results suggest a more timely new assessment product, like the ETAP, has significant public health and economic benefits compared with the traditional toxicity testing and human health assessment process.

Read the draft report:

• VOI Case Study Report (pdf) (3.1 MB)
• VOI Case Study Supplemental Material (pdf) (1.4 MB)

Results and Future Directions

The goal of the draft ETAP is to develop and operationalize a new process for timely human health assessment for chemicals that lack human health toxicity data. Once the chemical of interest is in the lab, an ETAP can be completed in less than a year. In the reports developed by the EPA for scientific peer review, a literature review and transcriptomic dose response analysis studies showed high concordance between transcriptomic and apical benchmark dose (BMD) values in traditional animal toxicity studies. The concordance was robust across species, sex, route of exposure, physical chemical properties, toxicokinetic half-life, and technology platform. The error associated with the concordance between the transcriptomic and apical BMD values was demonstrated to be approximately equivalent to the combined inter-study variability associated with the transcriptomic study and the two-year rodent bioassay. 

In July 2023,  EPA solicited public comment and held two separate ad hoc Board of Scientific Counselors (BOSC) panels met to review the ETAP and VOI materials. After these reviews, EPA will respond to comments, finalize and publish these reports. 

• Board of Scientific Counselors (BOSC)  EPA Transcriptomic Assessment Products (ETAP) Panel
• Board of Scientific Counselors (BOSC) Value of Information (VOI) Panel
• Standard Methods
• Value of Information Case Study
• Assessments

• Open access
• Published: 24 May 2024

Integration of case-based learning and three-dimensional printing for tetralogy of fallot instruction in clinical medical undergraduates: a randomized controlled trial

• Jian Zhao 1   na1 ,
• Xin Gong 1   na1 ,
• Jian Ding 1 ,
• Kepin Xiong 2 ,
• Kangle Zhuang 3 ,
• Rui Huang 1 ,
• Shu Li 4 &
• Huachun Miao 1  

BMC Medical Education volume  24 , Article number:  571 ( 2024 ) Cite this article

Metrics details

Case-based learning (CBL) methods have gained prominence in medical education, proving especially effective for preclinical training in undergraduate medical education. Tetralogy of Fallot (TOF) is a congenital heart disease characterized by four malformations, presenting a challenge in medical education due to the complexity of its anatomical pathology. Three-dimensional printing (3DP), generating physical replicas from data, offers a valuable tool for illustrating intricate anatomical structures and spatial relationships in the classroom. This study explores the integration of 3DP with CBL teaching for clinical medical undergraduates.

Sixty senior clinical medical undergraduates were randomly assigned to the CBL group and the CBL-3DP group. Computed tomography imaging data from a typical TOF case were exported, processed, and utilized to create four TOF models with a color 3D printer. The CBL group employed CBL teaching methods, while the CBL-3DP group combined CBL with 3D-printed models. Post-class exams and questionnaires assessed the teaching effectiveness of both groups.

The CBL-3DP group exhibited improved performance in post-class examinations, particularly in pathological anatomy and TOF imaging data analysis ( P  < 0.05). Questionnaire responses from the CBL-3DP group indicated enhanced satisfaction with teaching mode, promotion of diagnostic skills, bolstering of self-assurance in managing TOF cases, and cultivation of critical thinking and clinical reasoning abilities ( P  < 0.05). These findings underscore the potential of 3D printed models to augment the effectiveness of CBL, aiding students in mastering instructional content and bolstering their interest and self-confidence in learning.

The fusion of CBL with 3D printing models is feasible and effective in TOF instruction to clinical medical undergraduates, and worthy of popularization and application in medical education, especially for courses involving intricate anatomical components.

Peer Review reports

Tetralogy of Fallot (TOF) is the most common cyanotic congenital heart disease(CHD) [ 1 ]. Characterized by four structural anomalies: ventricular septal defect (VSD), pulmonary stenosis (PS), right ventricular hypertrophy (RVH), and overriding aorta (OA), TOF is a focal point and challenge in medical education. Understanding anatomical spatial structures is pivotal for learning and mastering TOF [ 2 ]. Given the constraints of course duration, medical school educators aim to provide students with a comprehensive and intuitive understanding of the disease within a limited timeframe [ 3 ].

The case-based learning (CBL) teaching model incorporates a case-based instructional approach that emphasizes typical clinical cases as a guide in student-centered and teacher-facilitated group discussions [ 4 ]. The CBL instructional methods have garnered widespread attention in medical education as they are particularly appropriate for preclinical training in undergraduate medical education [ 5 , 6 ]. The collection of case data, including medical records and examination results, is essential for case construction [ 7 ]. The anatomical and hemodynamic consequences of TOF can be determined using ultrasonography, computed tomography (CT), and magnetic resonance imaging techniques. However, understanding the anatomical structures from imaging data is a slow and challenging psychological reconstruction process for undergraduate medical students [ 8 ]. Three-dimensional (3D) visualization is valuable for depicting anatomical structures [ 9 ]. 3D printing (3DP), which creates physical replicas based on data, facilitates the demonstration of complex anatomical structures and spatial relationships in the classroom [ 10 ].

During the classroom session, 3D-printed models offer a convenient means for hands-on demonstration and communication, similar to facing a patient, enhancing the efficiency and specificity of intra-team communication and discussion [ 11 ]. In this study, we printed TOF models based on case imaging data, integrated them into CBL teaching, and assessed the effectiveness of classroom instruction.

Research participants

The study employed a prospective, randomized controlled design which received approval from the institutional ethics committee. Senior undergraduate students majoring in clinical medicine at Wannan Medical College were recruited for participation based on predefined inclusion criteria. The researchers implemented recruitment according to the recruitment criteria by contacting the class leaders of the target classes they had previously taught. Notably, these students were in their third year of medical education, with anticipation of progressing to clinical courses in the fourth year, encompassing Internal Medicine, Surgery, Obstetrics, Gynecology, and Pediatrics. Inclusion criteria for participants encompassed the following: (1) proficient communication and comprehension abilities, (2) consistent attendance without absenteeism or truancy, (3) absence of failing grades in prior examinations, and (4) capability to conscientiously fulfill assigned learning tasks. Exclusion criteria were (1) absence from lectures, (2) failure to complete pre-and post-tests, and (3) inadequate completion of questionnaires. For their participation in the study, Students were provided access to the e-book “Localized Anatomy,” authored by the investigators, as an incentive for their participation. Voluntary and anonymous participation was emphasized, with participants retaining the right to withdraw from the study at any time without providing a reason.

The study was conducted between May 1st, 2023, and June 30, 2023, from recruitment to completion of data collection. Drawing upon insights gained from a previous analogous investigation which yielded an effect size of 0.95 [ 10 ]. Sample size was computed, guided by a statistical consultant, with the aim of 0.85 power value, predicated on an effect size of 0.8 and a margin of error set at 0.05. A minimum of 30 participants per group was calculated using G*Power software (latest ver. 3.1.9.7; Heinrich-Heine-Universität Düsseldorf, Düsseldorf, Germany), resulting in the recruitment of a total of 60 undergraduate students. Each participant was assigned an identification number, with codes placed in boxes. Codes drawn from the boxes determined allocation to either the CBL group or the CBL-3DP group. Subsequently, participants were randomly assigned to either the CBL group, receiving instruction utilizing the CBL methodology, or the CBL-3DP group, which received instruction integrating both CBL and 3D Printed models.

Printing of TOF models

Figure  1 A shows the printing flowchart of the TOF models. A typical TOF case was collected from the Yijishan Hospital of Wannan Medical College. The CT angiography imaging data of the case was exported. Mimics Research 20.0 software (Mimics Innovation Suite version 20, Materialize, Belgium) was used for data processing. The cardiovascular module of the CT-Heart tool was employed to adjust the threshold range, independently obtain the cardiac chambers and vessels, post-process the chambers and vessels to generate a hollow blood pool, and merge it with the myocardial volume to construct a complete heart model. The file was imported into Magics 24.0 software (version 24.0; Materialize, Belgium) for correction using the Shell tool page. After repairs, the model entered the smoothing page, where tools such as triangular surface simplification, local smoothing, refinement and smoothing, subdivision of components, and mesh painting were utilized to achieve varying degrees of smoothness. Finally, optimized data were obtained and exported as stereolithography (STL) files. An experienced cardiothoracic surgeon validated the anatomical accuracy of the digital model.

The STL files were imported into a 3D printer (J401Pro; Sailner 3D Technology, China) for model printing. This printer can produce full-color medical models using different materials. The models were fabricated using two distinct materials: rigid and flexible. Both materials are suitable for the observational discussion of the teaching objectives outlined in our study. From the perspective of observing pathological changes in the TOF, there is no significant difference between the two materials.

Experimental flow chart of this study. A TOF model printing flow chart. B The instructional framework

Teaching implementation

Figure  1 B illustrates the instructional framework employed in this study. One week preceding the class session, all the students were tasked with a 30-minute self-study session, focusing on the theoretical content related to TOF as outlined in the Pediatrics and Surgery textbooks, along with a review of pertinent academic literature. Both groups received co-supervision from two basic medicine lecturers boasting over a decade of teaching experience, alongside a senior cardiothoracic surgeon. Teaching conditions remained consistent across groups, encompassing uniform assessment criteria and adherence to predefined teaching time frames, all conducted in a Project-Based Learning (PBL) classroom at Wannan Medical College. Additionally, a pre-course examination was administered to gauge students’ preparedness for self-study.

In adherence to the curriculum guidelines, the teaching objectives aimed to empower students to master TOF’s clinical manifestations, diagnostic modalities, and differential diagnoses, while acquainting them with treatment principles and surgical methodologies. Additionally, the objectives sought to cultivate students’ clinical reasoning abilities and problem-solving skills. the duration of instruction for the TOF theory session was standardized to 25 min. The didactic content was integrated with the TOF case study to construct a coherent pedagogical structure.

During the instructional session, both groups underwent teaching utilizing the CBL methodology. Clinical manifestations and case details of TOF cases were presented to stimulate students’ interest and curiosity. Subsequently, the theory of TOF, including its etiology, pathogenesis, pathologic anatomy, clinical manifestations, diagnostic methods, and therapeutic interventions, was briefly elucidated. Emphasis was then placed on the case, wherein selected typical TOF cases were explained, guiding students in analysis and discussion. Students were organized into four teams under the instructors’ supervision, fostering cooperative learning and communication, thereby deepening their understanding of the disease through continuous inquiry and exploration (Fig.  2 L). In the routinely equipped PBL classroom with standard heart models (Fig.  2 J, K), all students had prior exposure to human anatomy and were familiar with these models. Both groups were provided with four standard heart models for reference, while the CBL-3DP group received additional four 3D-printed models depicting TOF anomalies, enriching their learning experience (Fig.  2 D, G). After the lesson, summarization, and feedback sessions were conducted to consolidate group discussions’ outcomes, evaluate teaching effectiveness, and assess learning outcomes.

Heart models utilized in instructional sessions. A External perspective of 3D digital models. B, C Cross-sectional views following trans-septal sagittal dissection of the 3D digital model (PS: Pulmonary Stenosis; OA: Overriding Aorta; VSD: Ventricular Septal Defect; RVH: Right Ventricular Hypertrophy). D External depiction of rigid 3D printed model. E, F Sagittal sections of the rigid 3D printed model. G External portrayal of flexible 3D printed model. H, I Sagittal sections of the flexible 3D printed model. J, K The normal heart model employed in the instruction of the CBL group. L Ongoing classroom session

Teaching effectiveness assessment

Following the instructional session, participants from the two groups underwent a theoretical examination to assess their comprehension of the taught material. This assessment covered domains such as pathological anatomy, clinical manifestations, imaging data interpretation, diagnosis, and treatment relevant to TOF. Additionally, structured questionnaires were administered to evaluate the efficacy of the pedagogical approach employed. The questionnaire consisted of six questions designed to gauge participants’ understanding of the teaching content, enhancement of diagnostic skills, cultivation of critical thinking and clinical reasoning abilities, bolstering of confidence in managing TOF cases, satisfaction with the teaching mode, and satisfaction with the CBL methodology.

The questionnaire employed a 5-point Likert scale to gauge responses, with 5 indicating “strongly satisfied/agree,” 4 for “satisfied/agree,” 3 denoting “neutral,” 2 reflecting “dissatisfied/disagree,” and 1 indicating “strongly dissatisfied/disagree.” It comprised six questions, with the initial two probing participants’ knowledge acquisition, questions 3 and 4 exploring satisfaction regarding enhanced competence, and the final two assessing satisfaction with teaching methods and modes. Additionally, participants were encouraged to provide suggestions at the end of the questionnaire. To ensure the questionnaire’s validity, five esteemed lecturers in basic medical sciences with more than 10 years of experience verified its content and assessed its Content Validity Ratio and Content Validity Index to ensure alignment with the study’s objectives.

Statistical analysis

Statistical analyses were conducted utilizing GraphPad Prism 9.0 software. Aggregate score data for both groups were presented as mean ± standard deviation (x ± s). The gender comparisons were analyzed with the chi-square (χ2) test, while the other variables were compared using the Mann-Whitney U test. The threshold for determining statistical significance was set at P  < 0.05.

Three-dimensional printing models

After configuring the structural colors of each component (Fig.  2 A, B, C), we printed four color TOF models using both rigid and flexible materials, resulting in four life-sized TOF models. Two color TOF models were created using rigid materials (Fig.  2 D, E, F). These models, exhibiting resistance to deformation, and with a firm texture, smooth and glossy surface, and good transparency, allowing visibility of the internal structures, were deemed conducive to teaching and observation. We also fabricated two color TOF models using flexible materials (Fig.  2 G, H, I), characterized by soft texture, opacity, and deformability, allowing for easy manipulation and cutting. It has potential utility beyond observational purposes. It can serve as a valuable tool for simulating surgical interventions and may be employed to create tomographic anatomical specimens. In this study, both material models were suitable for observation in the classroom. The participants were able to discern the four pathological changes characteristic of TOF from surface examination or cross-sectional analysis.

Baseline characteristics of the students

In total, 60 students were included in this study. The CBL group comprised 30 students (14 males and 16 females), with an average age of (21.20 ± 0.76) years. The CBL-3DP group consisted of 30 students (17 males and 13 females) with an average age of 20.96 years. All the students completed the study procedures. There were no significant differences in age, sex ratio, or pre-class exam scores between the two groups ( P  > 0.05), indicating that the baseline scores between the two groups were comparable (Table  1 ).

Theoretical examination results

All students completed the research procedures as planned. The post-class theoretical examination encompassed assessment of pathological anatomy, clinical presentations, imaging data interpretation, diagnosis, and treatment pertinent to TOF. Notably, no statistically significant disparities were observed in the scores on clinical manifestations, diagnosis and treatment components between the cohorts, as delineated in Table  2 . Conversely, discernible distinctions were evident whereby the CBL-3DP group outperformed the CBL group notably in pathological anatomy, imaging data interpretation, and overall aggregate scores ( P  < 0.05).

Results of the questionnaires

All the 60 participants submitted the questionnaire. Comparing the CBL and CBL-3DP groups, the scores from the CBL-3DP group showed significant improvements in many areas. This included satisfaction with the teaching mode, promotion of diagnostic skills, bolstering of self-assurance in managing TOF cases, and cultivation of critical thinking and clinical reasoning abilities (Fig.  3 B, C, D, E). All of which improved significantly ( P  < 0.05 for the first aspects and P  < 0.01 for the rest). However, the two groups were not comparable ( P  > 0.05) in terms of understanding of the teaching content and Satisfaction with the CBL methodology (Fig.  3 A, F).

Upon completion of the questionnaires, participants were invited to proffer recommendations. Notably, in the CBL group, seven students expressed challenges in comprehending TOF and indicated a need for additional time for consolidation to enhance understanding. Conversely, within the CBL-3DP group, twelve students advocated for the augmentation of model repertoire and the expansion of disease-related data collection to bolster pedagogical efficacy across other didactic domains.

