collection on case study

• Privacy Policy

Home » Case Study – Methods, Examples and Guide

Case Study – Methods, Examples and Guide

Table of Contents

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.

About the author

Muhammad Hassan

Researcher, Academic Writer, Web developer

You may also like

Triangulation in Research – Types, Methods and...

Observational Research – Methods and Guide

Questionnaire – Definition, Types, and Examples

Quantitative Research – Methods, Types and...

Experimental Design – Types, Methods, Guide

One-to-One Interview – Methods and Guide

Have a language expert improve your writing

Run a free plagiarism check in 10 minutes, generate accurate citations for free.

• Knowledge Base

Methodology

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

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

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

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

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

Table of contents

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

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

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

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

Prevent plagiarism. Run a free check.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Research bias

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

Cite this Scribbr article

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

McCombes, S. (2023, November 20). What Is a Case Study? | Definition, Examples & Methods. Scribbr. Retrieved September 22, 2024, from https://www.scribbr.com/methodology/case-study/

Is this article helpful?

Shona McCombes

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

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

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

Research question

• Conceptual framework
• Conceptual vs. theoretical framework

Data collection

• Qualitative research methods
• Focus groups
• Observational research

What is a case study?

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

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

Case studies

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

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

Definition of a case study

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

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

Characteristics of case studies

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

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

The role of case studies in research

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

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

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

What is the purpose of a case study?

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

Why use case studies in qualitative research?

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

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

The explanatory, exploratory, and descriptive roles of case studies

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

The impact of case studies on knowledge development

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

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

Types of case studies

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

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

Exploratory case studies

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

Descriptive case studies

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

Explanatory case studies

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

Intrinsic, instrumental, and collective case studies

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

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

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

Critical information systems research

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

Health research

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

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

Asthma research studies

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

Other fields

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

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

Whatever field you're in, ATLAS.ti puts your data to work for you

Download a free trial of ATLAS.ti to turn your data into insights.

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

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

Propositions

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

Units of analysis

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

Argumentation

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

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

Ready to jumpstart your research with ATLAS.ti?

Conceptualize your research project with our intuitive data analysis interface. Download a free trial today.

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

Defining the research question

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

Selecting and defining the case

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

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

Developing a detailed case study protocol

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

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

Collecting data

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

Analyzing and interpreting data

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

Writing the case study report

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

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

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

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

Observations

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

Documents and artifacts

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

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

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

Ensuring the quality of data collection

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

Data analysis

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

Organizing the data

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

Categorizing and coding the data

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

Identifying patterns and themes

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

Interpreting the data

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

Verification of the data

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

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

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

Benefits include the following:

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

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

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

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

Ready to analyze your data with ATLAS.ti?

See how our intuitive software can draw key insights from your data with a free trial today.

Designing and Conducting Case Studies

This guide examines case studies, a form of qualitative descriptive research that is used to look at individuals, a small group of participants, or a group as a whole. Researchers collect data about participants using participant and direct observations, interviews, protocols, tests, examinations of records, and collections of writing samples. Starting with a definition of the case study, the guide moves to a brief history of this research method. Using several well documented case studies, the guide then looks at applications and methods including data collection and analysis. A discussion of ways to handle validity, reliability, and generalizability follows, with special attention to case studies as they are applied to composition studies. Finally, this guide examines the strengths and weaknesses of case studies.

Definition and Overview

Case study refers to the collection and presentation of detailed information about a particular participant or small group, frequently including the accounts of subjects themselves. A form of qualitative descriptive research, the case study looks intensely at an individual or small participant pool, drawing conclusions only about that participant or group and only in that specific context. Researchers do not focus on the discovery of a universal, generalizable truth, nor do they typically look for cause-effect relationships; instead, emphasis is placed on exploration and description.

Case studies typically examine the interplay of all variables in order to provide as complete an understanding of an event or situation as possible. This type of comprehensive understanding is arrived at through a process known as thick description, which involves an in-depth description of the entity being evaluated, the circumstances under which it is used, the characteristics of the people involved in it, and the nature of the community in which it is located. Thick description also involves interpreting the meaning of demographic and descriptive data such as cultural norms and mores, community values, ingrained attitudes, and motives.

