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Journal for Multicultural Education

ISSN : 2053-535X

Article publication date: 22 January 2021

Issue publication date: 4 June 2021

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

Design/methodology/approach

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

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

Research limitations/implications

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

Practical implications

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

Social implications

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

Originality/value

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

• Online learning
• New technologies
• Transformative knowledge

Acknowledgements

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

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

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Copyright © 2020, Emerald Publishing Limited

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Action research

A type of applied research designed to find the most effective way to bring about a desired social change or to solve a practical problem, usually in collaboration with those being researched.

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How do you define action research.

Professor David Coghlan explains action research as an approach that crosses many academic disciplines yet has a shared focus on taking action to address a problem. He describes the difference between this approach and empirical scientific approaches, particularly highlighting the challenge of getting action research to be taken seriously by academic journals

Dr. Nataliya Ivankova defines action research as using systematic research principles to address an issue in everyday life. She delineates the six steps of action research, and illustrates the concept using an anti-diabetes project in an urban area.

This is just one segment in a whole series about action research. You can find the rest of the series in our SAGE database, Research Methods:

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Action Research vs. Case Study

What's the difference.

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

Further Detail

Introduction.

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

Action Research

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

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

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

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

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

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

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

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

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

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

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

Similarities

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

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

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

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

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

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

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Home » Education » Difference Between Action Research and Case Study

Difference Between Action Research and Case Study

Main difference – action research vs case study.

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

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

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

What is Action Research

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

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

Action Research Process

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

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

What is a Case Study

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

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

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

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

Case Study Process

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

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

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

Action Research : Action research involves solving a problem.

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

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

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

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

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

Participants

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

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

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

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

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

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From Good to Great in Puerto Rico

Taking pedagogical practices to the next level, the challenge, insight + courage + action, developing a high-quality spanish literacy program.

Vimenti School in San Juan, Puerto Rico, is a dual language K-6 school, serving 274 students with 36 teachers. The school is a two-generation project committed to the economic development of families and whose mission is the eradication of child poverty in Puerto Rico. Since the pandemic’s interruptions, Vimenti has focused primarily on strengthening language skills in students’ first language—Spanish. The school’s leaders knew that getting instruction right was critical for their students, as a strong academic foundation is a key factor in ensuring young people have multiple pathways to thriving lives and careers.   

While there was potential and readiness for change, the school faced a challenge: How could they elevate teacher practice in Spanish language arts and empower students to become proficient readers, writers, and thinkers in their native language?  

Multilingual learners do best when teachers celebrate the linguistic and cultural assets that they bring to the classroom. With that in mind, Vimenti leaders wanted to provide their teachers with concrete models of what high-quality teaching and learning looks like in Spanish. In 2023, they brought in TNTP’s signature in-service teacher professional development program, Good to Great , which strengthens teacher practice by centering high-quality instructional materials and leading teachers through carefully structured cycles of planning, teaching, and reflection. Since 2015, TNTP has led this program with over 700 teachers in 12 states, focusing on multiple subjects and grade-bands and a range of student populations.  

Working closely with the leadership team at Vimenti, TNTP began with an analysis of the school’s current instructional landscape for Spanish language arts. This important step helped us better understand the learning environment, the teachers, and the students. Based on that deeper awareness, TNTP created a tailored approach that would coach educators on how they could better meet their students’ needs. The customized professional development and teaching intensive program consisted of three core components:  

1.  School Landscape Analysis – Listening and Learning:

• Led focus groups with teachers   
• Conducted classroom observations   
• Completed a curriculum audit   
• Met with school leaders  

2.  Professional Development:

• Co-constructed an instructional vision
• Built deep understanding of teacher identities
• Focused on pedagogical practices of close reading and daily writing, effective question sequences and lesson internalization  

3. Teaching Intensive:

• K-6 teachers implemented one week of lessons during their morning reading block.  
• Every afternoon teachers participated in reflection and planning sessions to analyze student work and prepare for the next day’s instruction.  

We invited educators to dive deeply into the importance of high expectations and grade-appropriate assignments for their students. During the one-week teaching intensive, Vimenti teachers spent the morning reading blocks implementing lessons and devoted the afternoons to reflection and planning sessions.  

From Developing Lessons to Lessons Learned

The TNTP team developed grade-appropriate lessons for teachers to implement, offered intensive professional development, accompanied them during their instruction, and facilitated guided reflection of student achievement so they could successfully plan for the next day’s instruction. Seeing students succeed showed Vimenti teachers what their students were capable of, and in turn, raised teachers’ own expectations for how they must structure instruction to boost academic achievement.  