Five-point Likert scores of students’ attitudes in CBL ( n  = 30) and CBL-3DP ( n  = 30) groups. A Understanding of teaching content. B Promotion of diagnostic skills. C Cultivation of critical thinking and clinical reasoning abilities. D Bolstering of self-assurance in managing TOF cases. E Satisfaction with the teaching mode. F Satisfaction with the CBL methodology. ns No significant difference, * p  < 0.05, ** p  < 0.01, *** p  < 0.001

TOF presents a significant challenge in clinical practice, necessitating a comprehensive understanding for effective diagnosis and treatment [ 12 ]. Traditional teaching methods in medical schools have relied on conventional resources such as textbooks, 2D illustrations, cadaver dissections, and radiographic materials to impart knowledge about complex conditions like TOF [ 13 ]. However, the limitations of these methods in fully engaging students and bridging the gap between theoretical knowledge and practical application have prompted a need for innovative instructional approaches.

CBL has emerged as a valuable tool in medical education, offering students opportunities to engage with authentic clinical cases through group discussions and inquiry-based learning [ 14 ]. By actively involving students in problem-solving and decision-making processes, CBL facilitates the application of theoretical knowledge to real-world scenarios, thus better-preparing students for future clinical practice [ 15 ]. Our investigation revealed that both groups of students exhibited comparable levels of satisfaction with the CBL methodology, devoid of discernible disparities.

CHD presents a formidable challenge due to the intricate nature of anatomical anomalies, the diverse spectrum of conditions, and individual variations [ 16 ]. Utilizing 3D-printed physical models, derived from patient imaging data, can significantly enhance comprehension of complex anatomical structures [ 17 ]. These models have proven invaluable in guiding surgical planning, providing training for junior or inexperienced pediatric residents, and educating healthcare professionals and parents of patients [ 18 ]. Studies indicate that as much as 50% of pediatric surgical decisions can be influenced by the insights gained from 3D printed models [ 19 ]. By providing tangible, anatomically accurate models, 3D printing offers a unique opportunity for people to visualize complex structures and enhance their understanding of anatomical intricacies. Our study utilized full-color, to-scale 3D printed models to illustrate the structural abnormalities associated with TOF, thereby enriching classroom sessions and facilitating a deeper comprehension of the condition.

Comparative analysis between the CBL-3DP group and the CBL group revealed significant improvements in post-test performance, particularly in pathological anatomy and imaging data interpretation. Additionally, questionnaire responses indicated higher levels of satisfaction and confidence among students in the CBL-3DP group, highlighting the positive impact of incorporating 3D printed models into the learning environment, improving the effectiveness of CBL classroom instruction. Despite the merits, our study has limitations. Primarily, participants were exclusively drawn from the same grade level within a single college, possibly engendering bias owing to shared learning backgrounds. Future research could further strengthen these findings by expanding the sample size and including long-term follow-up to assess the retention of knowledge and skills. Additionally, the influence of the 3D models depicting a normal heart on the learning process and its potential to introduce bias into the results warrants consideration, highlighting a need for scrutiny in subsequent studies.

As medical science continues to advance, the need for effective teaching methods becomes increasingly paramount. Our study underscores the potential of combining active learning approaches like CBL with innovative technologies such as 3D printing to enhance teaching effectiveness, improve knowledge acquisition, and foster students’ confidence and enthusiasm in pursuing clinical careers. Moving forward, further research and integration of such methodologies are essential for meeting the evolving demands of medical education, especially in areas involving complex anatomical understanding.

Conclusions

Integrating 3D-printed models with the CBL method is feasible and effective in TOF instruction. The demonstrated success of this method warrants broad implementation in medical education, particularly for complex anatomical topics.

Data availability

All data supporting the conclusions of this research are available upon reasonable request from the corresponding author.

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Acknowledgements

We extend our sincere appreciation to the instructors and students whose invaluable participated in this study.

This paper received support from the Education Department of Anhui Province, China (Grant Numbers 2022jyxm1693, 2022jyxm1694, 2022xskc103, 2018jyxm1280).

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Jian Zhao and Xin Gong are joint first authors.

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Department of Human Anatomy, Wannan Medical College, No.22 West Wenchang Road, Wuhu, 241002, China

Jian Zhao, Xin Gong, Jian Ding, Rui Huang & Huachun Miao

Department of Cardio-Thoracic Surgery, Yijishan Hospital of Wannan Medical College, Wuhu, China

Kepin Xiong

Zhuhai Sailner 3D Technology Co., Ltd., Zhuhai, China

Kangle Zhuang

School of Basic Medical Sciences, Wannan Medical College, Wuhu, China

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Contributions

Jian Zhao and Huachun Miao designed the research. Jian Zhao, Xin Gong, Jian Ding, Kepin Xiong designed the tests and questionnaires. Kangle Zhuang processed the imaging data and printed the models. Xing Gong and Kepin Xiong implemented the teaching. Jian Zhao and Rui Huang collected the data and performed the statistical analysis. Jian Zhao and Huachun Miao prepared the manuscript. Shu Li and Huachun Miao revised the manuscript. Shu Li provided the Funding acquisition. All authors reviewed and approved the final manuscript.

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Correspondence to Shu Li or Huachun Miao .

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Zhao, J., Gong, X., Ding, J. et al. Integration of case-based learning and three-dimensional printing for tetralogy of fallot instruction in clinical medical undergraduates: a randomized controlled trial. BMC Med Educ 24 , 571 (2024). https://doi.org/10.1186/s12909-024-05583-z

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A modern way to teach and practice manual therapy

• Roger Kerry 1 ,
• Kenneth J. Young   ORCID: orcid.org/0000-0001-8837-7977 2 ,
• David W. Evans 3 ,
• Edward Lee 1 , 4 ,
• Vasileios Georgopoulos 1 , 5 ,
• Adam Meakins 6 ,
• Chris McCarthy 7 ,
• Chad Cook 8 ,
• Colette Ridehalgh 9 , 10 ,
• Steven Vogel 11 ,
• Amanda Banton 11 ,
• Cecilia Bergström 12 ,
• Anna Maria Mazzieri 13 ,
• Firas Mourad 14 , 15 &
• Nathan Hutting 16  

Chiropractic & Manual Therapies volume  32 , Article number:  17 ( 2024 ) Cite this article

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Musculoskeletal conditions are the leading contributor to global disability and health burden. Manual therapy (MT) interventions are commonly recommended in clinical guidelines and used in the management of musculoskeletal conditions. Traditional systems of manual therapy (TMT), including physiotherapy, osteopathy, chiropractic, and soft tissue therapy have been built on principles such as clinician-centred assessment , patho-anatomical reasoning, and technique specificity. These historical principles are not supported by current evidence. However, data from clinical trials support the clinical and cost effectiveness of manual therapy as an intervention for musculoskeletal conditions, when used as part of a package of care.

The purpose of this paper is to propose a modern evidence-guided framework for the teaching and practice of MT which avoids reference to and reliance on the outdated principles of TMT. This framework is based on three fundamental humanistic dimensions common in all aspects of healthcare: safety , comfort , and efficiency . These practical elements are contextualised by positive communication , a collaborative context , and person-centred care . The framework facilitates best-practice, reasoning, and communication and is exemplified here with two case studies.

A literature review stimulated by a new method of teaching manual therapy, reflecting contemporary evidence, being trialled at a United Kingdom education institute. A group of experienced, internationally-based academics, clinicians, and researchers from across the spectrum of manual therapy was convened. Perspectives were elicited through reviews of contemporary literature and discussions in an iterative process. Public presentations were made to multidisciplinary groups and feedback was incorporated. Consensus was achieved through repeated discussion of relevant elements.

Conclusions

Manual therapy interventions should include both passive and active, person-empowering interventions such as exercise, education, and lifestyle adaptations. These should be delivered in a contextualised healing environment with a well-developed person-practitioner therapeutic alliance. Teaching manual therapy should follow this model.

Musculoskeletal (MSK) conditions are leading contributors to the burden of global disability and healthcare [ 1 ]. Amongst other interventions, manual therapy (MT) has been recommended for the management of people with MSK conditions in multiple clinical guidelines, for example [ 2 , 3 ].

MT has been described as the deliberate application of externally generated force upon body tissue, typically via the hands, with therapeutic intent [ 4 ]. It includes touch-based interventions such as thrust manipulation, joint mobilisation, soft-tissue mobilisation, and neurodynamic movements [ 5 ]. For people with MSK conditions, this therapeutic intent is usually to reduce pain and improve movement, thus facilitating a return to function and improved quality of life [ 6 ]. Patient perceptions of MT are, however, vague and sit among wider expectations of treatment including education, self-efficacy and the role of exercise, and prognosis [ 7 ].

Although the teaching and practice of MT has invariably changed over time, its foundations arguably remain unaltered and set in biomedical and outdated principles. This paper sets out to review contemporary literature and propose a revised model to inform the teaching and practice of MT.

The aim of this paper is to stimulate debate about the future teaching and practice of manual therapy through the proposal of an evidence-informed re-conceptualised model of manual therapy. The new model dismisses traditional elements of manual therapy which are not supported by research evidence. In place, the model offers a structure based on common humanistic principles of healthcare.

Consenus methodology

We present the literature synthesis and proposed framework as a consensus document to motivate further professional discussion developed through a simple three-stage iterative process over a 5-year period. The consensus methodology was classed as educational development which did not require ethical approval. Stage 1: a change of teaching practice was adopted by some co-authors (VG, RK, EL) on undergraduate and postgraduate Physiotherapy programmes at a UK University in 2018. This was a result of standard institutional teaching practice development which includes consideration of evidence-informed teaching. Stage 2: Input from a broader spectrum of stakeholders was sought, so a group of experienced, internationally-based educators, clinicians, and researchers from across the spectrum of manual therapy was convened. Perspectives were elicited through discussions in an iterative process. Stage 3: Presentations were made by some of the co-authors (VG, RK, SV, KY) to multidisciplinary groups (UK, Europe, North America) and feedback via questions and discussions was incorporated into further co-author discussions on the development of the framework. Consensus was achieved through repeated discussion of relevant elements. Figure  1 summarises the consensus methodology.

Summary and timeline of iterative consensus process for development of framework (MT: Manual Therapy; UG: Undergraduate; PG: Postgraduate)

Clinical & cost effectiveness of manual therapy

Manual therapy has been suggested to be a valuable part of a multimodal approach to managing MSK pain and disability, for example [ 8 ]. The majority of recent systematic reviews of clinical trials report a beneficial effect of MT for a range of MSK conditions, with at least similar effect sizes to other recommended approaches, for example [ 9 ]. Some systematic reviews report inconclusive findings, for example [ 10 ], and a minority report effects that were no better than comparison or sham treatments, for example [ 11 ].

Potential benefits must always be weighed against potential harms, of course. Mild to moderate adverse events from MT (e.g. mild muscle soreness) are common and generally considered acceptable [ 12 ], whilst serious adverse events are very rare and their risk may be mitigated by good practice [ 13 ]. MT has been reported by people with MSK disorders as a preferential and effective treatment with accepted levels of post-treatment soreness [ 14 ].

MT is considered cost-effective [ 15 ] and the addition of MT to exercise packages has been shown to increase clinical and cost-effectiveness compared to exercise alone in several MSK conditions [ 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 ]. Further, manual therapy has been shown to be less costly and more beneficial than evidence-based advice to stay active [ 24 ].

In summary, MT is considered a useful evidence-based addition to care packages for people experiencing pain and disability associated with MSK conditions. As such, MT continues to be included in national and international clinical guidelines for a range of MSK conditions as part of multimodal care.

Principles of traditional manual therapy (TMT)

Manual therapy has been used within healthcare for centuries [ 4 ] with many branches of MT having appeared (and disappeared) over time [ 25 ]. In developed nations today, MT is most commonly utilised by the formalised professional groups of physiotherapy, osteopathy, chiropractic, as well as groups such as soft tissue therapists. All of these groups have a history that borrows heavily from traditional healers and bone-setters [ 26 ].

Although there are many elements of MT, three principles appear to have become ubiquitous within what we shall now refer to as ‘traditional manual therapy’ (TMT): clinician-centred assessment , patho-anatomical reasoning , and technique specificity [ 27 , 28 , 29 , 30 ]. These principles continue to influence the teaching and practice of manual therapy over recent years, for example [ 31 ].

However, they have become increasingly difficult to defend given a growing volume of empirical evidence to the contrary.

Traditional manual therapy (TMT) principles: origins and problems

Clinician-centred assessment.

TMT has long had an emphasis on what we shall refer to as clinician-centred assessments . Within this, we claim, is an assumption that clinical information is both highly accurate and diagnostically important, for example [ 32 ]. Clinician-centred assessments include, for example, routine imaging, the search for patho-anatomical 'lesions’ and asymmetries, and specialised palpation. Although the focus of this paper is on the ‘hands-on’ examples of client-centred assessment, the notion of imaging is presented below to expose some of the flaws in the underlying belief system for TMT.

The emphasis on clinician-centred assessments has probably been driven, in part, by a desire for objective diagnostic tests which align well with gold-standard imaging. Indeed, since the discovery of x-rays, radiological imaging been used as an assessment for spinal pain – and a justification for using spinal manipulation – particularly in the chiropractic profession [ 33 ]. Contrary to many TMT claims, X-ray imaging is not without risk [ 34 ]. Additionally, until relatively recently (with the advent of magnetic resonance imaging) it was not widely appreciated that patho-anatomical ‘lesions’ believed to explain MSK pain conditions were nearly as common in pain-free individuals as those with pain [ 35 ]. Accordingly, the rates of unnecessary treatments, including surgery, are known to increase when imaging is used routinely [ 36 ]. For patients with non-specific low back pain, for example, imaging does not improve outcomes and risks overdiagnosis and overtreatment [ 37 ]. Hence, despite being objective in nature, the value of imaging for many MSK pain conditions (particularly spinal pain) has reduced drastically with clinical guidelines across the globe recommending against routine imaging for MSK pain of non-traumatic origin [ 38 ]. Even so, the practice of routine imaging continues [ 39 ].

Hands-on interventions are inextricably related to hands-on assessment [ 40 ], and often associated with claims of ‘specialisation’ [ 41 ]. By this we mean where a great level of training and precision are claimed to be necessary for influencing the interpretation of assessment findings, treatment decisions, and/or treatment outcomes. Implicit within this claim is that therapists who are unable to achieve such precision are not able to perform MT to an acceptable level (and thereby are not able to provide benefit to patients).

There are numerous studies that cast doubt over claims of highly specialised palpation skills. Palpation of anatomical landmarks does not reach a clinically acceptable level of validity [ 42 ]. Specialised motion palpation does not appear to be a good method for differentiating people with or without low back pain [ 43 ]. Poor content validity of specialised motion tests have been reported, in line with a lack of acceptable reference standards [ 44 ]. Palpable sensations reported by therapists are unlikely to be due to tissue deformation [ 45 ]. Furthermore, the delivery of interventions based on specialised palpatory findings is no better than non-specialised palpation [ 46 ]. Generally poor reliability of motion palpation skills has been reported, for example [ 47 ] and appear to be independent of clinician experience or training, for example [ 48 ]. Notably, person-centred palpation—for pain and tenderness for example—has slightly higher reliability, but is still fair at best [ 49 ].

This does not mean that palpation is of no use at all though; just that effective manual therapy does not depend upon it. For example, expert therapists can display high levels of interrater reliability during specialised motion palpation [ 50 ]. Focused training can improve the interrater reliability of specialised skills [ 51 ]. However, the validity of the phenomenon remains poor. Given the weight of the evidence and consistency of data over recent decades, we suggest that the role of clinician-centred hands-on assessment is no longer central to contemporary manual therapy.

Patho-anatomical reasoning

The justification for selecting particular MT interventions has historically been based upon the patho-anatomical status of local peripheral tissue [ 52 , 53 , 54 , 55 ]. Patho-anatomical reasoning, we propose, is the framework that links clinician-centred assessments to the desire for highly specific delivery of MT interventionsKey to this is the relationship between a patho-anatomic diagnosis and the assumed mechanisms of action of the intervention employed.