Unlike quantitative methods of research, like the survey, which focus on the questions of who, what, where, how much, and how many, and archival analysis, which often situates the participant in some form of historical context, case studies are the preferred strategy when how or why questions are asked. Likewise, they are the preferred method when the researcher has little control over the events, and when there is a contemporary focus within a real life context. In addition, unlike more specifically directed experiments, case studies require a problem that seeks a holistic understanding of the event or situation in question using inductive logic--reasoning from specific to more general terms.

In scholarly circles, case studies are frequently discussed within the context of qualitative research and naturalistic inquiry. Case studies are often referred to interchangeably with ethnography, field study, and participant observation. The underlying philosophical assumptions in the case are similar to these types of qualitative research because each takes place in a natural setting (such as a classroom, neighborhood, or private home), and strives for a more holistic interpretation of the event or situation under study.

Unlike more statistically-based studies which search for quantifiable data, the goal of a case study is to offer new variables and questions for further research. F.H. Giddings, a sociologist in the early part of the century, compares statistical methods to the case study on the basis that the former are concerned with the distribution of a particular trait, or a small number of traits, in a population, whereas the case study is concerned with the whole variety of traits to be found in a particular instance" (Hammersley 95).

Case studies are not a new form of research; naturalistic inquiry was the primary research tool until the development of the scientific method. The fields of sociology and anthropology are credited with the primary shaping of the concept as we know it today. However, case study research has drawn from a number of other areas as well: the clinical methods of doctors; the casework technique being developed by social workers; the methods of historians and anthropologists, plus the qualitative descriptions provided by quantitative researchers like LePlay; and, in the case of Robert Park, the techniques of newspaper reporters and novelists.

Park was an ex-newspaper reporter and editor who became very influential in developing sociological case studies at the University of Chicago in the 1920s. As a newspaper professional he coined the term "scientific" or "depth" reporting: the description of local events in a way that pointed to major social trends. Park viewed the sociologist as "merely a more accurate, responsible, and scientific reporter." Park stressed the variety and value of human experience. He believed that sociology sought to arrive at natural, but fluid, laws and generalizations in regard to human nature and society. These laws weren't static laws of the kind sought by many positivists and natural law theorists, but rather, they were laws of becoming--with a constant possibility of change. Park encouraged students to get out of the library, to quit looking at papers and books, and to view the constant experiment of human experience. He writes, "Go and sit in the lounges of the luxury hotels and on the doorsteps of the flophouses; sit on the Gold Coast settees and on the slum shakedowns; sit in the Orchestra Hall and in the Star and Garter Burlesque. In short, gentlemen [sic], go get the seats of your pants dirty in real research."

But over the years, case studies have drawn their share of criticism. In fact, the method had its detractors from the start. In the 1920s, the debate between pro-qualitative and pro-quantitative became quite heated. Case studies, when compared to statistics, were considered by many to be unscientific. From the 1930's on, the rise of positivism had a growing influence on quantitative methods in sociology. People wanted static, generalizable laws in science. The sociological positivists were looking for stable laws of social phenomena. They criticized case study research because it failed to provide evidence of inter subjective agreement. Also, they condemned it because of the few number of cases studied and that the under-standardized character of their descriptions made generalization impossible. By the 1950s, quantitative methods, in the form of survey research, had become the dominant sociological approach and case study had become a minority practice.

Educational Applications

The 1950's marked the dawning of a new era in case study research, namely that of the utilization of the case study as a teaching method. "Instituted at Harvard Business School in the 1950s as a primary method of teaching, cases have since been used in classrooms and lecture halls alike, either as part of a course of study or as the main focus of the course to which other teaching material is added" (Armisted 1984). The basic purpose of instituting the case method as a teaching strategy was "to transfer much of the responsibility for learning from the teacher on to the student, whose role, as a result, shifts away from passive absorption toward active construction" (Boehrer 1990). Through careful examination and discussion of various cases, "students learn to identify actual problems, to recognize key players and their agendas, and to become aware of those aspects of the situation that contribute to the problem" (Merseth 1991). In addition, students are encouraged to "generate their own analysis of the problems under consideration, to develop their own solutions, and to practically apply their own knowledge of theory to these problems" (Boyce 1993). Along the way, students also develop "the power to analyze and to master a tangled circumstance by identifying and delineating important factors; the ability to utilize ideas, to test them against facts, and to throw them into fresh combinations" (Merseth 1991).