Had I seen a [close reading] question like this… I am 95% sure I would have said ‘skip that one, you will not be able to answer it’… but exposing them was good and led to great results.”” — Third-grade teacher, Vimenti School  

Higher Teacher Expectations Lead to Increased Student Engagement

When we compared classroom observation data between the first and last observations, the results were dramatic. The percentage of students responsible for thinking in the classroom jumped to 75 percent, a stark contrast from initial observations where this was only observed sparingly if at all. Similarly, work requiring students to use textual details to demonstrate understanding saw similar gains. The percentage of teachers indicating high expectations for their students also increased from 50 percent to 67 percent after the one-week teaching institute.   

Following the institute, one second-grade teacher shared, “[Students] are more capable than we give them credit for… you realize that they could do it… we put limitations on them ourselves.”  

Teachers weren’t the only ones recognizing this mindset shift. We started and ended the program by administering student surveys, to ensure students had a voice in evaluating their academic experiences. Student sentiment improved over the week, with more students reporting that their teachers’ higher expectations encouraged them to do their best in class. Blending high expectations, solid instruction, and grade-level content, including culturally relevant texts, had begun to unlock immense potential for both students and teachers.  

Through our customized professional learning experience, TNTP created opportunities for Vimenti’s teachers to jumpstart instructional improvement and challenge their expectations of what their students could achieve. Teachers could see the immediate impact of their instructional improvements in real time, and with coaching support, began to shift the ownership of the learning process to their students. In just one week, students wrote significantly longer responses to questions, included more evidence from the text in their answers, and dove into more complex topics, demonstrating a deeper understanding of the texts.    

In partnership with school leaders, we ensured Vimenti’s teachers worked with high-quality, culturally relevant texts that were on the appropriate grade level for their students, empowering them to focus on accelerating learning for students, rather than on struggling to catch up from pandemic setbacks. Overall, Vimenti’s teachers and students had the chance to discover and develop new identities for themselves as educators and learners. The strong results give us confidence that the Good to Great summer institute catalyzed a continuous improvement cycle that will have an ongoing impact for Vimenti students.   

Contact us to learn more about how Good to Great can strengthen instruction in your school system.  

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Difference between Case Study and Action research

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

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

Difference between Case study and Action Research :

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Learning together for better health using an evidence-based Learning Health System framework: a case study in stroke

• Helena Teede 1 , 2   na1 ,
• Dominique A. Cadilhac 3 , 4   na1 ,
• Tara Purvis 3 ,
• Monique F. Kilkenny 3 , 4 ,
• Bruce C.V. Campbell 4 , 5 , 6 ,
• Coralie English 7 ,
• Alison Johnson 2 ,
• Emily Callander 1 ,
• Rohan S. Grimley 8 , 9 ,
• Christopher Levi 10 ,
• Sandy Middleton 11 , 12 ,
• Kelvin Hill 13 &
• Joanne Enticott   ORCID: orcid.org/0000-0002-4480-5690 1  

BMC Medicine volume  22 , Article number:  198 ( 2024 ) Cite this article

2 Altmetric

Metrics details

In the context of expanding digital health tools, the health system is ready for Learning Health System (LHS) models. These models, with proper governance and stakeholder engagement, enable the integration of digital infrastructure to provide feedback to all relevant parties including clinicians and consumers on performance against best practice standards, as well as fostering innovation and aligning healthcare with patient needs. The LHS literature primarily includes opinion or consensus-based frameworks and lacks validation or evidence of benefit. Our aim was to outline a rigorously codesigned, evidence-based LHS framework and present a national case study of an LHS-aligned national stroke program that has delivered clinical benefit.

Current core components of a LHS involve capturing evidence from communities and stakeholders (quadrant 1), integrating evidence from research findings (quadrant 2), leveraging evidence from data and practice (quadrant 3), and generating evidence from implementation (quadrant 4) for iterative system-level improvement. The Australian Stroke program was selected as the case study as it provides an exemplar of how an iterative LHS works in practice at a national level encompassing and integrating evidence from all four LHS quadrants. Using this case study, we demonstrate how to apply evidence-based processes to healthcare improvement and embed real-world research for optimising healthcare improvement. We emphasize the transition from research as an endpoint, to research as an enabler and a solution for impact in healthcare improvement.

Conclusions

The Australian Stroke program has nationally improved stroke care since 2007, showcasing the value of integrated LHS-aligned approaches for tangible impact on outcomes. This LHS case study is a practical example for other health conditions and settings to follow suit.