Theories for the mechanisms of action of MT interventions are many. Some of the most prominent include reductions of disc herniations [ 56 ], re-positioning of a bone or joint [ 32 ], removal of intra-articular adhesions [ 57 ], changes in the biomechanical properties of soft tissues [ 58 ], central pain modulation [ 59 ], and biochemical changes [ 60 ]. These theories have been used to justify the choice of certain interventions: a matching of diagnosis (i.e., existence of a lesion) to the effect of treatment takes place. However, most of these mechanistic theories either lack evidence or have been directly contested [ 61 ].

The causal relationship between proposed tissue-based factors such as posture, ergonomic settings, etc. and painful experience has also been disputed [ 62 ]. Although local tissue stiffness has been observed in people with pain, this is typically associated with neuromuscular responses, rather than patho-anatomical changes at local tissue level [ 63 , 64 , 65 , 66 ]. Overall, although some local tissue adaptions have been identified in people with recurrent MSK pain, this is inconsistent and the evidence is currently of low quality [ 67 ] are generally limited to short-term follow-up measures [ 68 ].

Technique specificity

TMT techniques have been taught with an emphasis that a particular direction, ‘grade’ of joint movement, or deformation of tissue at a very specific location in a certain way, is required to achieve a successful treatment outcome.

One problem with a demand for technique specificity in manual therapy is that an intervention does not always result in the intended effect. For example, posteroanterior forces applied during spinal mobilization consistently induce sagittal rotation, as opposed to the assumed posteroanterior translation, for example [ 69 ]. Furthermore, irrespective of the MT intervention chosen, restricting movements to a particular spinal segment is difficult and a regional, non-specific motion is typically induced, for example [ 70 ].

To support technique specificity, comparative data must repeatedly and reproducibly show superiority of outcome from specific MT interventions over non-specific MT, which is consistently not observed [ 71 , 72 , 73 ]. Some studies have demonstrated localised effects of targeted interventions [ 74 ] but there appears to be no difference in outcome related to: the way in which techniques are delivered [ 75 ]; whether technique selection is random or clinician-selected [ 41 ]; or variations in the direction of force or targeted spinal level [ 76 ]. Conversely, there is evidence that non-specific technique application may improve outcomes [ 77 , 78 , 79 ]. Further, sham techniques produce comparable results to specialised approaches [ 11 ].

Passive movement and localised touch have been associated with significant analgesic responses [ 80 ]. These data indicate the presence of an analgesic mechanism. Unfortunately, mechanistic explanation for the therapeutic effects of MT upon pain and disability still remain largely in a ‘black box’ state [ 81 ]. Nevertheless, there are several plausible mechanisms of action to explain the analgesic action of MT interventions, including the activation of modulatory spinal and supraspinal responses [ 82 , 83 , 84 , 85 ]. In support of this, MT interventions have been associated with a variety of neurophysiological responses [ 61 ]. However, it must be acknowledged that these studies provide mechanistic evidence based on association, which is insufficient to make causal claims [ 86 ]. Importantly, none of these neurophysiological responses have been directly related to either the analgesic mechanisms or clinical outcome and may therefore be incidental.

There is evidence that MT does not provide analgesia in injured tissues [ 87 , 88 ]. Conversely, MT has been shown to decrease inflammatory biomarkers [ 89 , 90 , 91 , 92 , 93 ], although these changes have not been evaluated in the longer-term, nor associated with clinical outcomes.

A modern framework for manual therapy

We propose a new direction for the future of MT in which the teaching and practice of this core dimension of MSK care are no longer based on the traditional principles of clinician-centred assessment , patho-anatomical reasoning , and technique specificity .

In doing so, this framework places MT more explicitly as part of person-centred care and appeals to common principles of healthcare, best available evidence, and contemporary theory which avoids unnecessary and over-complicated explanations of observed effects. The framework is simple in terms of implementation and delivery and contextualised by common elements of best practice for healthcare, in line with regulated standard of practice, e.g., [ 94 , 95 , 96 , 97 ]. Our proposal simply illustrates the operationalisation of these common elements through manual therapy.

Too much emphasis has been given to clinician-centred assessments and this should be rebalanced with an increased use of patient-centred assessments, such as a thorough case history, the use of validated patient-reported outcome measures (PROMS), and real-time patient feedback during assessments.

The new framework considers fundamental and humanistic dimensions of touch-based therapies, such as non-specific neuromodulation, communication and sense-making, physical education, and contextual clinical effectiveness. This aligns to contemporary ideas regarding therapeutic alliance and a move towards genuinely holistic healthcare [ 98 , 99 ]. The framework needs to be “open” in order to represent and allow expression of the complexity of the therapeutic encounter. However, to prevent the exploitation of this openness the framework is underpinned by evidence, and any manual therapy approaches without plausible and measurable mechanisms are not supported.

To provide the best care, common healthcare elements such as the safety and comfort of the person seeking help and therapist must be considered, and care should be provided as efficiently as possible. Our framework embraces these dimensions and employs an integration of current evidence. It is transdisciplinary in nature and may be adopted by all MT professions. Figure  1 provides a graphical representation of the framework. It is acknowledged that all components overlap, relate, and influence each. There are two main components: the practical elements on the inside, comprised of safety, comfort, and efficiency, and the conceptual themes on the outer regions, consisting of communication, context, and person-centred care Fig. 2 .

Representation of a modern teaching and practice framework for manual therapy. The image is purposefully designed to be simple, and has been developed primarily to be used as a teaching aid. When displayed in a learning environment, learners and clinicians can quickly refer to the image to check their practice against each element. To keep the image clear, each element of the image is described in detail in the text below”

Practical elements

Safety for people seeking help is a primary concern for all healthcare providers, with the aims to “ prevent and reduce risks, errors and harm that occur to patients [sic] during provision of health care… and to deliver quality essential health services ” [ 100 ]. This, and the notion of safety more generally (including that of the therapist), should be central to way MT is taught and practised.

A fundamentally safe context should be created where there is an absence of any obvious danger or risk of harm to physical or mental health. Consideration should be given to ensuring that communication and consent processes are orientated towards the safety of both the person seeking help and the therapist. The therapist should pay attention to any sense of threat that could be present in the physical, emotional, cognitive and environmental domains of the clinical encounter, and use skilful communication to mitigate anxiety about the assessment or therapeutic process.

Safety should also be considered in the clinical context of the assessment and treatment approach, ensuring that relevant and meaningful safety screenings have been undertaken [ 67 , 101 ]. There remains a need for good, skilful practice and development of manually applied techniques, but this can be achieved without reference to the principles of TMT and without the dogma of a proprietary therapeutic approach.

Comfort suggests that both the person seeking help and the therapist are physically and emotionally content during the assessment and therapeutic process. For example, the person seeking help is agreeable with any necessary state of dress (sociocultural difference should be considered); the person is relaxed and untroubled in whatever position they are in, and is adequately supported whether sitting, standing or recumbent during assessment and treatment; the therapist is comfortable with their positioning and posture; any discomfort produced by the therapeutic process is negotiated and agreed. Any physical mobilisation or touch should be applied with respect to the feedback from the person in relation to their comfort, rather than a pre-determined force based on the notion of resistance. This process requires clinical phronesis, sensitivity, responsivity, dexterity, and embodied communication [ 102 ].

The therapeutic process should be undertaken in a well-organised, competent manner aiming to achieve maximum therapeutic benefit with minimum waste of effort, time, or expense. To enhance the efficiency dimension, the assessment and therapeutic process should be an integral part of a holistic educational and/or activity-based approach to the management of the people which might also address psychological, nutritional, or ergonomic aspects of care, while being aware of social determinants to health. Recommendations exist which serve as a useful guide for enhancing care and promoting self-management in an efficient way [ 103 ].

A principle of this new model of MT is that therapists should not lose sight of the goals they develop with the people they help and ensure that there is coherence between their management aims and their techniques. Therapists should aim to support a person’s self-efficacy and use active approaches to empower them in their recovery. The overall number of therapeutic applications should be made in the context of fostering therapeutic alliance and supporting people to make sense of their situation and symptoms. This should be informed by contemporary views of the effects of manual therapy, emphasising a “physical education process” to promote sense-making and self-efficacy in alliance with the people they aim to help.

Clinical interactions need to be reproducible under a person’s own volition, serving to enhance self-empowerment. For example, someone could be taught how to “self-mobilise” if a positive effect is found with a particular therapeutic application. This should be appropriately scaffolded with behavioural change principles and functional contextualism that promote autonomy and self-management, rather than inappropriate reliance on the therapist [ 103 , 104 ].

An important and emergent notion from the proposed model is to question what constitutes indications for MT given that the model excludes traditional factors which would have informed whether manual therapy is indicated or not for a particular person. The response to this sits within the efficiency and safety dimensions: MT can be beneficial as part of a multi-dimensional approach to management across a broad population of people with musculoskeletal dysfunction, with no evidence to suggest any clinician-centered or patho-anatomical finding influences outcomes. The choice of whether or not to include MT as part of a management strategy should therefore be a product of a lack of contraindications and shared-decision making.

This framework aligns with evidence-based propositions that effectiveness and efficiency in assessment, diagnosis, and outcomes are not reliant on the therapist’s skill set of specialised elements of TMT, but rather other factors—for example variations in pain phenotypes [ 5 ].

Conceptual themes

Communication.

Communication is the overriding critical dimension to the whole therapeutic process and should be aimed at addressing peoples’ fundamental needs to make sense of their symptoms and path to recovery. The delivery and uptake of the therapy should therefore be operationalised in a communication process that meaningfully represents shared-decision making and the best possible attempt to contextualise the therapy in positive and evidence-informed explanations of the process and desired effects [ 105 ].

Within a therapeutic encounter, practitioners must give the time to listen to peoples’ accounts and explanations of their symptoms, including their ideas about their cause [ 106 ]. The assessment and diagnostic process should be a shared endeavour, for example, the negotiation of symptom reproduction. This should be done in a manner that facilitates sense-making, and which simultaneously encourages people to move on from unhelpful beliefs about their symptoms [ 107 , 108 ], encouraging understanding of the uncertain nature of pain and injury. Person-centered communication requires attention to what we communicate and how we communicate across the entire clinical interaction including interview, examination, and management planning [ 109 ]. Therapists need to be open, reflective, aware and responsive to verbal and non-verbal cues, and demonstrate a balance between engaging with people (e.g. eye-gaze) and writing/typing notes during the interview [ 110 , 111 , 112 ].

People should be given the opportunity to discuss their understanding of the diagnosis and options for treatment and rehabilitation. The decision-making process is dialogical, in which alternative options to the offered therapy should also be discussed with the comparative risks and benefits of all available management options, including doing nothing [ 113 , 114 ].

The therapist must fully appreciate the potential consequences of touch without consent. Continual dialogue should ensure that all parties are moving towards mutually agreed goals. The context of the therapy should be explicitly communicated to give appropriate context for any particular intervention as part of a holistic, evidence-based approach [ 115 , 116 , 117 ]. Therapists should be aware that their own beliefs can affect the way they communicate with their people; in the same way, a person’s context affects how they communicate what they expect from their treatment [ 107 , 118 , 119 , 120 ]. The construction of contextual healing scenarios which support positive outcomes, whilst minimising nocebic effects, is critical to effective healthcare [ 121 , 122 , 123 ].

There is a growing academic interest in the nature, role, and purpose of social and affective touch, and any re-framing of MT should consider touch as a means of communication to develop and enhance cooperative communications and strengthen the therapeutic relationship [ 124 , 125 , 126 , 127 , 128 , 129 ]. It can be soothing for a person in pain to experience the caring touch of a professional therapist [ 130 ]; on the other hand, probing, diagnostic, and touch can be experienced as alienating [ 131 , 132 , 133 ]. Touch can alter a person’s sense of body ownership and their ability to recognise and process their emotions by modulating interoceptive precision [ 129 , 134 , 135 ], and intentional touch may be perceived differently from casual, unfocussed touch [ 136 , 137 ]. There is also a thesis that touch generates shared understanding and meaning [ 138 , 139 , 140 ]. This wider appreciation of touch should be embedded in modern MT communication.

The contextual quality of a person’s experience of the therapeutic encounter can affect satisfaction and clinical outcomes [ 141 , 142 , 143 , 144 , 145 ]. The context in which therapeutic care takes place should therefore be developed to enhance this experience. There could be very local, practical aspects of the context, such as the type of passive information available in the clinical space, e.g. replacing biomedical and pathological imagery and objects with positive, active artefacts; judicious and thoughtful organisation and use of treatment tables to discourage a sense of passivity and disempowerment; allocating a comfortable space where communication can take place; colour schemes and light sources which facilitate positivity; ensuring consistency through all clinical and administrative staff promoting encouraging and non-nocebic messages. Importantly, the way the therapist dresses influences peoples’ perception of their healthcare experience [ 146 , 147 ], and that in turn should be contextually and culturally sensitive [ 148 , 149 , 150 ].

Beyond the local clinical space is the broader social environment. The undertaking of MT should serve a role in a person’s engagement with their social environment. For example, someone returning home after engaging with their therapist and disseminating positive health messages within their home and social networks; people acting as advocates for self-empowered healthcare. Furthermore, early data have demonstrated that aligning treatment with the beliefs and values of culturally and linguistically diverse communities enhances peoples’ engagement with their healthcare [ 151 ].

Person-centred care

Here we borrow directly from one of the most established and clinically useful definitions of Person-Centered Medicine [ 152 ]:

“(Person-Centered Medicine is) an affordable biomedical and technological advance to be delivered to patients [sic] within a humanistic framework of care that recognises the importance of applying science in a manner that respects the patients [sic] as a whole person and takes full account of [their] values, preferences, aspirations, stories, cultural context, fears, worries and hopes and thus that recognises and responds to [their] emotional, social and spiritual necessities in addition to [their] physical needs” [ 152 ] , p219.

Person-centred care incorporates a person’s perspective as part of the therapeutic process. In practice, therapists need to communicate in a manner that creates adequate conversational space to elicit a person’s agenda (i.e. understanding, impact of pain, concerns, needs, and goals), which guides clinical interactions. This approach encourages greater partnership in management [ 109 , 153 , 154 ].

A roadmap outlining key actions to implement person-centeredness in clinical practice has been outlined in detail elsewhere [ 155 ]. This includes screening for serious pathology, health co-morbidities and psychosocial factors; adopting effective communication; providing positive health education; coaching and supporting people towards active self-management; and facilitating and managing co-care (when needed) [ 154 ].

It is critical and necessary now to make these features explicit and central to the revised model of MT proposed in this paper. We wish to identify common ground across all MT professions in order to achieve a trans-disciplinary understanding of the evidence supporting the use of MT.

We acknowledge that our arguments here are rooted in empiricism and deliberately based on available research data from within the health science disciplines. We also acknowledge that there is a wider debate about future directions in person-centred care arising from the current evolution of the evidence-based health care movement, which has pointed to the need to learn more about peoples’ lived experiences, to redefine the model of the therapeutic relationship. Although beyond the scope of this paper, a full exploration of modern health care provision involves reconsideration of the ethics and legal requirements of communication and shared decision-making [ 156 , 157 , 158 , 159 ]. The authors envision this paper as a stimulus for self-reflection, stakeholder discussions, and ultimately change that can positively impact outcomes for people who seek manual therapy interventions.

Manual therapy has long been part of MSK healthcare and, given that is likely to continue. Current evidence suggests that effectiveness does not rely on the traditional principles historically developed in any of the major manual therapies. Therefore, the continued teaching and practice based on the principles of clinician-centred palpation , patho-anatomical reasoning , and technique specificity are no longer justified and may well even limit the value of MT.

A revised and reconceptualised framework of MT, based on the humanistic domains of safety, comfort and efficiency and underpinned by the dimensions of communication, context and person-centred care will ensure an empowering, biopsychosocial, evidence-informed approach to MSK care. We propose that the future teaching and practice of MT in physiotherapy, osteopathy, chiropractic, and all associated hands-on professions working within the healthcare field should be based on this new framework.