In addition to the practical application and testing of scholarly knowledge, case discussions can also help students prepare for real-world problems, situations and crises by providing an approximation of various professional environments (i.e. classroom, board room, courtroom, or hospital). Thus, through the examination of specific cases, students are given the opportunity to work out their own professional issues through the trials, tribulations, experiences, and research findings of others. An obvious advantage to this mode of instruction is that it allows students the exposure to settings and contexts that they might not otherwise experience. For example, a student interested in studying the effects of poverty on minority secondary student's grade point averages and S.A.T. scores could access and analyze information from schools as geographically diverse as Los Angeles, New York City, Miami, and New Mexico without ever having to leave the classroom.

The case study method also incorporates the idea that students can learn from one another "by engaging with each other and with each other's ideas, by asserting something and then having it questioned, challenged and thrown back at them so that they can reflect on what they hear, and then refine what they say" (Boehrer 1990). In summary, students can direct their own learning by formulating questions and taking responsibility for the study.

Types and Design Concerns

Researchers use multiple methods and approaches to conduct case studies.

Types of Case Studies

Under the more generalized category of case study exist several subdivisions, each of which is custom selected for use depending upon the goals and/or objectives of the investigator. These types of case study include the following:

Illustrative Case Studies These are primarily descriptive studies. They typically utilize one or two instances of an event to show what a situation is like. Illustrative case studies serve primarily to make the unfamiliar familiar and to give readers a common language about the topic in question.

Exploratory (or pilot) Case Studies These are condensed case studies performed before implementing a large scale investigation. Their basic function is to help identify questions and select types of measurement prior to the main investigation. The primary pitfall of this type of study is that initial findings may seem convincing enough to be released prematurely as conclusions.

Cumulative Case Studies These serve to aggregate information from several sites collected at different times. The idea behind these studies is the collection of past studies will allow for greater generalization without additional cost or time being expended on new, possibly repetitive studies.

Critical Instance Case Studies These examine one or more sites for either the purpose of examining a situation of unique interest with little to no interest in generalizability, or to call into question or challenge a highly generalized or universal assertion. This method is useful for answering cause and effect questions.

Identifying a Theoretical Perspective

Much of the case study's design is inherently determined for researchers, depending on the field from which they are working. In composition studies, researchers are typically working from a qualitative, descriptive standpoint. In contrast, physicists will approach their research from a more quantitative perspective. Still, in designing the study, researchers need to make explicit the questions to be explored and the theoretical perspective from which they will approach the case. The three most commonly adopted theories are listed below:

Individual Theories These focus primarily on the individual development, cognitive behavior, personality, learning and disability, and interpersonal interactions of a particular subject.

Organizational Theories These focus on bureaucracies, institutions, organizational structure and functions, or excellence in organizational performance.

Social Theories These focus on urban development, group behavior, cultural institutions, or marketplace functions.

Two examples of case studies are used consistently throughout this chapter. The first, a study produced by Berkenkotter, Huckin, and Ackerman (1988), looks at a first year graduate student's initiation into an academic writing program. The study uses participant-observer and linguistic data collecting techniques to assess the student's knowledge of appropriate discourse conventions. Using the pseudonym Nate to refer to the subject, the study sought to illuminate the particular experience rather than to generalize about the experience of fledgling academic writers collectively.

For example, in Berkenkotter, Huckin, and Ackerman's (1988) study we are told that the researchers are interested in disciplinary communities. In the first paragraph, they ask what constitutes membership in a disciplinary community and how achieving membership might affect a writer's understanding and production of texts. In the third paragraph they state that researchers must negotiate their claims "within the context of his sub specialty's accepted knowledge and methodology." In the next paragraph they ask, "How is literacy acquired? What is the process through which novices gain community membership? And what factors either aid or hinder students learning the requisite linguistic behaviors?" This introductory section ends with a paragraph in which the study's authors claim that during the course of the study, the subject, Nate, successfully makes the transition from "skilled novice" to become an initiated member of the academic discourse community and that his texts exhibit linguistic changes which indicate this transition. In the next section the authors make explicit the sociolinguistic theoretical and methodological assumptions on which the study is based (1988). Thus the reader has a good understanding of the authors' theoretical background and purpose in conducting the study even before it is explicitly stated on the fourth page of the study. "Our purpose was to examine the effects of the educational context on one graduate student's production of texts as he wrote in different courses and for different faculty members over the academic year 1984-85." The goal of the study then, was to explore the idea that writers must be initiated into a writing community, and that this initiation will change the way one writes.