Peer Review reports

Internationally, health systems are facing a crisis, driven by an ageing population, increasing complexity, multi-morbidity, rapidly advancing health technology and rising costs that threaten sustainability and mandate transformation and improvement [ 1 , 2 ]. Although research has generated solutions to healthcare challenges, and the advent of big data and digital health holds great promise, entrenched siloes and poor integration of knowledge generation, knowledge implementation and healthcare delivery between stakeholders, curtails momentum towards, and consistent attainment of, evidence-and value-based care [ 3 ]. This is compounded by the short supply of research and innovation leadership within the healthcare sector, and poorly integrated and often inaccessible health data systems, which have crippled the potential to deliver on digital-driven innovation [ 4 ]. Current approaches to healthcare improvement are also often isolated with limited sustainability, scale-up and impact [ 5 ].

Evidence suggests that integration and partnership across academic and healthcare delivery stakeholders are key to progress, including those with lived experience and their families (referred to here as consumers and community), diverse disciplines (both research and clinical), policy makers and funders. Utilization of evidence from research and evidence from practice including data from routine care, supported by implementation research, are key to sustainably embedding improvement and optimising health care and outcomes. A strategy to achieve this integration is through the Learning Health System (LHS) (Fig.  1 ) [ 2 , 6 , 7 , 8 ]. Although there are numerous publications on LHS approaches [ 9 , 10 , 11 , 12 ], many focus on research perspectives and data, most do not demonstrate tangible healthcare improvement or better health outcomes. [ 6 ]

Monash Learning Health System: The Learn Together for Better Health Framework developed by Monash Partners and Monash University (from Enticott et al. 2021 [ 7 ]). Four evidence quadrants: Q1 (orange) is evidence from stakeholders; Q2 (green) is evidence from research; Q3 (light blue) is evidence from data; and, Q4 (dark blue) is evidence from implementation and healthcare improvement

In developed nations, it has been estimated that 60% of care provided aligns with the evidence base, 30% is low value and 10% is potentially harmful [ 13 ]. In some areas, clinical advances have been rapid and research and evidence have paved the way for dramatic improvement in outcomes, mandating rapid implementation of evidence into healthcare (e.g. polio and COVID-19 vaccines). However, healthcare improvement is challenging and slow [ 5 ]. Health systems are highly complex in their design, networks and interacting components, and change is difficult to enact, sustain and scale up. [ 3 ] New effective strategies are needed to meet community needs and deliver evidence-based and value-based care, which reorients care from serving the provider, services and system, towards serving community needs, based on evidence and quality. It goes beyond cost to encompass patient and provider experience, quality care and outcomes, efficiency and sustainability [ 2 , 6 ].

The costs of stroke care are expected to rise rapidly in the next decades, unless improvements in stroke care to reduce the disabling effects of strokes can be successfully developed and implemented [ 14 ]. Here, we briefly describe the Monash LHS framework (Fig.  1 ) [ 2 , 6 , 7 ] and outline an exemplar case in order to demonstrate how to apply evidence-based processes to healthcare improvement and embed real-world research for optimising healthcare. The Australian LHS exemplar in stroke care has driven nationwide improvement in stroke care since 2007.

An evidence-based Learning Health System framework

In Australia, members of this author group (HT, AJ, JE) have rigorously co-developed an evidence-based LHS framework, known simply as the Monash LHS [ 7 ]. The Monash LHS was designed to support sustainable, iterative and continuous robust benefit of improved clinical outcomes. It was created with national engagement in order to be applicable to Australian settings. Through this rigorous approach, core LHS principles and components have been established (Fig.  1 ). Evidence shows that people/workforce, culture, standards, governance and resources were all key to an effective LHS [ 2 , 6 ]. Culture is vital including trust, transparency, partnership and co-design. Key processes include legally compliant data sharing, linkage and governance, resources, and infrastructure [ 4 ]. The Monash LHS integrates disparate and often siloed stakeholders, infrastructure and expertise to ‘Learn Together for Better Health’ [ 7 ] (Fig.  1 ). This integrates (i) evidence from community and stakeholders including priority areas and outcomes; (ii) evidence from research and guidelines; (iii) evidence from practice (from data) with advanced analytics and benchmarking; and (iv) evidence from implementation science and health economics. Importantly, it starts with the problem and priorities of key stakeholders including the community, health professionals and services and creates an iterative learning system to address these. The following case study was chosen as it is an exemplar of how a Monash LHS-aligned national stroke program has delivered clinical benefit.