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Kerry, R., Young, K.J., Evans, D.W. et al. A modern way to teach and practice manual therapy. Chiropr Man Therap 32 , 17 (2024). https://doi.org/10.1186/s12998-024-00537-0

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Flood vulnerability assessment in rural and urban informal settlements: case study of Karonga District and Lilongwe City in Malawi

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• Isaac Kadono Mwalwimba 1 ,
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Flood vulnerability assessment (FVA) informs the disaster risk reduction and preparedness process in both rural and urban areas. However, many flood-vulnerable regions like Malawi still lack FVA supporting frameworks in all phases (pre-trans-post disaster). Partly, this is attributed to lack of the evidence-based studies to inform the processes. This study was therefore aimed at assessing households’ flood vulnerability (HFV) in rural and urban informal areas of Malawi, using case studies of Traditional Authority (T/A) Kilupula of Karonga District (KD) and Mtandire Ward in Lilongwe City (LC). A household survey was used to collect data from a sample of 545 household participants. Vulnerability was explored through a combination of underlying vulnerability factors (UVFs)-physical-social-economic-environmental and cultural with vulnerability components (VCs)-exposure-susceptibility and resilience. The UVFs and VCs were agglomerated using binomial multiple logit regression model. Variance inflation  factor (VIF) was used to check the multicollinearity of variables in the regression model. HFV was determined based on the flood vulnerability index (FVI). The data were analysed using Multiple Correspondence Analysis (MCA), artificial neural network (ANN) and STATA. The results reveal a total average score of high vulnerability (0.62) and moderate vulnerability (0.52) on MCA in T/A Kilupula of Karonga District and Mtandire Ward of Lilongwe City respectively. The FVI revealed very high vulnerability on enviroexposure factors (EEFs) ( \(0.9\) ) in LC and \((0.8\) ) in KD, followed by ecoresilience factors (ERFs) (0.8) in KD and \((0.6\) ) in LC and physioexposure factors (PEFs) ( \(0.5)\) in LC besides 0.6 in KD for the combined UVFs and VCs. The study concludes that the determinants of households’ flood vulnerability are place settlement, low-risk knowledge, communication accessibility, lack of early warning systems, and limited access to income of household heads. The study recommends that an FVA framework should be applied to strengthen the political, legal, social, and economic responsibilities of government for building the resilience of communities and supporting planning and decision-making processes in flood risk management.

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1 Introduction

Floods are a natural hazard that many communities have to cope with. Climate change and variability have resulted in changes in terms of the frequency and magnitudes of flood-inducing storms in many regions (Hodgkins et al. 2017 ; Kundzewicz et al. 2019 ). The Emergency Events Database (CRED, 2019) reported that around 50,000 people died and approximately 10% of the world population was affected by floods between 2009 and 2019 (Moreira et al. 2021 ). In recent years, the world has deviated from flood hazard control to flood vulnerability assessments (Ndanusa et al. 2022; Ran et al. 2018). This is because the vulnerability of a community partly induces floods to become disasters (Nong and Sathyna 2020 ; Salami et al. 2017 ) and such assessments are important in strategic decision-making and planning (de Risi et al. 2013 ). Consequently, vulnerability assessment has become a primary component of flood hazard mitigation, preparedness and management (Ndanusa et al. 2022). Based on the findings of many studies in the assessment of flood vulnerability, it has been noted that several studies have not combined indicators of UVFs and VCs in their assessments. Those that have combined the indicators (Karagiorgos et al. 2016 ; Mwale 2014 ; Nazeer and Bork 2021 ) have not gone further to propose FVA frameworks to support decision-making, creating a gap which has been addressed in this current study. Anwana and Oluwatobi ( 2023 ) provided a review of the literature on flood vulnerability in informal settlements globally and in South Africa, in particular. Their review found a distinct knowledge gap in flood vulnerability studies. In the Ibadan metropolis area of Nigeria, Salami et al. ( 2017 ) proposed and applied a flood vulnerability assessment framework to provide flood vulnerability assessments of the human settlements and their preparedness to mitigate flood risk. The study established that previous experience of flooding was a key factor in awareness levels, although this awareness was not significantly related to the level of preparedness during flooding. De Risi et al. ( 2013 ) proposed a probabilistic and modular approach to analysing flood vulnerability in informal settlements of Dar es Salaam City in Tanzania. Alam et al. ( 2022 ) conducted a vulnerability assessment based on household views from the Dammar Char in Southeastern Bangladesh by constructing a vulnerability index using quantitative and qualitative data. The study revealed that, on average, the people living in the Dammar Char have a high vulnerability to coastal hazards and disasters. In North-West Khyber Pakhtunkhwa of Pakistan, Nazeer and Bork ( 2019 ) carried out a flood vulnerability assessment through different methodologies of rescaling, weighting and aggregation schemes to construct the flood vulnerability indices. The study found that the weighting scheme had a greater influence on the flood vulnerability ranking compared to data rescaling and aggregation schemes. Oyedele et al. ( 2022 ) analysed vulnerability to flooding in Kogi State of Nigeria as a function of exposure, susceptibility and lack of resilience using 16 sets of indicators. The indicators were normalized and aggregated to compute the flood vulnerability index for the 20 purposively selected communities. The study established that the selected communities had varying levels of risk of flooding, “very high” to “high” vulnerability to flooding. Munyai et al. ( 2019 ) examined flood vulnerability in three rural villages in South Africa’s northern Limpopo Province using a flood vulnerability index. The study revealed that all three villages have a “vulnerability to floods” level, from medium to high vulnerability. While all these studies have assessed flood vulnerability, a framework for guiding its assessment process has been not proposed. The lack of such a framework implies that flood risk reduction is not programmed to address current and future risks. This could be a reason why disaster risk management in Malawi, for example, is described as post-event humanitarian actions and reactive.

The Sentinels-4-African DRR rank Malawi position 11 out of 53 African countries affected by floods from 1927 to 2022 with statistics of 42 events, 948 deaths and 3531, 145 people affected (Danzeglocke et al. 2023). Similarly, the 2011 Climate Change Vulnerability Index by the British Risk Analysis Firm Maplecroft ranks Malawi 15 out of 16 countries with extreme risks to climate change impacts in the world. GOM (2023) indicates that over twenty-five disasters experienced in Malawi have been associated with severe rainfall events in the last decade. For instance, between the periods of 2015–2023, about four major floods induced by tropical cyclones have affected communities. The most destructive was the floods of 11–13 March 2023, influenced by tropical cyclone Freddy (TCF), which killed about 679 people, injured 2178 people, displaced about 563,602 people, and about 511 people were reported missing, including causing several other damages and loss in sectors such as agriculture, infrastructure, food security and health (GOM, 2023). A “state of disaster” was declared on the 13th of March in the districts that were affected by the cyclone namely; Blantyre City and District, Chikwawa District, Chiradzulu District, Mulanje District, Mwanza District, Neno District, Phalombe district, Nsanje district, Thyolo district and Zomba city and district. Relatedly, in January 2022, the passage of a tropical storm named “Ana” over southern Malawi with heavy rainfall caused rivers to overflow, floods and landslides. The flooding affected 19 districts in the southern region and among the heavily affected districts were Chikwawa, Mulanje, Nsanje and Phalombe. The event caused 46 deaths, and 206 injuries, 152,000 people were displaced with several infrastructural damages. The country also experienced the worst cyclone Idai which originated from Mozambique in 2019. This cyclone induced floods which killed 60 people as well as affected 975,000, displaced 86,976 and injured 672 people (PDNA, 2019 ). In January and February 2015, over 1 million people were affected and about US$ 335 million was incurred on infrastructural damage (PDNA, 2015 ). However, floods have been considered largely as a rural manifestation during the past years (Chawawa, 2018 ), with district councils taking the lead in flood management through the development of disaster risk management strategies and policies (Manda and Wanda, 2017 ). This neglect made disaster management policies and strategies to be limited to cities as compared to rural areas. Recently, Lilongwe City has experienced numerous flooding with varying impacts of damage in schools, health centres, shops, houses and loss of lives (LCDRMP, 2017). This increased occurrence and devastating impacts calls for putting measures in place to protect people living in flood-prone areas, including flood risk reduction, prevention, mitigation and management. However, strong measures cannot be put without FVA which is a cornerstone for disaster risk reduction (Munyai et al. 2019 ; Nazeer and Bork 2021 ; Nong and Sathyna 2020 ).

FVA provides a significant opportunity towards identifying factors leading to flooding losses (Lidiu et al. 2018; Nazeer and Bork 2021 ; Ndanusa et al. 2022). FVA is an impetus in which science may help to build a resilient society (Ran et al. 2018; Birkmann et al. 2013 ). In addition, FVA provides metrics that can support decision-making processes and policy interventions (Mwale et al. 2015 ; Ndanusa et al. 2014) and is a proactive task for pre-hazard management and planning activities (Parvin et al. 2022 ). Nazir et al. (2013) argue that FVA provides an association between theoretical conceptions of flood vulnerability and daily administrative processes. Mwale ( 2014 ) holds that vulnerability must be quantified and analysed to identify specific dimensions of vulnerability. Birkmann et al. ( 2013 ) add that the need to understand vulnerability is a primary component of disaster risk reduction at the household and community level and culture of building resilience. Iloka ( 2017 ) highlights that measuring vulnerability helps to determine immediate impacts on lives as well as future impacts of the affected households and communities. The Sendai Framework (2015–2030), an international policy for DRR also emphasises vulnerability assessment as a tool for minimizing the impact of hazards (UNISDR 2017 ). The Sendai Framework posits that vulnerability assessment should be conducted to understand risk in all dimensions of vulnerability, capacity, exposure of persons, hazard characteristics and the environment (UNISDR 2017 ). Birkmann et al. ( 2013 ) suggest that a vulnerability assessment is a prerequisite to reducing any natural hazard's impacts. Therefore, this study was aimed at assessing household flood vulnerability in both rural and urban informal settlements in Malawi. This was achieved by: (1) analysing the variability of households' flood vulnerability (based on physical, social, economic, environmental and cultural factors (2) quantifying household vulnerability to floods in Karonga District and Lilongwe City using multicollinearity analysis of vulnerability factors (physical, social, economic, environmental and cultural) and vulnerability components (exposure, susceptibility and resilience) (3) proposing FVA framework for rural and urban informal settlements, including constructing a multi-hazard vulnerability indicators which is missing in most studies. The study contributes to scanty literature on FVA in developing countries such as Malawi. As many areas of Malawi are flood-prone, the study directly informs decision-making for both preparedness and mitigation measures among the vulnerable communities.

2 Materials and methods

2.1 study approach.

This study carried out flood vulnerability assessment (FVA) using an inductive approach (Abass 2018 ; Kissi et al. 2015 ). The use of an inductive approach allows the study to apply quantitative techniques (Fig.  1 ). These techniques helped to isolate variables and indicators that were significant to contribute to household flood vulnerability.

Methodology layout

2.2 Study area

This study was carried out in Karonga District and Lilongwe City in the northern and central regions of Malawi respectively. Specifically, this study was carried out in Mtandire Ward and Traditional Authority Kilupula in Karonga District and Lilongwe City respectively.

The target flood-prone area of T/A Kilupula in KD was the Lufilya catchment (Fig.  2 ). This study targeted two groups of village headmen (GVH) in T/A Kilupula of the northern part of Karonga district. These include GVH Matani Mwakasangila and Mujulu Gweleweta in Traditional Authority Kilupula. The area of GVH Matani Mwakasangila is found in T/A Kilupula located about 16 km north of Karonga town. GVH Matani Mwakasangila has five Village headmen (VH) namely Eliya Mwakasangila, Matani Mwakasangila, Chipamila, Shalisoni Mwakasangila and Fundi Hamisi. The greater part of the area—Eliya Mwakasangila, Chipamila and Matani Mwakasangila, are bounded by Lake Malawi to the eastern side and the M1 road-Songwe-Tanzania border to the Western side. The other two villages Shalisoni Mwakasangila and Fundi Hamisi are to the Western side of the M1 road. The area has numerous networks of rivers such as Lufilya, Kasisi, Fwira, Ntchowo, and Kasoba.

Map T/A Kilupula in Karonga District showing Villages of Study Area

This catchment of T/A Kilupula was selected based on the frequency of flood occurrence (Table  1 ). Kissi et al. ( 2015 ) indicate that the magnitude of an extreme event is inversely related to its frequency of occurrence. It was also chosen because the nature of their locations is prone to flooding (Mwalwimba 2020 , 2024 ; SEP-2013–2018). This makes the residents vulnerable to flood hazards that cause disaster every year.

The area is dominated by floodplains along the shores of Lake Malawi (SEP-2013–2018). These areas are flat and low-lying areas as such this becomes the pre-requisite to flooding in the event of a heavy downpour (Karonga Met Office 2021). Furthermore, the choice of this area was due to settlement patterns, located in flood plains and issues of culture that have forced the people to occupy dangerous areas and even occupy the protected areas rendering them vulnerable to the effects of flooding (Mwalwimba 2020 ) (Fig.  3 ).

Settlement patterns of households in T/A Kilupula of Karonga District

Lilongwe district hosts the capital city of Malawi. The district became the host of the Capital city in 1975 after it was relocated from Zomba. The district owes its name to the Lilongwe River, which flows across the centre of the district (SEP, 2017–2022). The city has grown tremendously since 2005 when the government relocated all the head offices from Blantyre (SEP 2017 ). This growth has been also amplified by the presence of numerous opportunities in the city like access to socio-economic services and availability of markets for the produced products. This growth has contributed in generating a lot of vulnerable conditions of people to hazards such as floods, accidents, fires, droughts, environmental degradation and disease epidemics (LCDRM 2017) because of increased environmental degradation, and increased conversion of agricultural land into urban infrastructural development. Though hazards in the city overlap and interact in cause and effect, floods are the most frequently occurring hazards that affect many parts of the city (SEP 2017 ). As a category related to water and weather, floods, mostly affect areas like Mtandire (area 56), Kauma, Kaliyeka, Chipasula, Kawale, Nankhaka, Area 22, Kauma, New Shire, Area 25, Kawale, and Mgona in the city (LCDRM 2017) (Fig.  4 ).

Map of Malawi showing the Location of Karonga District and Lilongwe City

Mtandire Ward in Lilongwe City (Fig.  5 ) was chosen because it is an informal settlement, a condition that would likely put residents susceptible to environmental hazards like floods. The records indicate that floods repeated in 2013, 2014, 2015, 2016 and 2017. Data indicates that in February 2017, floods caused a magnitude of the disaster which caused great damage; more than 4000 people were affected including loss of people’s lives. The affected areas were Mtandire, Kauma, New Shire, Area 25, Kawale, Nankhaka and Mgona.

Settlement Patterns in Mtandire Ward of Lilongwe City

2.3 Flood vulnerability

Vulnerability is a complex concept and includes diverse components (Rana et al. 2018). Therefore, vulnerability requires a comprehensive methodology which can help to reveal various components (Moreira et al. 2021 ). Rana et al. (2018) stipulate that there is a lack of integrated methodology that fuses all the components. This study used an indicator-based approach to quantitatively assess household flood vulnerability. As accorded by ISDR (2014), the quantitative approach was useful in establishing indicators of the FVA framework. Kablan et al. ( 2017 ), and Nazeer and Bork ( 2021 ) agree that quantitative indicators are used to predict flood vulnerability. However, variation exists in the selection of the quantitative tools (Kissi et al. 2015 ). For instance, Nazeer and Bork ( 2021 ) applied Pearson’s correlation to predict flood vulnerability. Kissi et al. ( 2015 ) used deductive and inductive approaches to select flood vulnerability indicators. This study used binomial multiple logistical regression to predict household flood vulnerability. The use of this method allowed us to agglomerate the indicators of the UVFs and VCs (Fig.  6 ).

Conceptual framework

2.3.1 Conceptual framework on flood vulnerability

This study developed a conceptual framework based on the understanding that a vulnerability occurs as an intersection of biophysical vulnerability and social vulnerability (Iloka 2017 ; Wisner et al. 2004 , Cutter 2003). This entails that the combination of hazard (floods) and vulnerability to harm society depends on the physical risk and social risk.