The second example is Janet Emig's (1971) study of the composing process of a group of twelfth graders. In this study, Emig seeks to answer the question of what happens to the self as a result educational stimuli in terms of academic writing. The case study used methods such as protocol analysis, tape-recorded interviews, and discourse analysis.

In the case of Janet Emig's (1971) study of the composing process of eight twelfth graders, four specific hypotheses were made:

• Twelfth grade writers engage in two modes of composing: reflexive and extensive.
• These differences can be ascertained and characterized through having the writers compose aloud their composition process.
• A set of implied stylistic principles governs the writing process.
• For twelfth grade writers, extensive writing occurs chiefly as a school-sponsored activity, or reflexive, as a self-sponsored activity.

In this study, the chief distinction is between the two dominant modes of composing among older, secondary school students. The distinctions are:

• The reflexive mode, which focuses on the writer's thoughts and feelings.
• The extensive mode, which focuses on conveying a message.

Emig also outlines the specific questions which guided the research in the opening pages of her Review of Literature , preceding the report.

Designing a Case Study

After considering the different sub categories of case study and identifying a theoretical perspective, researchers can begin to design their study. Research design is the string of logic that ultimately links the data to be collected and the conclusions to be drawn to the initial questions of the study. Typically, research designs deal with at least four problems:

• What questions to study
• What data are relevant
• What data to collect
• How to analyze that data

In other words, a research design is basically a blueprint for getting from the beginning to the end of a study. The beginning is an initial set of questions to be answered, and the end is some set of conclusions about those questions.

Because case studies are conducted on topics as diverse as Anglo-Saxon Literature (Thrane 1986) and AIDS prevention (Van Vugt 1994), it is virtually impossible to outline any strict or universal method or design for conducting the case study. However, Robert K. Yin (1993) does offer five basic components of a research design:

• A study's questions.
• A study's propositions (if any).
• A study's units of analysis.
• The logic that links the data to the propositions.
• The criteria for interpreting the findings.

In addition to these five basic components, Yin also stresses the importance of clearly articulating one's theoretical perspective, determining the goals of the study, selecting one's subject(s), selecting the appropriate method(s) of collecting data, and providing some considerations to the composition of the final report.

Conducting Case Studies

To obtain as complete a picture of the participant as possible, case study researchers can employ a variety of approaches and methods. These approaches, methods, and related issues are discussed in depth in this section.

Method: Single or Multi-modal?

To obtain as complete a picture of the participant as possible, case study researchers can employ a variety of methods. Some common methods include interviews , protocol analyses, field studies, and participant-observations. Emig (1971) chose to use several methods of data collection. Her sources included conversations with the students, protocol analysis, discrete observations of actual composition, writing samples from each student, and school records (Lauer and Asher 1988).

Berkenkotter, Huckin, and Ackerman (1988) collected data by observing classrooms, conducting faculty and student interviews, collecting self reports from the subject, and by looking at the subject's written work.

A study that was criticized for using a single method model was done by Flower and Hayes (1984). In this study that explores the ways in which writers use different forms of knowing to create space, the authors used only protocol analysis to gather data. The study came under heavy fire because of their decision to use only one method.

Participant Selection

Case studies can use one participant, or a small group of participants. However, it is important that the participant pool remain relatively small. The participants can represent a diverse cross section of society, but this isn't necessary.

For example, the Berkenkotter, Huckin, and Ackerman (1988) study looked at just one participant, Nate. By contrast, in Janet Emig's (1971) study of the composition process of twelfth graders, eight participants were selected representing a diverse cross section of the community, with volunteers from an all-white upper-middle-class suburban school, an all-black inner-city school, a racially mixed lower-middle-class school, an economically and racially mixed school, and a university school.

Often, a brief "case history" is done on the participants of the study in order to provide researchers with a clearer understanding of their participants, as well as some insight as to how their own personal histories might affect the outcome of the study. For instance, in Emig's study, the investigator had access to the school records of five of the participants, and to standardized test scores for the remaining three. Also made available to the researcher was the information that three of the eight students were selected as NCTE Achievement Award winners. These personal histories can be useful in later stages of the study when data are being analyzed and conclusions drawn.

Data Collection

There are six types of data collected in case studies:

• Archival records.
• Interviews.
• Direct observation.
• Participant observation.

In the field of composition research, these six sources might be:

• A writer's drafts.
• School records of student writers.
• Transcripts of interviews with a writer.
• Transcripts of conversations between writers (and protocols).
• Videotapes and notes from direct field observations.
• Hard copies of a writer's work on computer.