Australian Stroke Learning Health System

Internationally, the application of LHS approaches in stroke has resulted in improved stroke care and outcomes [ 12 ]. For example, in Canada a sustained decrease in 30-day in-hospital mortality has been found commensurate with an increase in resources to establish the multifactorial stroke system intervention for stroke treatment and prevention [ 15 ]. Arguably, with rapid advances in evidence and in the context of an ageing population with high cost and care burden and substantive impacts on quality of life, stroke is an area with a need for rapid research translation into evidence-based and value-based healthcare improvement. However, a recent systematic review found that the existing literature had few comprehensive examples of LHS adoption [ 12 ]. Although healthcare improvement systems and approaches were described, less is known about patient-clinician and stakeholder engagement, governance and culture, or embedding of data informatics into everyday practice to inform and drive improvement [ 12 ]. For example, in a recent review of quality improvement collaborations, it was found that although clinical processes in stroke care are improved, their short-term nature means there is uncertainty about sustainability and impacts on patient outcomes [ 16 ]. Table  1 provides the main features of the Australian Stroke LHS based on the four core domains and eight elements of the Learning Together for Better Health Framework described in Fig.  1 . The features are further expanded on in the following sections.

Evidence from stakeholders (LHS quadrant 1, Fig.  1 )

Engagement, partners and priorities.

Within the stroke field, there have been various support mechanisms to facilitate an LHS approach including partnership and broad stakeholder engagement that includes clinical networks and policy makers from different jurisdictions. Since 2008, the Australian Stroke Coalition has been co-led by the Stroke Foundation, a charitable consumer advocacy organisation, and Stroke Society of Australasia a professional society with membership covering academics and multidisciplinary clinician networks, that are collectively working to improve stroke care ( https://australianstrokecoalition.org.au/ ). Surveys, focus groups and workshops have been used for identifying priorities from stakeholders. Recent agreed priorities have been to improve stroke care and strengthen the voice for stroke care at a national ( https://strokefoundation.org.au/ ) and international level ( https://www.world-stroke.org/news-and-blog/news/world-stroke-organization-tackle-gaps-in-access-to-quality-stroke-care ), as well as reduce duplication amongst stakeholders. This activity is built on a foundation and culture of research and innovation embedded within the stroke ‘community of practice’. Consumers, as people with lived experience of stroke are important members of the Australian Stroke Coalition, as well as representatives from different clinical colleges. Consumers also provide critical input to a range of LHS activities via the Stroke Foundation Consumer Council, Stroke Living Guidelines committees, and the Australian Stroke Clinical Registry (AuSCR) Steering Committee (described below).

Evidence from research (LHS quadrant 2, Fig.  1 )

Advancement of the evidence for stroke interventions and synthesis into clinical guidelines.

To implement best practice, it is crucial to distil the large volume of scientific and trial literature into actionable recommendations for clinicians to use in practice [ 24 ]. The first Australian clinical guidelines for acute stroke were produced in 2003 following the increasing evidence emerging for prevention interventions (e.g. carotid endarterectomy, blood pressure lowering), acute medical treatments (intravenous thrombolysis, aspirin within 48 h of ischemic stroke), and optimised hospital management (care in dedicated stroke units by a specialised and coordinated multidisciplinary team) [ 25 ]. Importantly, a number of the innovations were developed, researched and proven effective by key opinion leaders embedded in the Australian stroke care community. In 2005, the clinical guidelines for Stroke Rehabilitation and Recovery [ 26 ] were produced, with subsequent merged guidelines periodically updated. However, the traditional process of periodic guideline updates is challenging for end users when new research can render recommendations redundant and this lack of currency erodes stakeholder trust [ 27 ]. In response to this challenge the Stroke Foundation and Cochrane Australia entered a pioneering project to produce the first electronic ‘living’ guidelines globally [ 20 ]. Major shifts in the evidence for reperfusion therapies (e.g. extended time-window intravenous thrombolysis and endovascular clot retrieval), among other advances, were able to be converted into new recommendations, approved by the Australian National Health and Medical Research Council within a few months of publication. Feedback on this process confirmed the increased use and trust in the guidelines by clinicians. The process informed other living guidelines programs, including the successful COVID-19 clinical guidelines [ 28 ].

However, best practice clinical guideline recommendations are necessary but insufficient for healthcare improvement and nesting these within an LHS with stakeholder partnership, enables implementation via a range of proven methods, including audit and feedback strategies [ 29 ].