This conceptual framework indicates that two forces create vulnerability of households/communities to floods. First, households can be vulnerable to floods when subjected to the underlying vulnerability factors (physical, social, economic, environmental and cultural causes). Each of the causes, physical-social-economic-environmental-cultural, have the indicators that are used to identify households’ vulnerability to floods. Depending on variations that exist among these indicators in terms of their scores, percentages, inertias and probability values, households may be determined and/or predicted their vulnerabilities. The second force is determined by vulnerability components (exposure, susceptibility and resilience) (Kissi et al. 2015 ). Households are vulnerable to floods if they are exposed and susceptible to it and have less resilient to withstand its impacts (Rana et al. 2018). In this study, exposure is portrayed as the extent to which an area that is subject to an assessment falls within the geographical range of the hazard event (Nazeer and Bork 2021 ). This implies that exposure looks at possibility of flooding to impact people and their physical objects (Nazeer and Bork 2021 ) in the location they live. Furthermore, susceptibility means the predisposition of elements at risk (social and cultural) to suffering harm resulting from the levels of fragility conditions (Birkmann et al. 2013 ; Kablan et al. 2017 ; Nazeer and Bork 2021 ). Resilience of households is evaluated based on the capacity of people or society potentially exposed to hazards to adapt, by resisting or changing in order to reach and maintain an acceptable level of functioning and structure (Ndanusa et al. 2022). This is determined by the degree to which the social system is capable of organising itself to increase its capacity for learning from past disasters for better future protection and to improve risk reduction measures as well as to recover from the impact of natural hazard (Birkmann et al. 2013 ; Nazeer and Bork 2021 ). Iloka ( 2017 ) states that low incomes, lack of resources, and unemployment are some of the factors that make vulnerability leading to disasters. This study’s conceptual framework highlights the scenario that the occurrence of hazards (floods) in a community (Lilongwe city and Karonga district) where households are subjected to many characteristics in the vulnerability factors while at the same time the households are exposed and are susceptible to floods, the condition may turn floods to become disasters. It is only when the households have enough resilience and adaptive measures that they can either cope up with or respond quickly to the hazard (floods). Similarly, if the households are not resilient and have fewer adaptive measures, a situation that may increase vulnerability of households to the hazard impact resulting in a devastating disaster. Therefore, lack of adaptive capacity means that the community may be limited to respond to the disaster on time thereby their vulnerability will be always high. This conceptual framework gives a basis that flood vulnerability assessment therefore should examine factors that predict household vulnerability to floods and link them to the composite indicators of vulnerability, including understanding their adaptive capacity that would help them to cope with flood impacts. The assessment, using this framework should analyse several indicators from the underlying vulnerability factors and components of vulnerability to fully identify which of these conditions contribute to vulnerability in a specific location to generate standardised indicators of flood vulnerability assessment.

2.3.2 Indicators of flood vulnerability

Flood vulnerability was explored through the lens of underlying vulnerability factors (UVFs)-physical-social-economic-environmental and cultural (Table  2 ). The physical vulnerability (PV) has been defined as the vulnerability of the physically constructed materials. The indicators were defined as pre-underlying factors that may contribute to the constructed elements (houses & other infrastructures) being vulnerable to flood hazards. Social vulnerability (SV) is looked at by the influences of the variety of social processes which create the vulnerability of households to floods (Joakim 2008 ). Economic vulnerability (EcV) is defined as the influences of economic processes existing in the community i.e. livelihood activities that may or may not contribute to household vulnerability. Environmental vulnerability (EnV) is the vulnerability of the built environment as described by pre-existing conditions like residing in prone areas and use of natural resource base. Cultural vulnerability has been defined as vulnerability influenced by cultural fabric such as beliefs, customs, cultural conflicts and absence of resource ownership.

The vulnerability components (VCs)-exposure-susceptibility and resilience (Table  3 ) were combined by UVFs. Physical and environmental factors linked to exposure (i.e. human settlement damage, house type, location, rivers). Social and cultural factors combined with susceptibility (i.e. community accessibility, flood risk awareness, adaptation mechanisms, warning systems) to determine household vulnerability. Economic factors linked with resilience (i.e. a source of income, the capacity of economic skills and resource skills).

Both the UVFs and VCs were selected based on a thorough review of contemporary frameworks such as Pressure and Released Mode (Wisner et al. 2014 ); Urban Flood Vulnerability Framework (Salami et al. 2017 ); and the Hazard of Place Model (Cutter 1996 ). Since there is no generally acceptable way of selecting vulnerability indicators (Kablan et al. 2014; Nazeer and Bork 2021 ), this study considered the indicators based on a cut-off point of probable value zero to one where zero represents the minimum and one indicates maximum values (Kissi et al. 2015 ; Nazeer and Bork 2021 ; Ndanusa et al. 2022). Data on the UVFs and VCs were collected using a quantitative cross-sectional structured survey questionnaire from 200 and 345 household participants in T/A Kilupula of KD and Mtandire Ward of LC respectively. The questionnaire was programmed in KoBocollect and Android tablets were used to capture the data from household participants. Data were also collected for the elements at risk from each underlying vulnerability component to determine the contribution of vulnerability for the households.

The vulnerability component indicators (Table  3 ) were normalised to have a comparable set of indicators, the study adopted the Min–Max normalisation to convert the values to a linear scale (such as 0–1) (Balica et al 2012 ; Erena et al. 2019; Kissi et al. 2015 ; Nazeer and Bork 2021 ; Ndanusa et al. 2022). Vulnerability increases with an increase in exposure and susceptibility, and it decreases with an increase in Resilience (Kissi et al. 2015 ; Mwale 2014 ; Munyani et al. 2019 ; Nazieer 2021). Therefore, normalisation was based on the assumptions that:

(a) Vulnerability (V) increases as the absolute value of the indicator also increases. In this case, where the functional relationship between the indicator and vulnerability is positive, the normalised indicator is derived using the following equation (Oyedele et al. 2022 ).

(b) Vulnerability (V) decreases with an increasing absolute value of the indicator. Here, when the relationship between vulnerability and the indicator is found to be negative, the data are rescaled by applying the equation (Oyedele et al. 2022 ).

where Xi = normalised value; Xa = actual value; XMax = maximum value; XMin = minimum value for an indicator i (1, 2, 3... n) across the selected communities.

Furthermore, no weight was assigned to the indicators of vulnerability components. The reason for not including weights was that most of the responses during the stakeholders’ engagement were contradictory and highly inflicting. Therefore, to avoid an index value that will mislead the end users, the normalised indicator was aggregated into its respective sub-indices for the final flood vulnerability index. The additive arithmetic function was employed in the aggregation of the indicator into its respective sub-indices (exposure, susceptibility, and lack of resilience) using an equation (Kissi et al. 2015 ; Nazeer and Bork 2021 ; Oyedele et al. 2022 ).

The overall flood value of the vulnerability index was computed with Eq. ( 4 ), an additive function (Nazeer and Bork, 2019 ; Lee and Choi 2018; Oyedele et al. 2022 ).

where SIE means sub-indices exposure, Susceptibility (SIS), and lack of resilience (SILoR) for “n” numbers of indicators in each component of vulnerability.

The study measured the level of vulnerability of the elements at risk in all the underlying vulnerability factors (Table  4 ). These were evaluated based on the constructed scale which modified the Balica et al. ( 2012 ) and was calibrated as (0–0.2) very low vulnerability; (0.2–0.49) moderate vulnerability; (0.5–0.59) vulnerability (0.6–0.79) high vulnerability and (0.8–1) very high vulnerability. However, in the actual data collection tool (household questionnaire survey), Mwalwimba ( 2020 ) measurements scale of “not vulnerable”, “slightly vulnerable”, “vulnerable”, “severely vulnerable” and “do not know” were used and later the percentage obtained during univariate analysis were computed and compared to the weighting scale constructed (Balica et al. 2012 ) (3.10). Ndanusa et al. (2022) argued that a breakdown of the elements at risk poses a serious threat to communities' vulnerability and prosperity. This consequently contributes to the higher vulnerability of the community to hazards.

2.4 Study population and sampling determination

The target flood-prone area of TA Kilupula in KD was selected based on the frequency of flood occurrence. Kissi et al. ( 2015 ) indicate that the magnitude of an extreme event is inversely related to its frequency of occurrence. Whilst, Mtandire Ward in Lilongwe City was chosen because it is an informal settlement. Household participants in Mtandire ward were those specifically in two Group Village Headmen, Chibwe and Chimombo of Senior Chief Ligomeka. These villages are located along the Lingadzi River opposite area 49 (New Gulliver). This study used a total of 10 headmen (VH). The choice of the VH was based on proximity to Lingadzi River. Mtandire has a total population of 66,574 people, but 5000 people are reported to be at risk of floods (MDCP 2010–2021; MPHC 2018). Relatedly, the target population in Karonga district were households of GVH Matani Mwakasangila and Mujulu Gweleweta in Traditional Authority (TA) Kilupula. These household villages share a network of water systems such as Lufilya, Mberere, Ntchowo and Fwira (Mwalwimba 2020 ). This study used a total of 10 village headmen (VH), five from each GVH. The choice of five VH in each GVH was based on the fact that each GVH in T/A Kilupula has a minimum number of five Village Headmen (Karonga Chief Classification 2016). T/A Kilupula has a total population of 78,424 people, with approximately 9500 households at risk of floods (KD-SEP 2013-2018; MPHC 2018).

The sample size (n) for this study was calculated using the formula in Fisher et al. ( 2010 ) as shown in the Eq. ( 5 ). The formula in Eq. ( 5 ) returns the minimum sample size required to ensure the reliability of the results.

In Eq. ( 7 ), Z is the confidence level (1.96 for 95%), p is the proportion of the target households, q = is the alternative (1-P) and d is the power of precision (d = 0.05 at 95%). The formula requires knowing the target population (P) and it also assumes “P” to be 0.5 which is conservative. Therefore, the fact that the number of households prone to floods in T/A Kilupula and Mtandire ward is known, using this formula, 384 and 246 households were obtained from Mtandire ward and T/A Kilupula respectively. The study used 0.5 (50%) to represent “P” in Mtandire Ward and 0.2 (20%) to represent “P’ in T/A Kilupula. The reason for differentiating the “P” was that in the Mtandire ward, the whole area was selected while in T/A Kilupula not all the GVHs were selected and involved in the survey. Furthermore, unlike in T/A Kilupula where the population is sparsely distributed and households were selected based on location to flood-prone areas, in Mtandire ward 50% was used as conservative because of high population density such it was possible to interview many households. During data collection, the researcher managed to collect data from 345 and 200 household participants, representing 90% and 81% of the total sampled in Mtandire ward and T/A Kilupula respectively. The reason for not completing the actual sample size was that the household survey interviewed houses along the buffer zones of Lingadzi and Lufilya rivers and the whole area of the buffer was randomly selected. Therefore, continuing to interview every household in the buffered area would have meant interviewing every household. This would have worked against the rule of simple random sampling strategy and survey ethics (Kissi et al. 2015 ).

2.5 Questionnaire design and administration

This study used a structured household questionnaire survey. This questionnaire captured information that provided the linkages of households’ vulnerability factors, exposure, susceptibility and resilience. Associations of vulnerability factors have been supported in the literature (Kissi et al 2015 ; Mwale 2014 ; Nazeer and Bork 2021 ). Nazeer and Bork ( 2021 ) argue that the issue of double counting of the indicators is an important step to be considered in the formation of composite indicators. The household questionnaire survey was coded in KoBoToolBox. The household questionnaire survey was administered face-to-face with household participants who were above 21 years old. The age parameter was controlled in the KoBoToolBox environment such that the interviewers could not proceed with administering the questionnaire if this question was not answered even if the age entered was below 21. It is also important to note that the attributes of the variable age were not coded because it is a continuous variable hence the ages were manually collected from the participants. Finally, the household questionnaire survey was pretested and piloted in Mchesi and Mwanjasi in LC and KD respectively. Before pretesting and piloting, the research assistants (RAs) were trained to have a common local understanding of the terms that were contained in the questionnaire, specifically vulnerability, floods, resilience, susceptibility, adaptive capacity and exposure.

2.6 Data analysis

To determine variations among the indicator variables of UVFs for the predicted factors, a Minitab statistical test called Multiple Correspondence Analysis (MCA) was computed. MCA produced two outputs called “Indicator Analysis Matrix” and “Column Contribution table”. The column of contribution is used to determine the variations that exist between indicators (Husson 2014). On the other hand, the total inertia in the Analysis of Indicator Matrix (AIM) was averaged for all the five UVFs in LC and KD to obtain a single inertia which was used to determine a multi-correspondence variations of vulnerability factors (MIHVF).The indicators in the assessment that contributed to flood vulnerability were marked with red ink in the measurement scale of important (INT) and very important (VINT). The significance levels between demographics and vulnerability factors were analysed using the single chi-square test and a combined value analysis package. Also, chi-square tests and probability value ( p value) were used to compute significance levels of variables in UVFs and VCs. The formula for chi-square statistics is:

In addition, it follows a with (r−1) (c−1) degrees of freedom. Where

O ij is the observed counts in cell ij; i = 1, 2, 3…..r and j = 1, 2, 3…..c where r is the number of rows and c is the number of columns in an r × c contingency table.

E ij the expected counts in cell ij; i = one, 2, 3…..r and j = 1, 2, 3…..c where r is the number of rows and c is the number of columns in an r × c contingency table.

Those that were significant were computed in the modified binomial multiple logistical regression model using equations. All these were performed in “r” and STATA version 12.

A post-analysis of computed results was carried out using an artificial neural network (ANN). ANN is a machine learning method that stands more independent in comparison than statistical methods (Ludin et al. 2018; Parvin et al. 2022 ). Several studies have used ANN to predict specific events (Mwale 2014 ). Due to its predictive ability, this method was applied in this study as a post-analysis to predict the causes of flood vulnerability of the variables which were statistically tested using a combined P value package between UVFs and VCs. ANN comprises several nodes and interconnected programming elements (Mwale 2014 ; Parvin, et al. 2022 ). It contains input layers, hidden layers and output layers (Ahmadi 2015 ) (Fig.  7 ).

Example of ANN using MLP

The multivariate level used the multiple binomial logistical regression model (Eq.  6 ) (Israel 2013) to predict household flood vulnerability. It utilised a paired comparison model (Hamidi et al. 2020; Chen et al. 2013), in which each UVF was linked with a selected vulnerability component (exposure, susceptibility and resilience). This link is accorded in the studies of Wallen et al. (2014) and Mwale ( 2014 ). This model generated significant levels of physical exposure, social-susceptibility, eco-resilience, enviro-exposure and cultural-susceptibility. Then, the Flood Vulnerability Index (FVI) was applied to determine which factor contributes to vulnerability (Balica et al. 2012 ; Kissi et al. 2015 ). The FVI uses a probability range of 0–1 (Balica et al. 2012 ) where 0 means not vulnerable and 1 means more vulnerable. Using Eq.  1 , the paired attributes were run in r environment through the modified binomial logit multiple regression (Eq.  6 ). However, it would have been significant to use logit-ordered regression since the vulnerability has a certain order (Kissi et al. 2015 ; Hamidi et al., 2020).

where \({y}_{j}\) is a response variable (i.e., as selected from exposure, susceptibility and resilience) \({\beta }_{i}\) is intercepted (values generated by the equation after extraction in r- environment, \({\delta }_{i}\) is predictor variable (selected from physical, social, economic, environmental and cultural), \({O}_{i}\) operator (i.e., measurement scale, less important and very important which considered by the model), \({\epsilon }_{j}\) is an error. This equation was applicable for all the \(UVFs,\) thus parameters in the \(UVFs\) were predicted separately based on the \(VCs\) to which they were associated. The link of UVFs and VCs in the regression model was computed in an implicit relationship showing the predictor and response variables (Table  5 ).

The binomial logit regression model was used based on three assumptions which implied that:

The indicators for UVFs should be measured as a proportional value of household participants involved during the survey. The percentage values should be generated using a scale range with the operator of “ less important ”; “ important ” and “ very important ” to contribute to flood vulnerability”. However, for flood vulnerability determination, a cut-off point should be placed at greater or equal to 50% for each indicator from the operator of the scale range of “important” and “very important”. In this case, all the values generated in the scale of “less important” as responded by the participants should be left out during determination and selection.