Depending on whether researchers have chosen to use a single or multi-modal approach for the case study, they may choose to collect data from one or any combination of these sources.

Protocols, that is, transcriptions of participants talking aloud about what they are doing as they do it, have been particularly common in composition case studies. For example, in Emig's (1971) study, the students were asked, in four different sessions, to give oral autobiographies of their writing experiences and to compose aloud three themes in the presence of a tape recorder and the investigator.

In some studies, only one method of data collection is conducted. For example, the Flower and Hayes (1981) report on the cognitive process theory of writing depends on protocol analysis alone. However, using multiple sources of evidence to increase the reliability and validity of the data can be advantageous.

Case studies are likely to be much more convincing and accurate if they are based on several different sources of information, following a corroborating mode. This conclusion is echoed among many composition researchers. For example, in her study of predrafting processes of high and low-apprehensive writers, Cynthia Selfe (1985) argues that because "methods of indirect observation provide only an incomplete reflection of the complex set of processes involved in composing, a combination of several such methods should be used to gather data in any one study." Thus, in this study, Selfe collected her data from protocols, observations of students role playing their writing processes, audio taped interviews with the students, and videotaped observations of the students in the process of composing.

It can be said then, that cross checking data from multiple sources can help provide a multidimensional profile of composing activities in a particular setting. Sharan Merriam (1985) suggests "checking, verifying, testing, probing, and confirming collected data as you go, arguing that this process will follow in a funnel-like design resulting in less data gathering in later phases of the study along with a congruent increase in analysis checking, verifying, and confirming."

It is important to note that in case studies, as in any qualitative descriptive research, while researchers begin their studies with one or several questions driving the inquiry (which influence the key factors the researcher will be looking for during data collection), a researcher may find new key factors emerging during data collection. These might be unexpected patterns or linguistic features which become evident only during the course of the research. While not bearing directly on the researcher's guiding questions, these variables may become the basis for new questions asked at the end of the report, thus linking to the possibility of further research.

Data Analysis

As the information is collected, researchers strive to make sense of their data. Generally, researchers interpret their data in one of two ways: holistically or through coding. Holistic analysis does not attempt to break the evidence into parts, but rather to draw conclusions based on the text as a whole. Flower and Hayes (1981), for example, make inferences from entire sections of their students' protocols, rather than searching through the transcripts to look for isolatable characteristics.

However, composition researchers commonly interpret their data by coding, that is by systematically searching data to identify and/or categorize specific observable actions or characteristics. These observable actions then become the key variables in the study. Sharan Merriam (1988) suggests seven analytic frameworks for the organization and presentation of data:

• The role of participants.
• The network analysis of formal and informal exchanges among groups.
• Historical.
• Thematical.
• Ritual and symbolism.
• Critical incidents that challenge or reinforce fundamental beliefs, practices, and values.

There are two purposes of these frameworks: to look for patterns among the data and to look for patterns that give meaning to the case study.

As stated above, while most researchers begin their case studies expecting to look for particular observable characteristics, it is not unusual for key variables to emerge during data collection. Typical variables coded in case studies of writers include pauses writers make in the production of a text, the use of specific linguistic units (such as nouns or verbs), and writing processes (planning, drafting, revising, and editing). In the Berkenkotter, Huckin, and Ackerman (1988) study, for example, researchers coded the participant's texts for use of connectives, discourse demonstratives, average sentence length, off-register words, use of the first person pronoun, and the ratio of definite articles to indefinite articles.

Since coding is inherently subjective, more than one coder is usually employed. In the Berkenkotter, Huckin, and Ackerman (1988) study, for example, three rhetoricians were employed to code the participant's texts for off-register phrases. The researchers established the agreement among the coders before concluding that the participant used fewer off-register words as the graduate program progressed.

Composing the Case Study Report

In the many forms it can take, "a case study is generically a story; it presents the concrete narrative detail of actual, or at least realistic events, it has a plot, exposition, characters, and sometimes even dialogue" (Boehrer 1990). Generally, case study reports are extensively descriptive, with "the most problematic issue often referred to as being the determination of the right combination of description and analysis" (1990). Typically, authors address each step of the research process, and attempt to give the reader as much context as possible for the decisions made in the research design and for the conclusions drawn.