Evidence from data and practice (LHS quadrant 3, Fig.  1 )

Data systems and benchmarking : revealing the disparities in care between health services. A national system for standardized stroke data collection was established as the National Stroke Audit program in 2007 by the Stroke Foundation [ 30 ] following various state-level programs (e.g. New South Wales Audit) [ 31 ] to identify evidence-practice gaps and prioritise improvement efforts to increase access to stroke units and other acute treatments [ 32 ]. The Audit program alternates each year between acute (commencing in 2007) and rehabilitation in-patient services (commencing in 2008). The Audit program provides a ‘deep dive’ on the majority of recommendations in the clinical guidelines whereby participating hospitals provide audits of up to 40 consecutive patient medical records and respond to a survey about organizational resources to manage stroke. In 2009, the AuSCR was established to provide information on patients managed in acute hospitals based on a small subset of quality processes of care linked to benchmarked reports of performance (Fig.  2 ) [ 33 ]. In this way, the continuous collection of high-priority processes of stroke care could be regularly collected and reviewed to guide improvement to care [ 34 ]. Plus clinical quality registry programs within Australia have shown a meaningful return on investment attributed to enhanced survival, improvements in quality of life and avoided costs of treatment or hospital stay [ 35 ].

Example performance report from the Australian Stroke Clinical Registry: average door-to-needle time in providing intravenous thrombolysis by different hospitals in 2021 [ 36 ]. Each bar in the figure represents a single hospital

The Australian Stroke Coalition endorsed the creation of an integrated technological solution for collecting data through a single portal for multiple programs in 2013. In 2015, the Stroke Foundation, AuSCR consortium, and other relevant groups cooperated to design an integrated data management platform (the Australian Stroke Data Tool) to reduce duplication of effort for hospital staff in the collection of overlapping variables in the same patients [ 19 ]. Importantly, a national data dictionary then provided the common data definitions to facilitate standardized data capture. Another important feature of AuSCR is the collection of patient-reported outcome surveys between 90 and 180 days after stroke, and annual linkage with national death records to ascertain survival status [ 33 ]. To support a LHS approach, hospitals that participate in AuSCR have access to a range of real-time performance reports. In efforts to minimize the burden of data collection in the AuSCR, interoperability approaches to import data directly from hospital or state-level managed stroke databases have been established (Fig.  3 ); however, the application has been variable and 41% of hospitals still manually enter all their data.

Current status of automated data importing solutions in the Australian Stroke Clinical Registry, 2022, with ‘ n ’ representing the number of hospitals. AuSCR, Australian Stroke Clinical Registry; AuSDaT, Australian Stroke Data Tool; API, Application Programming Interface; ICD, International Classification of Diseases; RedCAP, Research Electronic Data Capture; eMR, electronic medical records

For acute stroke care, the Australian Commission on Quality and Safety in Health Care facilitated the co-design (clinicians, academics, consumers) and publication of the national Acute Stroke Clinical Care Standard in 2015 [ 17 ], and subsequent review [ 18 ]. The indicator set for the Acute Stroke Standard then informed the expansion of the minimum dataset for AuSCR so that hospitals could routinely track their performance. The national Audit program enabled hospitals not involved in the AuSCR to assess their performance every two years against the Acute Stroke Standard. Complementing these efforts, the Stroke Foundation, working with the sector, developed the Acute and Rehabilitation Stroke Services Frameworks to outline the principles, essential elements, models of care and staffing recommendations for stroke services ( https://informme.org.au/guidelines/national-stroke-services-frameworks ). The Frameworks are intended to guide where stroke services should be developed, and monitor their uptake with the organizational survey component of the Audit program.

Evidence from implementation and healthcare improvement (LHS quadrant 4, Fig.  1 )

Research to better utilize and augment data from registries through linkage [ 37 , 38 , 39 , 40 ] and to ensure presentation of hospital or service level data are understood by clinicians has ensured advancement in the field for the Australian Stroke LHS [ 41 ]. Importantly, greater insights into whole patient journeys, before and after a stroke, can now enable exploration of value-based care. The LHS and stroke data platform have enabled focused and time-limited projects to create a better understanding of the quality of care in acute or rehabilitation settings [ 22 , 42 , 43 ]. Within stroke, all the elements of an LHS culminate into the ready availability of benchmarked performance data and support for implementation of strategies to address gaps in care.