The linkage of UVFs and VCs should be based on statistical tests using P-values or correlation (r) or simply any statistical test applicable to the researcher. The values that are significant at a certain confidence level (i.e. 0.05 in this study) should be selected to be included in the framework for specific combinations like Physical Exposure Factors (PEFs), Socio-Susceptibility Factors (SSFs), Eco-Resilience Factors (ERFs), Enviro-Exposure Factors (EEFs) and Cultural-Susceptibility Factors (CSFs). Furthermore, those values significant at an appropriate confidence level should be considered as factors generating flood vulnerability in the studied areas.

Multicollinearity of the UVF and VC variables should be checked using variance independent factor (VIF) to assess the level of correlation in the regression model. It is assumed that a variable with VIF ≥ 10 has higher variance inflation in influencing other response variance and is redundant with other variables. As such, that variable should be dropped. In this study, the VIF process was done in SPSS.

Flood vulnerability index (FVI) was used in the determination of household flood vulnerability based on the output of the analysis of the results. A summarized comparison flood vulnerability index (FVI) probability scale 0 to 1 (Balica et al. 2012 ) has been presented in Table  6 .

Results were presented on spatial distribution maps, computed in ArcGIS 10.8 Desktop. Shapefiles for Malawi administrative boundaries were downloaded from MASDAP (Malawi Spatial Data Application Portal). Then Excel was used to generate the tabulated information and pie charts and later exported the output to ArcMap. The Maps were coloured to show the contribution of each variable to households' flood vulnerability (Fig.  8 ).

Vulnerability levels

3 Results and discussions

3.1 variability of underlying vulnerability factors.

The results of Multiple Correspondence Analysis (MCA) output have been outlined in Tables 7 , 8 , 9 , 10 and 11 , with those with higher quality value (Qual.), inertia, correlation (Corr.) and contribution (Contr.) marked with red ink to depict variation in flood vulnerability.

The results in Table  7 show all the physical variables marked by red ink have larger quality values in Mtandire Ward of LC. However, the results in T/A Kilupula of KD show the greater quality value in the scale of “VINT” for indicator values of poor construction standards for houses (0.551) and lack of construction materials (0.708). Furthermore, the results also indicate a higher correlation (corr.) for poor construction standards for houses in the scale value of “INT” and ‘VINT, accounting for a higher amount of inertia in both rural and urban areas. Construction of roads and other infrastructures (0.234) account for a high contribution to the inertia in Mtandire Ward of LC while poor construction of housing standards account for a higher inertia value (0.201) in both Mtandire Ward of LC and (0.313) and in T/A Kilupula of KD (Table  7 ). The results further established that physical elements at risk on the scale of “severe vulnerable” have the vulnerability thresholds of 0.5 and 0.6 in Mtandire ward and T/A Kilupula respectively.

The results of MCA show a significant contribution of vulnerability with a quality value in the category of social security on the scale of INT (0.506) and VINT (0.500). The results further show a significant contribution of vulnerability in the category of inavailability of health services (0.513) in the scale of INT in LC. In T/A Kilupula of KD, the results show significant quality values on lack of capacity to cope (0.821) in the scale of INT, social security and human rights in the scale of INT and VINT (Table  7 ). While the results of the inert values in Mtandire Ward of LC do not deviate much from the expected, in T/A Kilupula of KD the inert value of lack of capacity to cope (0.124) in scale of INT and social security (0.117) in a scale of VINT deviate from the expected value. The results also indicate a higher correlation (corr.) social security (0.504) and human rights (0.648) and unavailability of health services (0.506) in Mtandire Ward of LC while lack of capacity to cope (0.790) and social security (0.560) have higher Corr in T/A Kilupula of KD accounting higher amount of inertia to contribute to vulnerability. The results further show all the indicator variables in the scale of “INT) contribute higher to the inertia in Mtandire Ward of LC while only lack of capacity to cope (0.2613) and social security (0.2141) contribute higher to the same in T/A Kilupula of KD (Table  8 ).

The results in Table  9 show that lack of markets (0.574) and poverty (0.513) in the scale of “INT” have higher quality value in Mtandire Ward of LC while lack of credit unions and lack of markets showed higher quality value in T/A Kilupula of KD. These results suggest that lack of markets, poverty and lack of credit unions contribute more to household vulnerability to floods than lack of alternative livelihoods. The results further show that all the indicator variables in Mtandire Ward of LC have an inertia value at the expected rate of less than 10% while in T/A Kilupula of KD lack of credit unions (0.103), lack of markets (0.499) and poverty (0.123) display values that deviate from the expected. Similarly, the results show a weak correlation (less than 1) for all the economic indicator variables in Mtandire Ward of LC and only lack of markets (0.499) is close to 1 in T/A Kilupula of KD thereby contributing highly to the inertia. The lack of credit unions and lack of markets account for a high contribution to the inertia, thereby suggesting a high contribution to flood vulnerability. The results also found that the economic elements at risk have a higher vulnerability value in T/A Kilupula (0.55) compared to Mtandire ward (0.33) on the scale of severe vulnerable.

The results in Table  10 show that except for poor land management in T/A Kilupula of KD for scales of INT and VINT, environmental mismanagement and inappropriate use of resources have larger quality values in Mtandire Ward of LC and T/A Kilupula of KD. No indicator variable depicted the unexpected inertia value in Mtandire Ward of LC and T/A Kilupula of KD. In LC, the results further revealed that the correlation is higher for environmental mismanagement (0.524) in the scale of INT, poor land management is also higher in both scales and inappropriate use of resources (0.518) in the scale of INT. However, extensive paving (0.674), environmental mismanagement (0.557) and poor land management (0.677) have higher correlation values close to one. Environmental mismanagement (0.169), poor land management (0.202; 0.104) and inappropriate use of resources (0.152; 0.105) account for high contribution to the inertia in Mtandire Ward of LC while extensive paving (0.1721) and environmental mismanagement (0.137; 0.101) account for higher contributions in T/A Kilupula of KD (Table  10 ). It was also found that environmental elements at risk are more vulnerable in T/A Kilupula of Karonga on a scale of “slightly vulnerable” (Fig. 4.39) compared to the Mtandire ward of Lilongwe City.

The results in Mtandire Ward of LC showed that lack of safety measures (0.551) and lack of personal responsibility (0.632) have high-quality values above the cut-off of 50% while in T/A Kilupula of KD traditional beliefs (0.508), settlements conditions (0.579), lack of safety measures (0.596) and lack of personal responsibility (0.636) have high-quality values. No indicator variable depicted the unexpected inertia value in Mtandire Ward of LC and T/A Kilupula of KD. The results further revealed no strong correlation (close to 1) in Mtandire Ward of LC to contribute to inertial variability. Nevertheless, in T/A Kilupula of KD, the results showed a strong correlation between traditional beliefs (0.506) and poor settlement conditions (0.576). This suggests people living in Mtandire Ward are not aware that they live informally. It was noted that Mtandire Ward is not properly defined as it is part of the Lilongwe City or Lilongwe District. While results show no higher value for contribution (Contr) in Mtandire Ward of LC, traditional beliefs (0.187), settlement conditions (0.199) and language of communication (0.1526) account for high contribution to the inertia in KD (Table  11 ).

Cumulatively, the results of the MCA for all indicators in the category of quality value \(\ge\) 0.50 (50%) revealed an average of “high vulnerability” (0.62) in T/A Kilupula of KD and “moderately vulnerability” (0.52) in Mtandire Ward of LC. Based on individual factors, the results found high physical vulnerability in both T/A Kilupula (0.61) and Mtandire Ward (0.65), high social vulnerability in T/A Kilupula (0.68) compared to moderate social vulnerability in Mtandire Ward (0.58), high economic vulnerability in T/A Kilupula (0.60) compared to moderate economic vulnerability in Mtandire Ward (0.51), high environmental vulnerability in both T/A Kilupula (0.67) and Mtandire Ward (0.68) and moderate cultural vulnerability in T/A Kilupula (0.54) compared to very low cultural vulnerability in Mtandire Ward (0.16).

3.1.1 Artificial neural network: multi-layer Perceptron (MLP)

The results of the ANN in multi-layer perceptron (MLP) to show the relationship between the indicators used in the UVFs and those in the VCs are presented in Tables 12 , 13 , 14 , 15 and 16 .

The results of exposure linked with physical factors reveal that there is a strong relationship between house type with PCS in T/A Kilupula of KD, while in Mtandire Ward of LC the relationship is not very strong (−9.116) (Table  12 ). The relationships of house type with CRFs imply that these contribute to household flood vulnerability. Lack of construction materials (PCMs) has a strong network value in T/A Kilupula of KD compared to Mtandire Ward of LC with a negative value (Table  12 ). The results reveal that houses made up of bamboo followed by those made up of mudstone are strongly associated with PCS in T/A Kilupula of KD. The results further show that houses made up of unburnt bricks are strongly associated with poor settlement conditions in Mtandire Ward of LC. Lack of construction materials has a strong relationship in T/A Kilupula of KD than in Mtandire Ward of LC. Similarly, CRF and AI have a strong relationship with house material type in Mtandire Ward of LC thereby contributing to high household flood vulnerability in LC.

In Table  13 , the results revealed that sex is significant with social vulnerability factors (0.0539), physical vulnerability factors (0.0371), economic vulnerability factors (0.0562) and cultural vulnerability factors (0.0594) in KD while only environmental factors are significant with sex (0.0331) in LC. The result further revealed that marital status is significant with physical vulnerability factors in T/A Kilupula of KD (0.0265), environmental factors (0.0383) and economic factors (0.0497) in Mtandire ward of LC while in T/A Kilupula (0.0526) with cultural factors (Table  13 ). In terms of education, the results established that social factors (0.001), environmental factors (0.0064) and economic factors (0.0235) are significant to education in Mtandire ward of LC while economic factors (0.0378) are significant in T/A Kilupula of KD (Table  13 ). Finally, the results show that cultural factors (0.0075) and economic factors (0.0106) are significant to occupation in T/A Kilupula and Mtandire ward respectively (Table  13 ).

The results show positive and negative outcome of LOC in T/A Kilupula of KD and Mtandire Ward of LC respectively (Table  14 ). These results point to the fact that lack of capacity to cope contributes to household vulnerability in T/A Kilupula of KD than in Mtandire Ward of LC. The results further show that LAL and LS have positive values both in Mtandire Ward of LC and T/A Kilupula of KD, but with greater contribution to household flood vulnerability in Mtandire Ward of LC. Finally, the results reveal that AHS has positive and negative value in T/A Kilupula of KD and Mtandire Ward of LC. This result indicates that AHS contribute to household flood vulnerability in T/A Kilupula of KD compared to Mtandire Ward of LC (Table  14 ).

The results of ANN revealed that all the UVFs for economic factors have positive values in Mtandire Ward of LC and T/A Kilupula of KD, but with higher values in Mtandire Ward of LC. Lack of income generating activities was revealed to be higher both in Mtandire Ward of LC and T/A Kilupula of KD. These results imply that the NCU, LAL, PO and LGA contribute to household flood vulnerability in Mtandire Ward of LC and T/A Kilupula of KD (Table  15 ).

The results of geography linked with environmental factors reveal that there is strong relationship between them, all with a value greater than “0” in Mtandire Ward of LC compared to T/A Kilupula of KD (Table  15 ). The results show that poor land management (PLM) has strong network value (9.554) in Mtandire Ward of LC and (0.951) in T/A Kilupula of KD, followed by RPA in Mtandire Ward of LC (3.839). These results point to the fact that the CL, RPA, EMS, PLM and IUR contribute to households flood vulnerability in LC and KD, with higher contribution in Mtandire Ward of LC (Table  16 ).

The results of communication linked with cultural factors revealed a strong relationship between in the sets of the combined indicators, all with value greater than “0” in Mtandire Ward of LC compared to T/A Kilupula of KD (Table  16 ). The results show that traditional beliefs (TB) have strong network value (79.789) in T/A Kilupula of KD compared to a network value of 7.872 in Mtandire Ward of LC followed by cultural conflicts with value of 11.864 in T/A Kilupula of KD compared to a value of 6.426 in Mtandire Ward of LC (Table  17 ).

3.1.2 Relationships between vulnerability factors and components

This section combined underlying vulnerability factors (UVFs) and vulnerability components (VCs) to determine indicators that integrate the two parameters to determine households’ vulnerability. The analysis was carried through bivariate statistical test after normalisation of indicators of UVFs and VCs (Table  18 ). The results between physical factors and exposure variables reveals significant relationships between proximity to rivers and settlements (0.0380) in KD, house type (0.0001) in LC and roofing material (0.0072) in Lilongwe and (0.0364) in KD.. The results reveal that all the susceptibility factors are significant to social factors. This result indicates that the susceptibility variables contribute to generate households’ vulnerability to floods in Mtandire ward of LC and T/A Kilupula of KD. The results show that communication accessibility, access to healthcare, access to water, and sanitation contribute to vulnerability to floods in LC and KD are all significant at P-value 0.05 in both Mtandire Ward and T/A Kilupula (Table  16 ). The results reveal that all the resilience variables are significant to economic factors in KD while only income of household head is significant in LC. This result indicates the resilience variables contribute to generate households’ economic vulnerability to floods in T/A Kilupula district than in Mtandire Ward (Table  18 ). The results reveal that some exposure variables combined with environmental variables contribute to household’s flood vulnerability. While geography contributes to very high vulnerability of households to floods in T/A Kilupula of KD (0. 0084), the same is not the case in Mtandire Ward of LC (0.864). House type contributes to very high vulnerability of households to floods in Mtandire Ward of LC compared to T/A Kilupula in KD while roofing material contributes to generate vulnerability in both Mtandire Ward of LC and T/A Kilupula of KD (Table  17 ). The combined results of susceptibility variables with human/cultural factors reveal that communication accessibility contributes to flood vulnerability in Mtandire Ward of LC (0.0002) and not in T/A Kilupula of KD (0.5136). The results further indicate that limited education facilities as well as health facilities contribute to vulnerability in T/A Kilupula of KD and not in Mtandire Ward of LC at p-value 0.05 (Table  18 ).

3.2 Quantification and prediction of household vulnerability

The binomial Logit Multiple Regression was computed in r to generate five scores outlined in the Eqs. 12 to 15 .

3.2.1 Computation of socio-susceptibility score

The underlying social vulnerability factors (SVFs) linked with communication accessibility (ca) in the susceptibility indicators generated the output of socio-susceptibility score (Eq.  12 ).

where S = Susceptibility, ca = communication accessibility, HR = human rights, HS = health services sint = scale of less important, svint = scale of very important.

The above output (Eq.  12 ) linked the susceptibility indicators (communication accessibility) with social variables. Therefore, to compute the scores in Lilongwe City (Mtandire Ward) and Karonga District (T/A Kilupula), the percentage values generated using descriptive statistics from the scale of “important” and “very important” were separately inputted in the equation (Eq.  12 ).

3.2.2 Computation of physio-exposure score

The underlying physical vulnerability factors (PVFs) linked with housing material types (hmt) in the exposure indicators generated the output of physio-exposure score (Eq.  13 ).

where E = Exposure, hmt = housing material type, PC = Poor construction, CM = Construction materials, CR = Construction of roads, sint = scale of less important, svint = scale of very important.

The output (Eq.  13 ) linked the exposure indicators (housing material type) with physical variables. Therefore, to compute the scores in Lilongwe City (Mtandire Ward) and Karonga District (T/A Kilupula), the percentage values generated using descriptive statistics from the scale of “important” and “very important” were separately inputted in the equation (Eq.  13 ).

3.2.3 Computation of eco-resilience score

The underlying economic vulnerability factors (EVFs) linked with income of household head (ihh) in the resilience indicators generated the output of eco-resilience score (Eq.  14 ).

where R = Resilience, ihh = income of household head, PV = Poverty, AL = Alternative livelihoods, sint = scale of less important, svint = scale of very important.

The output (Eq.  14 ) linked the resilience indicators (income of household head) with economic variables. Therefore, to compute the scores in Lilongwe City (Mtandire Ward) and Karonga District (T/A Kilupula), the percentage values generated using descriptive statistics from the scale of “important” and “very important” were separately inputted in the equation (Eq.  14 ).

3.2.4 Computation of enviro-exposure score

The underlying environmental vulnerability factors (EVFs) linked with geography (ge) in the exposure indicators generated the output of enviro-exposure score (Eq.  15 ).

where E = Exposure, Ge = Geography, CL = Cultivated land, EM = Environmental mismanagement, PLM = Poor land management, AUR = Inappropriate use of resources, sint = scale of less important, svint = scale of very important.