Implementation research to grow the evidence base for effective improvement interventions has also been a key pillar in the Australian context. These include multi-component implementation interventions to achieve behaviour change for particular aspects of stroke care, [ 22 , 23 , 44 , 45 ] and real-world approaches to augmenting access to hyperacute interventions in stroke through the use of technology and telehealth [ 46 , 47 , 48 , 49 ]. The evidence from these studies feeds into the living guidelines program and the data collection systems, such as the Audit program or AuSCR, which are then amended to ensure data aligns to recommended care. For example, the use of ‘hyperacute aspirin within the first 48 h of ischemic stroke’ was modified to be ‘hyperacute antiplatelet…’ to incorporate new evidence that other medications or combinations are appropriate to use. Additionally, new datasets have been developed to align with evidence such as the Fever, Sugar, and Swallow variables [ 42 ]. Evidence on improvements in access to best practice care from the acute Audit program [ 50 ] and AuSCR is emerging [ 36 ]. For example, between 2007 and 2017, the odds of receiving intravenous thrombolysis after ischemic stroke increased by 16% 9OR 1.06 95% CI 1.13–1.18) and being managed in a stroke unit by 18% (OR 1.18 95% CI 1.17–1.20). Over this period, the median length of hospital stay for all patients decreased from 6.3 days in 2007 to 5.0 days in 2017 [ 51 ]. When considering the number of additional patients who would receive treatment in 2017 in comparison to 2007 it was estimated that without this additional treatment, over 17,000 healthy years of life would be lost in 2017 (17,786 disability-adjusted life years) [ 51 ]. There is evidence on the cost-effectiveness of different system-focussed strategies to augment treatment access for acute ischemic stroke (e.g. Victorian Stroke Telemedicine program [ 52 ] and Melbourne Mobile Stroke Unit ambulance [ 53 ]). Reciprocally, evidence from the national Rehabilitation Audit, where the LHS approach has been less complete or embedded, has shown fewer areas of healthcare improvement over time [ 51 , 54 ].

Within the field of stroke in Australia, there is indirect evidence that the collective efforts that align to establishing the components of a LHS have had an impact. Overall, the age-standardised rate of stroke events has reduced by 27% between 2001 and 2020, from 169 to 124 events per 100,000 population. Substantial declines in mortality rates have been reported since 1980. Commensurate with national clinical guidelines being updated in 2007 and the first National Stroke Audit being undertaken in 2007, the mortality rates for men (37.4 deaths per 100,000) and women (36.1 deaths per 100,0000 has declined to 23.8 and 23.9 per 100,000, respectively in 2021 [ 55 ].

Underpinning the LHS with the integration of the four quadrants of evidence from stakeholders, research and guidelines, practice and implementation, and core LHS principles have been addressed. Leadership and governance have been important, and programs have been established to augment workforce training and capacity building in best practice professional development. Medical practitioners are able to undertake courses and mentoring through the Australasian Stroke Academy ( http://www.strokeacademy.com.au/ ) while nurses (and other health professionals) can access teaching modules in stroke care from the Acute Stroke Nurses Education Network ( https://asnen.org/ ). The Association of Neurovascular Clinicians offers distance-accessible education and certification to develop stroke expertise for interdisciplinary professionals, including advanced stroke co-ordinator certification ( www.anvc.org ). Consumer initiative interventions are also used in the design of the AuSCR Public Summary Annual reports (available at https://auscr.com.au/about/annual-reports/ ) and consumer-related resources related to the Living Guidelines ( https://enableme.org.au/resources ).

The important success factors and lessons from stroke as a national exemplar LHS in Australia include leadership, culture, workforce and resources integrated with (1) established and broad partnerships across the academic-clinical sector divide and stakeholder engagement; (2) the living guidelines program; (3) national data infrastructure, including a national data dictionary that provides the common data framework to support standardized data capture; (4) various implementation strategies including benchmarking and feedback as well as engagement strategies targeting different levels of the health system; and (5) implementation and improvement research to advance stroke systems of care and reduce unwarranted variation in practice (Fig.  1 ). Priority opportunities now include the advancement of interoperability with electronic medical records as an area all clinical quality registry’s programs needs to be addressed, as well as providing more dynamic and interactive data dashboards tailored to the need of clinicians and health service executives.

There is a clear mandate to optimise healthcare improvement with big data offering major opportunities for change. However, we have lacked the approaches to capture evidence from the community and stakeholders, to integrate evidence from research, to capture and leverage data or evidence from practice and to generate and build on evidence from implementation using iterative system-level improvement. The LHS provides this opportunity and is shown to deliver impact. Here, we have outlined the process applied to generate an evidence-based LHS and provide a leading exemplar in stroke care. This highlights the value of moving from single-focus isolated approaches/initiatives to healthcare improvement and the benefit of integration to deliver demonstrable outcomes for our funders and key stakeholders — our community. This work provides insight into strategies that can both apply evidence-based processes to healthcare improvement as well as implementing evidence-based practices into care, moving beyond research as an endpoint, to research as an enabler, underpinning delivery of better healthcare.

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Abbreviations

Australian Stroke Clinical Registry

Confidence interval

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Acknowledgements

The following authors hold National Health and Medical Research Council Research Fellowships: HT (#2009326), DAC (#1154273), SM (#1196352), MFK Future Leader Research Fellowship (National Heart Foundation #105737). The Funders of this work did not have any direct role in the design of the study, its execution, analyses, interpretation of the data, or decision to submit results for publication.

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Helena Teede and Dominique A. Cadilhac contributed equally.

Authors and Affiliations

Monash Centre for Health Research and Implementation, 43-51 Kanooka Grove, Clayton, VIC, Australia

Helena Teede, Emily Callander & Joanne Enticott

Monash Partners Academic Health Science Centre, 43-51 Kanooka Grove, Clayton, VIC, Australia

Helena Teede & Alison Johnson

Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Level 2 Monash University Research, Victorian Heart Hospital, 631 Blackburn Rd, Clayton, VIC, Australia

Dominique A. Cadilhac, Tara Purvis & Monique F. Kilkenny

Stroke Theme, The Florey Institute of Neuroscience and Mental Health, University of Melbourne, Heidelberg, VIC, Australia

Dominique A. Cadilhac, Monique F. Kilkenny & Bruce C.V. Campbell

Department of Neurology, Melbourne Brain Centre, Royal Melbourne Hospital, Parkville, VIC, Australia

Bruce C.V. Campbell

Department of Medicine, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Victoria, Australia

School of Health Sciences, Heart and Stroke Program, University of Newcastle, Hunter Medical Research Institute, University Drive, Callaghan, NSW, Australia

Coralie English

School of Medicine and Dentistry, Griffith University, Birtinya, QLD, Australia

Rohan S. Grimley

Clinical Excellence Division, Queensland Health, Brisbane, Australia

John Hunter Hospital, Hunter New England Local Health District and University of Newcastle, Sydney, NSW, Australia

Christopher Levi

School of Nursing, Midwifery and Paramedicine, Australian Catholic University, Sydney, NSW, Australia

Sandy Middleton

Nursing Research Institute, St Vincent’s Health Network Sydney and and Australian Catholic University, Sydney, NSW, Australia

Stroke Foundation, Level 7, 461 Bourke St, Melbourne, VIC, Australia

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HT: conception, design and initial draft, developed the theoretical formalism for learning health system framework, approved the submitted version. DAC: conception, design and initial draft, provided essential literature and case study examples, approved the submitted version. TP: revised the manuscript critically for important intellectual content, approved the submitted version. MFK: revised the manuscript critically for important intellectual content, provided essential literature and case study examples, approved the submitted version. BC: revised the manuscript critically for important intellectual content, provided essential literature and case study examples, approved the submitted version. CE: revised the manuscript critically for important intellectual content, provided essential literature and case study examples, approved the submitted version. AJ: conception, design and initial draft, developed the theoretical formalism for learning health system framework, approved the submitted version. EC: revised the manuscript critically for important intellectual content, approved the submitted version. RSG: revised the manuscript critically for important intellectual content, provided essential literature and case study examples, approved the submitted version. CL: revised the manuscript critically for important intellectual content, provided essential literature and case study examples, approved the submitted version. SM: revised the manuscript critically for important intellectual content, provided essential literature and case study examples, approved the submitted version. KH: revised the manuscript critically for important intellectual content, provided essential literature and case study examples, approved the submitted version. JE: conception, design and initial draft, developed the theoretical formalism for learning health system framework, approved the submitted version. All authors read and approved the final manuscript.

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Teede, H., Cadilhac, D.A., Purvis, T. et al. Learning together for better health using an evidence-based Learning Health System framework: a case study in stroke. BMC Med 22 , 198 (2024). https://doi.org/10.1186/s12916-024-03416-w

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DOI : https://doi.org/10.1186/s12916-024-03416-w

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• Managing Substance Use Disorders
• Health Equity
• Data Resources
• Additional HHS Resources
• Overdose Prevention Resources
• Management and Treatment of Pain
• Clinical Practice Guideline at a Glance
• Clinical Care and Treatment
• Health Care Provider Toolkits
• Electronic CDS Tools for Opioids
• Strategies and Partnerships
• Resources for Public Health Professionals
• Journal Articles
• MMWR Articles
• Guides and Meeting Reports
• Related Publications
• Overdose Data to Action
• Drug-Free Communities (DFC)

Overdose Data to Action Case Studies

At a glance.