The output (Eq.  15 ) linked the exposure indicators (geography) with environmental variables. Therefore, to compute the scores in Lilongwe City (Mtandire Ward) and Karonga District (T/A Kilupula), the percentage values generated using descriptive statistics from the scale of “important” and “very important” were separately inputted in the equation (Eq.  15 ).

3.2.5 Computation of cultural-susceptibility score

The underlying cultural vulnerability factors (CVFs) linked with inaccessibility of communication (ic) in the susceptibility indicators generated the output of cultural-susceptibility score (Eq.  15 ).

where S = Susceptibility, cb = cultural behaviour, LN = local norms, sint = scale of less important, svint = scale of very important.

The output (Eq.  16 ) linked the susceptibility indicators (cultural behaviour) with cultural variables. Therefore, to compute the scores in Lilongwe City (Mtandire Ward) and Karonga District (T/A Kilupula), the percentage values generated using descriptive statistics from the scale of “important” and “very important” were separately inputted in the equation (Eq.  16 ).

The score measure of UVF (physical, social, economic, environmental and cultural) against VCs (exposure, susceptibility and resilience) generated a single value according to the association which was as follows: Physical with exposure factors (PEFs), Social with susceptibility factors (SSFs), economic with resilience factors (ERFs), environmental with exposure factors (EEFs) and cultural with susceptibility factors (CSFs). This association further generated value that was divided by the total sample size 345 and 200 household participants in Lilongwe City and Karonga District and multiplied by the 100 percent to obtain a percentage value of each category in the calibrated formula, for example:

Then the percentage result obtained in equation (Eq.  17 ) for each factor was further divided by 100% to generate the vulnerability level (extent of vulnerability) of each factor (i.e., V L PEFs). This computed arbitrary value was compared to the FVI to predict the extent of vulnerability per factor, for example:

where V L PEFs means the extent (level) of vulnerability to Physio-Exposure factors. This formula was applied to all the combined categories (i.e., SSFs, ERFs, EEFs and CSFs) by substituting the category that was required to be worked out in the equation to obtain the value that was used to determine vulnerability. Finally, the result was used to predict vulnerability in terms of “high vulnerability” and “very high vulnerability” per the FVI scale range. Ordinal categories for the indicators of vulnerability determinants (less important, important and very important) and indicators of elements at risk (not vulnerable, small vulnerable, vulnerable, highly vulnerable and very highly vulnerable) were used for selection of variables.

Finally, the relationship (using Eq.  18 ) generated results in the category of the physio-exposure factors (PEFs), social susceptibility factors (SSFs), eco-resilience factors (ERFs), enviro-exposure factors (EEFs) and cultural-susceptibility factors (CSFs) (Fig.  8 ).

The results of PEFs fall in scale range of “vulnerability” in Mtandire Ward of Lilongwe City (0.52) compared to “high vulnerability” in T/A Kilupula of Karonga District (0.64). This means that while it contributes to vulnerability in both areas, it is much higher in T/A Kilupula of KD compared to the Mtandire ward of LC. The results of the digitized flood maps overlayed with surveyed households’ showed that most houses that are highly vulnerable to floods are between a distance of 0.06–0.12 km to Lingadzi river in Mtandire ward of LC and 0.198–0.317 km along the buffer zones of Lufilya river in T/A Kilupula of KD (Figs.  9 and 10 ).

Map of Mtandire showing households/buildings about Wetlands and drainage systems

Map of T/A Kilupula showing households/buildings about Wetlands and drainage systems

4 Discussion

Though variations exist in the causes of vulnerability, the results of this study have demonstrated that the vulnerability of households to floods in rural and urban informal settlements is very high based on a lack of building materials, proximity to catchments, and limited communication among other factors. Similar, to this finding Alam et al., ( 2022 ) also found a high vulnerability value of 0.7015 for rural people living in the Dammar Char in Southeastern Bangladesh compared to urban areas. While, Alam et al. ( 2022 ), did not specify the causes of such high vulnerability, this study attributes the high vulnerability to the aspect of lack of construction materials, distance to markets and transport cost that people have to incur to access construction materials in rural areas. These causes agree with the findings of Qasim et al. ( 2016 ) in which vulnerability to flooding was attributed to poor/lack of materials used to construct houses. The results also revealed that poor construction of infrastructural facilities falls in the scale of “high flood vulnerability in both LC and KD. This implies that substandard construction of infrastructure such as houses contributes to vulnerability. This finding is supported by literature that substandard infrastructures contribute to flood vulnerability (Salami et al. 2017 ). Furthermore, the ANN results in MLP revealed a strong association of physical vulnerability factors (lack of construction materials, construction of infrastructures, and ageing infrastructures) with housing type. This implies that they contribute to generating vulnerability because people live in substandard houses. This finding confirms the result finding of Movahad et al. (2020) and Aliyu Baba Nabegu (2018) who indicated that people are vulnerable to floods because they usually live in substandard housing conditions which become prone to floods.

The SFFs generated a vulnerability value (0.61) for people living in T/A Kilupula in Karonga District compared to a low vulnerability value (0.2) for people living in Mtandire Ward in Lilongwe City. The above findings indicate that key factors for households’ flood vulnerability are associated with knowledge of building codes and standards. This means that the culture of shelter safety is lacking and that there is a lack of knowledge of the type of houses that they can build to resist floods and any other type of natural hazards. These could be attributed to dynamic pressures influencing households’ vulnerability to floods. That’s to say, people do have enough resources, decision-making, and societal skills to access housing materials that can help them build strong houses. In this situation, the programming of flood risk management and in general DRM mitigation, preparedness and recovery measures should focus on reducing the pressures by strengthening households’ knowledge and building standards. This can be achieved through designing mitigation measures that address the root causes that contribute to increased vulnerabilities in the pre-flood and post-flood phases rather than focusing too much on the trans-flooding phase. In terms of social-susceptibility vulnerability, the results found that the SSFs that contribute to generating vulnerability both in T/A Kilupula of KD and Mtandire Ward of LC are lack of access to health services, human rights, limited institutional capacities and lack of awareness. However, the binomial logistical regression of the SFFs generated a vulnerability value (0.61) for people living in the studied area of KD compared to a low vulnerability value (0.2) of people living in the studied area of LC. This finding differs from the findings of Munyai et al. ( 2019 ) in Muungamunwe Village in South Africa, which found that the value of FVI social was 0.80 higher than all the factors assessed. However, it is noted that the later study did not comprehensively link various factors between UVFs and VCs to determine the degree of contribution to vulnerability. The results further imply that the socio-susceptibility factors contribute to higher vulnerability in rural areas than in urban areas. This finding is supported by the study of Mwale ( 2014 ) in which social susceptibility was categorised from “high to very high vulnerability” among the communities in rural Lowershire of Chikwawa and Nsanje Districts of Malawi.

The ERFs contribute to “very high vulnerability” in Karonga (0.8) and “high vulnerability” in Mtandire Ward of Lilongwe City (0.6). The high vulnerability is linked to factors such as poverty, lack of alternative livelihoods, and lack of income-generating activities. Similar to these results, the study of Mwale ( 2014 ) also established a predominantly very high economic susceptibility based on causes such as a lack of economic resources, an undiversified economy and a lack of employment opportunities among communities in the lower Shire Valley of Malawi. Despite the results revealing the same outcome, the earlier study linked economics with susceptibility measures while this study agglomerated economics with resilience measures. The existing variation placed some causes in different association order. For example, poverty in the study of Mwale ( 2014 ) was categorised as a social susceptibility indicator, while in this study it was used as the eco-resilience measure. The understanding of this study is that poverty is a measure of the income level of a household. That is to say, a household with enough income will be less poor thereby becoming more resilient and vice versa. Therefore, poverty was classified as a cause of “high vulnerability” both in Mtandire Ward of LC with a value of 0.73 and T/A Kilupula of KD with a value of 0.68. On the other hand, the lack of alternative livelihoods contributes to “vulnerability” in Mtandire Ward with a value of 0.54 while ‘high vulnerability” in T/A Kilupula with a value of 0.71). These findings point out the notion that programming current and future flood disaster mitigation plans and vulnerability reduction measures requires the formulation of relevant financial and economic measures which may contribute to poverty alleviation in the community and society.

The EEFs revealed “very high vulnerability” in both Mtandire Ward of LC (0.8) and T/A Kilupula of KD (0.9). The EEFs revealed “very high vulnerability” of EEFs (0.8) in Mtandire Ward and (0.9) in T/A Kilupula. Except for the pressure on cultivated land in Mtandire Ward, all underlying environmental vulnerability factors (UEVFs) contribute to vulnerability in both rural and urban areas. This result points out that pressure on land is an environmental indicator that predicts households’ vulnerability to floods in rural areas (T/A Kilupula) and not in urban areas (Mtandire Ward). The high vulnerability depicted by the EEFs is a total indication that households are more vulnerable due to the built environment. This could be attributed to the fact that people have allowed development in areas where danger exists due to the lack of policy and legal systems to help and guide government and enterprises in disaster risk management. This argument is supported by literature that development in dangerous areas increases peoples’ exposure to danger (Birkmann et al. 2013 ; Nazeer and Bork 2021 ). Barbier et al. (2012) support that environmental damage affects the well-being of the local people since it leads to soil degradation which eventually causes low food production. To this end, laws and policies to regulate development and habitation in risk areas should be seamlessly programmed into the current and future flood mitigation and preparedness plans at all levels.

Finally, the CSFs revealed a low vulnerability in both Mtandire Ward of LC (0.34) and T/A Kilupula of KD (0.39) (Fig.  6 ). In the FVI scale, the SSFs and CSFs contribute to low vulnerability in Mtandire Ward of LC while only the CSFs contribute to low vulnerability in T/A Kilupula of KD (Fig.  3 ). The CSFs show a value of 0.34 in Mtandire Ward and 0.39 in T/A Kilupula, indicating that it contributes to low vulnerability in both areas. However, it was established that household flood vulnerability in T/A Kilupula is high due to other factors such as cultural beliefs of conserving their ancestors’ graveyards and land ownership issues . In support of this result, Iloka ( 2017 ) found that a system of beliefs regarding hazards and disasters contributes to vulnerability. The findings of the author further established that cultural issues do not assist households to be resilient to floods. In Mtandire Ward of LC, it was observed that land use and human occupancy in risk areas contribute to household flood vulnerability. Furthermore, it was reported that rich people have occupied places which are not habitable thereby changing the course of the Lingadzi River. Further to this, youths have resorted to destroying the banks of the river due to a lack of economic activities and high unemployment. It was noted that people do not fear or abide by city regulations because there is no punishment that they receive from city councils.

4.1 FVA indicators for rural and urban informal settlements

Based on the results, and to provide proper flood mitigation and programming of current and future challenges in flood management, this study constructed the FVA framework as a combination of variables from the UVFs and VCs (Fig.  11 ). On the one hand, the physio-exposure indicators (PEIs) relate to the housing and infrastructure in the physical vulnerability factors (PVFs). These should be evaluated based on exposure with its operator house material and type to understand how they contribute to vulnerability (Eq.  13 ). In Fig.  11 , those that intersect (housing typology (HT), poor construction of standards (PCS), lack of building materials (LBM) and loss of physical assets (LPA) and infrastructural standards) are the PEIs for both rural and urban areas. While location (LC) and growth of informal settlement (GIS) are PEIs for rural and urban areas respectively. On the other hand, the enviro-exposure indicators (EEIs) relate to environmental causes such as land use planning and management. These were quantified based on exposure variables, specifically location (Eq.  15 ). In the Fig.  11 , environmental mismanagement (EM), proximity to rivers (PR), poor land management (PLM), inappropriate use of resources (IUR) and siltation of rivers (SR), river catchment morphology (RCM) flooding risk location (FRL) intersect, implying that they are the EEIs for both rural and urban informal areas. Those outside the intersection apply specifically as EEIs conforming either in Lilongwe including waste management (WM), land use planning (LUP) or in Karonga, cultivated land (CL) and topography (TP).

FVA framework

This study derived the physio-exposure indicators (PEIs) and enviro-exposure indicators (EEIs) by agglomerating them with the exposure factors (housing material and geography respectively). This demonstrates the notion that flood risk is a product of exposure to the hazard (flood) and vulnerability. Literature reveals that exposure entails the probability of flooding affecting physical objects-buildings and people (Mwalwimba 2024 ; Balica et al. 2012 ; Nazeer and Bork 2021 ) due to location. Since location is an exposure variable, defined by the geographical position to which the assessment was done (Nazeer et al. 2022), this study relates the physical causes to that location/geography to predict household vulnerability and thereby all the significant indicators were grouped as physio-exposure factors (PEFs) to give rise to the PEI. Also, significant indicators were grouped as enviro-exposure factors (EEFs) and referred to as the EEIs in Fig.  11 . The PEIs and EEIs correlate with the indicators propagated in the hazard of place model (Joakim 2008 ), which relates the vulnerability determinates to biophysical vulnerability i.e. geography, location and proximity.

The amount of social risk experienced by the household was understood by agglomerating socio-susceptibility indicators (SSIs). The SSIs relate to the linkage of social causes with access to communication as a susceptibility variable (Eq.  12 ). Susceptibility deals with elements that influence an individual or household to respond to the hazard itself. In Fig.  11 , the SSIs, lack of access to health services (LHS), communication accessibility (CA), access to training and advocacy (ATA) and level of sanitation (LS) are indicators that intersect, implying they apply to both rural and urban informal areas. However, lack of human rights (LHR) and level of waste management and drainage systems (LWDS) are SSIs in rural and urban respectively. Relatedly, cultural-susceptibility indicators (CSIs) link cultural causes with access to communication in the susceptibility category. Susceptibility deals with elements that influence an individual or household to respond to the hazard itself. In Fig.  11 , lack of personal responsibility, lack of adherence to regulations, lack of institutional support and flood perception are indicators that intersect, implying that they are the CSIs for both rural and urban areas. However, cultural beliefs and myths about floods should be indicators to be evaluated specifically in rural areas, while power conflicts, limited DRR strategies and lack of cooperation should be used to assess vulnerability in urban areas, though they can apply to rural areas too. So, access to communication is a susceptibility condition which may result in making households vulnerable to floods because they cannot anticipate the impending flooding. Hence this study related social and cultural causes with access to communication to develop a combination of socio-susceptibility factors (SSFs) and cultural-susceptibility factors (CSFs). Qasim et al. ( 2016 ) stated that certain beliefs and poverty play a role in the lack of resilience among communities. Birkmann et al. ( 2013 ) and Kablan et al. ( 2017 ) stated that susceptibility relates to the predisposition of the elements at risk in social and ecological spheres. Hence, most of the susceptibility factors relate to social and cultural causes because they are all an integral part of humanity's suffering if conditions do not support them to withstand and resist the natural hazard impacts.

The eco-resilience indicators (ERIs) should put much emphasis on economic causes of vulnerability. Economic indicators such as limited access to alternative livelihoods and poverty contribute to generating vulnerability. These indicators may or may not be affected by the resilience of households to the shock. As such, resilience is measured based on the ability of the households to cope with the event. As such, key factors to measure resilience include access to resources, improved livelihoods and access to income among others. The framework therefore strongly overlaps economic causes with resilience factors to assess the vulnerability of households to floods. In Fig.  11 , poverty (PO), limited livelihoods (LVs), lack of income of household head (LIHH), and loss of economic assets (LEA) are indicators that intersect, implying that they are eco-resilience indicators (ERIs) that can be used for vulnerability assessment in both rural and urban areas. The ERIs for only rural lack of markets (LM), limited credit unions (LCU) and reduction in agricultural land (RAL) while in urban informal settlements, they include lack of employment opportunities (LEO). Birkmann et al. ( 2013 ) stipulated that resilience comprises pre-event risk reduction, time-coping, and post-event response actions. Therefore, this study relates the economic causes of resilience to give rise to the eco-resilience indicators (ERIs) (Fig.  11 ).

The adaptive capacity provides key adaptive measures that can be incorporated to deal with vulnerability conditions generated from each intersected category. The adaptive measures relating to housing strategies can be utilised to minimised flood impact on households under the physio-exposure factors in the category of the PEIs are strengthening the availability of building materials (SULBM), enforcement of building codes and standards (EBCS) and empowering locals on flood resilient structures (ELFRS). Similarly, social organisational measures can be utilised to minimise socio-susceptibility factors relating to SSIs. The adaptive capacities that can contribute to reducing vulnerability in the category are the ability to make decisions (AMD), the ability to organise and coordinate (AOC) and communal strategic grains for resilient buildings (CSGRB). In addition, the economic measures can be utilised to minimise flood impacts relating to eco-resilience factors for the category of ERIs and they include saving agricultural produce (SAP), strengthening diversification (SD) strengthening livelihoods opportunities (SLO) can be used as adaptive capacity under this category. In terms of exposure, households to adapt to flood impact can use land management measures. These practices include: elevating house location (EHL), afforestation and re-afforestation (AR) and building dykes and embankments (BDE) can be used as adaptive capacity under this category. Finally, households can minimise the cultural-susceptibility factors that generate their vulnerability through the application of warning systems for impending flooding (WS) and the use of indigenous and scientific knowledge (ISK). This is contrary to the PAR model (Wisner et al., 2004 ) and Urban Flood Vulnerability Assessment (Salami et al. 2017 ), which did not elaborate the adaptive strategies. However, the FVA relates well with the ISDR framework (2004) on adaptive capacity because the ISDR (2004) emphasizes disaster risk reduction through adaptive responses such as awareness knowledge, development of public commitment, application of risk reduction measures, early warning and preparedness (Mwale 2014 ).

5 Assumptions of the FVA framework

Assumptions are key to the realisation of the results. They are critical for achieving the successful implementation of an intervention. In this regard, the fact that the FVA framework provides the indicators which can be used to assess flood vulnerability in rural and urban informal settlements, the following eleven assumptions are vital to achieving the results:

The UFV should be constituted by physical, social, economic, environmental and cultural factors while the VC is composed of exposure, susceptibility and resilience to determine flood vulnerability. The selection of variables for these key components should consider vulnerability in a combination of physical and social sciences.

The UVFs and VCs should be linked to generate Physio-Exposure Factors (PEF), Socio-Susceptibility Factors (SSF), Eco-Resilience Factors (ERF), Enviro-Exposure Factors (EEF) and Cultural-Susceptibility Factors (CSF) to determine flood vulnerability or any particular hazard.

The generated indicators in the PEF, SSF, ERF, EEF and CSF should lead to the production of physio-exposure indicators (PEIs), social susceptibility indicators (SSIs), eco-resilience indicators (ERIs), enviro-exposure indicators (EEIs) and cultural-susceptibility indicators (CSIs), which in turn should capture indicators for FVA framework (Fig.  11 ).

A comprehensive flood vulnerability assessment framework that can give rise to multi-hazard vulnerability assessment should deviate from the common systematisations of vulnerability by using one set of variables. A combination of UVFs and VCs should be used to generate a wide range of issues and variables.

The linkage between the factors that amplify vulnerability and those that can enhance vulnerability reduction should be demonstrated through adaptive capacity and disaster risk reduction measures and incorporated in the framework. Those that cannot be quantified should be supported by qualitative methods.

The linkage of the UVFs and VCs as a key explanation of the generation of vulnerability should be emphasised and the conceptual framework for FVA should provide clear connectivity of the variables of the UVFs and VCs.

The variables for UVFs (physical, social, economic, environmental and cultural) should be measured as the absolute proportion value of household participants involved during the survey. The percentage values should be generated using a scale range with operators of “ less important ”; “ important ” and “ very important ” to contribute to flood vulnerability”. However, for flood vulnerability determination, a cut-off point should be placed at greater or equal to 0.5 (50%) for each indicator from the operator of the scale range of “important” and “very important”. In this case, all the values generated in the scale of “less important” as responded by the participants should be left out during determination of flood vulnerability.

The selected variables UVFs indicators (at 50%) should be tested using the variables of VCs (exposure, susceptibility and resilience) in the order stipulated in 2 and 3 through statistical tests using P-values or correlation (r) or simply any statistical test applicable by the researcher. The values that are significant at a certain confidence level (i.e. 0.05 in this study) should be selected to be included in the framework for specific combinations like PEFs, SSFs, ERFs, EEFs and CSFs (Fig.  11 ). Furthermore, those values significant at an appropriate confidence level should be considered as factors generating flood vulnerability.

Household vulnerability to floods should be predicted based on logistical regression test between the UVFs for all the operators of less important, important and very important and the VCs indicators (in exposure, susceptibility and resilience). The selection of the VC indicators should be based on those that were significant during the statistical test. Furthermore, variance independent factor (VIF) should be used to check the multicollinearity of the indicators for computation in the regression model.

Demographic characteristics should be statistically tested to determine their significant level of P-value 0.05 with the underlying vulnerability factors (UVFs) to explain who is vulnerable to what. However, because other explanations might be hidden in a quantitative assessment, a qualitative –in-depth assessment must be done to understand those hidden issues per se. In so doing, the assessment would be informative in identifying the factors that give rise to the pressures that generate vulnerable conditions in society for different groups.

Adaptive capacity should be assessed both quantitatively and qualitatively since it is a component of vulnerability reduction. This entails that if adaptive capacity is sufficient, it is likely that households' response to floods would be high and vulnerability is also likely to reduce and vice versa.

5.1 FVA application and comparability

The FVA should be applied as a pre-hazard, trans-hazard and post-hazard (flood) tool. In the pre-hazard category, all the proposed indicators should be used to determine vulnerable conditions which may (or may not) put some households at risk of flood disaster in the event of a flood occurrence. In the trans-hazard, the FVA indicators should be used to determine the vulnerabilities of households to identify the households that have been affected by floods as part of the disaster response and recovery process. In so doing, the FVA indicators should be used as a means of establishing strategies for disaster response and recovery as part of building back better. As a post-hazard tool, indicators should be used to determine the vulnerabilities that contributed to a disaster situation. Users should prioritize these indicators as a means of building DRR for disaster rehabilitation and reconstruction. In this case, the FVA framework contrasts itself to available tools such as the Unified Beneficiary Register (UBR) and Hazard Rapid Assessment (HRA) which largely are implemented only after the hazard in Malawi. Furthermore, it separates indicators that generate vulnerability in subsectors, but most available frameworks do not portray this separation. Therefore, participating enterprises can implement the FVA framework based on the needs of the assessment. The FVA framework can be implemented through hydrological assessment, flood modelling, quantitative, qualitative, GIS and remote sensing methodologies, giving opportunity to multiple users. The framework emphasizes UVFs (physical, social, economic, environmental and cultural) and VCs (exposure, susceptibility and resilience) as intersection constructs of flood vulnerability in urban and rural areas of Malawi and other places where it can be applied. It provides very simplified indicators of assessing flood vulnerability at local and national levels, deviating from the generalised frameworks that look at a wider scale like the PAR model (Wisner et al., 2004 ). More importantly, the framework provides tailor-made indicators thereby localizing the assessment of flood vulnerability in Malawi. This framework gives indicators that can be easily measured and evaluated at any level using different tools (statistical applications) thereby giving empirical scientific data on floods. The framework is coined strategically for researchers to utilise it in measuring the vulnerability of a single underlying factor of interest (i.e., physical vulnerability or social vulnerability etc.). It also gives simplified indicators that can be utilised by policy and decision-makers for planning interventions. The framework provides a good alignment of adaptive capacity to underlying vulnerability factors and components. In this case, the framework integrates DRR into vulnerability reduction strategies. Unlike the PAR model (Wisner et al., 2004 ) which does not explain exactly the measures of vulnerability reduction, this framework, through the integration of adaptive capacity, has filled up this gap. Finally, the framework intersects the significant factors of vulnerability in a set theory analysis giving new thinking in outlining FVA indicators in Malawi and beyond. The framework goes beyond the Community-Based Disaster Risk Index (CBDRI) by Bollin et al. (2003) which provides a proper link of indicators between vulnerability factors and components. For example, the CBDRI considers vulnerability components as structure, population, economy, environmental and capacity measures (Mwale et al. 2015 ) yet alone these could be grouped as conditions that generate flood vulnerability as tested in the FVA framework.

From the findings of this study, the FVA is comparable with various contemporary disaster management frameworks such as the PAR Model (Wisner et al. 2014 ), the Hazard of Place Framework (Cutter 1996 ), the Sustainable Livelihood Model (2004), the Community-based Disaster Risk Management Model (Kelman 2010 ), Turner et al. (2003) framework and the International Disaster Risk Reduction Framework (ISDR 2004). Therefore, based on the indicators intersected in Fig.  11 (such as housing conditions, access to information, access to resources, poor land use, social networks, and location), the FVA framework correlates well with most of the indicators stipulated in Hazard of place model (Cutter 1996 ), PAR model (Winser et al. 2014 ), Urban Flood Vulnerability Assessment Framework (Salami et al. 2017 ), ISDR framework (2004). However, the FVA framework has provided simplified indicators of flood vulnerability assessment because the indicators are simple to be used by experts and non-experts whether they are in urban or rural areas. They can be easily understood by ordinary users and policymakers. Furthermore, the indicators can be used for multi-hazards vulnerability assessment, since the H and F in the constituted equation can be changed based on hazard. In this case, the FVA Framework is widening vulnerability assessment beyond a focus on floods. The FVA, therefore, eliminates the gaps that most studies in literature mainly focus on, single hazards, ignoring the multi-hazard assessment (Kamanga et al. 2020 ). The FVA includes variables that can be measurable through quantitative and ANN (machine learning platform) thereby expanding the process of vulnerability analysis.

The FVA separated the indicators that generate vulnerability in different subsectors of UVFs and VCs. This separation deviates from most of the contemporary frameworks. Joakim ( 2008 ) noted that most contemporary frameworks fail to portray the linkages and networks that exist with the layers or sections leading to the vulnerability. For example, the PAR (Wisner et al. 2014 ) model provides a generalised causation of vulnerability. It portrays the progression of vulnerability from root causes to unsafe conditions, but it fails to explicitly acknowledge the linkages that exist within each progression (Joakim 2008 ). The FVA has provided a straightforward linkage of indicators by systematizing and assessing vulnerability in different subsectors. Similarly, the International Strategy for Disaster Reduction (ISDR) (2004) framework, the Hazard of Place Framework (HOP) (Cutter 1996 ), Borgardi, Birkmann and Cadona (BCC) (2004) and the Turner et al. (2003) framework, all have methodological difficulty of translation of some concepts into practice (Mwale 2014 ). This methodological variation, further makes the contemporary frameworks to be difficult to incorporate different links that exist between vulnerability factors. Mwale ( 2014 ) argues that the HOP framework does not provide a causal explanation of the vulnerability, instead variables are selected the way they are. Joakim ( 2008 ) further noted that the applicability of the HOP framework is a Canadian context, giving an impression that some indicators might manifest themselves differently in small political, economic and social processes. However, the HOP framework in some instances, relates very well with FVA, particularly the inclusion of perceptions, emphasis on understanding the underlying vulnerability factors, and inclusion of mitigation and adaptive capacity in the analysis of vulnerability. It is also highlighted that Turner II et al.’s (2003) framework is too theoretical and lacks specificity (Mwale 2014 ). This means that the framework is not simple and easy to use. The ISDR (2004) does not link the preparedness response system and thereby not explicit on how vulnerability can be reduced. Also, the use of one-dimensional indicators is demonstrated in the Turner II et al. (2003) framework which defines vulnerability in terms of exposure, susceptibility and responses. For this part, the ISDR (2004) defines vulnerability in the realms of social, economic, environmental and physical (Mwale 2014 ), missing the aspects of exposure, susceptibility and resilience. Above all, most of these frameworks have neglected to agglomerate the UVFs and VCs in their analysis and development of vulnerability frameworks. These FVA have attempted to fill these gaps, giving vulnerability assessment a new direction. In Malawi and SSA in general, Mwale et al. ( 2015 ) in a study of contemporary disaster management framework quantification of flood risk in rural lower Shire Valley, Malawi found medium, high and very high flood vulnerability in the same construct of indicators of the FVA framework. This implies that the FVA indicators are locally comparable and can be used for the decision-making process. The FVA indicators are more practical and can ably enhance community and household resilience. These indicators can thus be applied in promoting the resilience of communities to mitigate flood risks and key components for planning and decision-making processes.

6 Conclusion

This study carried out flood vulnerability assessment (FVA) using quantitative methods by utilising MCA, ANN (machine learning) and multiple logistical regression. The high flood vulnerability and lack of adaptive capacity among the households and communities in rural and urban informal settlements is an indication that catchment management in most areas remains a challenge to the water sector, disaster professionals and other players. This study highlights place settlement (proximity to catchments), low-risk knowledge, limited access to communication, poor sanitation, limited institutional capacity, and lack of alternative livelihoods as key drivers of flood vulnerability. These, among others, prevent households near the catchments from living in harmony and at peace with their water resources catchments. As the FVA framework specifies the indicators that contribute to flood vulnerability in rural and urban informal settlements, it is important to consider shifting towards investing in the adaptive capacity of communities along the catchments for better resilience building. The FVA framework considered adaptive capacity to mean actions taken by households to manage their catchments and livelihoods before, during and after floods. The adaptive measures entail the level of resilience households would be (or would not be) to floods. This study considered it crucial to constitute this framework in this manner to provide a roadmap for identifying the underlying causes of household levels of vulnerability to floods. This flood vulnerability assessment framework is applicable for both rural and urban and could be fit for purpose in sectors such as climate change, water resources management, disaster risk management, disaster risk reduction, integrated water management, food security, health, environmental management, engineering etc. The government might find the framework significant to establish clear regulations and accountability mechanisms to ensure that their involvement genuinely contributes to sustainable and equitable outcomes. Enterprises would find the framework useful for mapping vulnerability to natural hazards to address current and future risks in communities, including building community resilience and a line of separation with government.

7 Recommendations

The FVA framework is the first attempt to agglomerate operators in the UVFs and VCs through a multicollinearity analysis in a logit multiple regression to give rise to indicators in the PEIs, SSIs, ERIs, EEIs and CSIs for flood vulnerability assessment. The framework emphasises both understanding the conditions that generate vulnerability and those that can reduce vulnerability. Therefore, the study emphasises that the Malawi government through the Department of Disaster Management Affairs (DODMA) should strengthen disaster risk reduction by maintaining (1) political responsibility through the formulation of public policies with a clear understanding of people’s vulnerabilities (2) Legal responsibility through incorporating the framework as a way of perfecting the legal system, enforce the laws and establish laws that are not a centric symbol of disaster enterprise (3) Social responsibility through applying the framework to harmonise systems to be fair and just, without treating others in a sense of societal leniency, greenwashing practices and prioritisation of profit over environmental and social responsibility (4) Economic responsibility through utilising the framework to formulate relevant financial and economic measures i.e. disaster risk funds, to make disaster funds not to base on the declaration of a disaster.

Similarly, mapping vulnerability to natural hazards in urban areas should be enhanced to provide data necessary for developing disaster risk awareness and communication strategies vital to strengthening urban risk knowledge of natural hazards. The framework should be applied in promoting the resilience of communities to mitigate flood risks and can be a key component for planning and decision-making processes both in rural and urban areas. Finally, this study focused on one rural area and one urban informal area, so there is a need for district-wide or city-wide study and/or there is a need for study in urban between planned settlement and unplanned traditional housing areas (UTHA).

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The publication of this research received financial support from the NORHED Project on Climate Change and Ecosystem Management in Malawi and Tanzania (#63826) and the Centre for Resilient Agri-Food Systems (CRAFS) under the Africa Centres of Excellence (ACE2) programme.

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Mwalwimba, I.K., Manda, M. & Ngongondo, C. Flood vulnerability assessment in rural and urban informal settlements: case study of Karonga District and Lilongwe City in Malawi. Nat Hazards (2024). https://doi.org/10.1007/s11069-024-06601-5

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Received : 08 October 2023

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DOI : https://doi.org/10.1007/s11069-024-06601-5

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