CDC created case studies to capture in-depth information from Overdose Data to Action (OD2A)-funded jurisdictions about current and emerging practices related to overdose prevention and response.

Each of the highlighted jurisdictions was funded through the multiyear Overdose Data to Action (OD2A) cooperative agreement (2019-2023), focused on understanding and tracking the complex and changing nature of the drug overdose epidemic and the need for seamless integration of data into prevention strategies.

Six key topic areas were identified for interviews, analysis, and dissemination. Within each topic, specific activities and programs from various jurisdictions are captured as case studies. Programs and projects were selected based on a thorough review of OD2A activities. These case studies illustrate overdose prevention and response efforts that can be shared with practitioners as they consider how to adapt interventions to their local context.

Related resources‎

Adverse childhood experiences or aces.

Case Studies: Adverse Childhood Experiences

Injury-Free Louisiana Shared Risk and Protective Factors Academy – Louisiana Strengthening Families Program – South Carolina

OD2A Case Study: Adverse Childhood Experiences

Harm Reduction

Case Studies: Harm Reduction

Harm Reduction Community Linkage Project – Illinois

OD2A Case Study: Harm Reduction

Linkage to Care in Non-Public Safety Settings

Case Studies: Linkage to Care in Non-Public Safety Settings

Linkage to Care and Overdose Education & Naloxone Distribution Program – Massachusetts

OD2A Case Study: Linkage to Care in Non-Public Safety Settings

Public Safety-Led Post-Overdose Outreach Programs

Case Studies: Public Safety-Led Post-Overdose Outreach Programs

Quick Response Teams Program – West Virginia Rapid Response Emergency Addiction Crisis Teams Program – Franklin County, Ohio

OD2A Case Study: Public Safety-Led Post-Overdose Outreach Programs

State and Local Integration Activities

Case Studies: State and Local Integration

Surveillance Response Intervention Calls – Rhode Island Coalitions – California

OD2A Case Study: State and Local Integration

Stigma Reduction

Case Studies: Stigma Reduction

Motivational interviewing and compassion training – Vermont Stigma/Harm Reduction Training – Vermont

OD2A Case Study: Stigma Reduction

Overdose Prevention

Overdose prevention is a CDC priority that impacts families and communities. Drug overdose is a leading cause of preventable death in the U.S.

For Everyone

Health care providers, public health.

ORIGINAL RESEARCH article

This article is part of the research topic.

Measuring Diets and Food Choice in the Context of a Changing World

Measuring and Shaping the Nutritional Environment via Food Sales Logs: Case Studies of Campus-Wide Food Choice and a Call to Action Provisionally Accepted

• 1 Swiss Federal Institute of Technology Lausanne, Switzerland
• 2 Université de Fribourg, Switzerland
• 3 Microsoft Research (United States), United States

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

Although diets influence health and the environment, measuring and changing nutrition is challenging. Traditional measurement methods face challenges, and designing and conducting behavior-changing interventions is conceptually and logistically complicated. Situated local communities such as university campuses offer unique opportunities to shape the nutritional environment and promote health and sustainability. The present study investigates how passively sensed food purchase logs typically collected as part of regular business operations can be used to monitor and measure on-campus food consumption and understand food choice determinants.First, based on 38 million sales logs collected on a large university campus over eight years, we perform statistical analyses to quantify spatio-temporal determinants of food choice and characterize harmful patterns in dietary behaviors, in a case study of food purchasing at EPFL campus. We identify spatial proximity, food item pairing, and academic schedules (yearly and daily) as important determinants driving the on-campus food choice. The case studies demonstrate the potential of food sales logs for measuring nutrition and highlight the breadth and depth of future possibilities to study individual food-choice determinants. We describe how these insights provide an opportunity for stakeholders, such as campus offices responsible for managing food services, to shape the nutritional environment and improve health and sustainability by designing policies and behavioral interventions. Finally, based on the insights derived through the case study of food purchases at EPFL campus, we identify five future opportunities and offer a call to action for the nutrition research community to contribute to ensuring the health and sustainability of on-campus populations-the very communities to which many researchers belong.

Keywords: food choice, Measurement, Monitoring, determinants, Digital traces, Health, sustainability, policy

Received: 30 May 2023; Accepted: 14 May 2024.

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

* Correspondence: Dr. Kristina Gligorić, Swiss Federal Institute of Technology Lausanne, Lausanne, 1015, Vaud, Switzerland

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