This contextualization usually includes a detailed explanation of the researchers' theoretical positions, of how those theories drove the inquiry or led to the guiding research questions, of the participants' backgrounds, of the processes of data collection, of the training and limitations of the coders, along with a strong attempt to make connections between the data and the conclusions evident.

Although the Berkenkotter, Huckin, and Ackerman (1988) study does not, case study reports often include the reactions of the participants to the study or to the researchers' conclusions. Because case studies tend to be exploratory, most end with implications for further study. Here researchers may identify significant variables that emerged during the research and suggest studies related to these, or the authors may suggest further general questions that their case study generated.

For example, Emig's (1971) study concludes with a section dedicated solely to the topic of implications for further research, in which she suggests several means by which this particular study could have been improved, as well as questions and ideas raised by this study which other researchers might like to address, such as: is there a correlation between a certain personality and a certain composing process profile (e.g. is there a positive correlation between ego strength and persistence in revising)?

Also included in Emig's study is a section dedicated to implications for teaching, which outlines the pedagogical ramifications of the study's findings for teachers currently involved in high school writing programs.

Sharan Merriam (1985) also offers several suggestions for alternative presentations of data:

• Prepare specialized condensations for appropriate groups.
• Replace narrative sections with a series of answers to open-ended questions.
• Present "skimmer's" summaries at beginning of each section.
• Incorporate headlines that encapsulate information from text.
• Prepare analytic summaries with supporting data appendixes.
• Present data in colorful and/or unique graphic representations.

Issues of Validity and Reliability

Once key variables have been identified, they can be analyzed. Reliability becomes a key concern at this stage, and many case study researchers go to great lengths to ensure that their interpretations of the data will be both reliable and valid. Because issues of validity and reliability are an important part of any study in the social sciences, it is important to identify some ways of dealing with results.

Multi-modal case study researchers often balance the results of their coding with data from interviews or writer's reflections upon their own work. Consequently, the researchers' conclusions become highly contextualized. For example, in a case study which looked at the time spent in different stages of the writing process, Berkenkotter concluded that her participant, Donald Murray, spent more time planning his essays than in other writing stages. The report of this case study is followed by Murray's reply, wherein he agrees with some of Berkenkotter's conclusions and disagrees with others.

As is the case with other research methodologies, issues of external validity, construct validity, and reliability need to be carefully considered.

Commentary on Case Studies

Researchers often debate the relative merits of particular methods, among them case study. In this section, we comment on two key issues. To read the commentaries, choose any of the items below:

Strengths and Weaknesses of Case Studies

Most case study advocates point out that case studies produce much more detailed information than what is available through a statistical analysis. Advocates will also hold that while statistical methods might be able to deal with situations where behavior is homogeneous and routine, case studies are needed to deal with creativity, innovation, and context. Detractors argue that case studies are difficult to generalize because of inherent subjectivity and because they are based on qualitative subjective data, generalizable only to a particular context.

Flexibility

The case study approach is a comparatively flexible method of scientific research. Because its project designs seem to emphasize exploration rather than prescription or prediction, researchers are comparatively freer to discover and address issues as they arise in their experiments. In addition, the looser format of case studies allows researchers to begin with broad questions and narrow their focus as their experiment progresses rather than attempt to predict every possible outcome before the experiment is conducted.

Emphasis on Context

By seeking to understand as much as possible about a single subject or small group of subjects, case studies specialize in "deep data," or "thick description"--information based on particular contexts that can give research results a more human face. This emphasis can help bridge the gap between abstract research and concrete practice by allowing researchers to compare their firsthand observations with the quantitative results obtained through other methods of research.

Inherent Subjectivity

"The case study has long been stereotyped as the weak sibling among social science methods," and is often criticized as being too subjective and even pseudo-scientific. Likewise, "investigators who do case studies are often regarded as having deviated from their academic disciplines, and their investigations as having insufficient precision (that is, quantification), objectivity and rigor" (Yin 1989). Opponents cite opportunities for subjectivity in the implementation, presentation, and evaluation of case study research. The approach relies on personal interpretation of data and inferences. Results may not be generalizable, are difficult to test for validity, and rarely offer a problem-solving prescription. Simply put, relying on one or a few subjects as a basis for cognitive extrapolations runs the risk of inferring too much from what might be circumstance.

High Investment

Case studies can involve learning more about the subjects being tested than most researchers would care to know--their educational background, emotional background, perceptions of themselves and their surroundings, their likes, dislikes, and so on. Because of its emphasis on "deep data," the case study is out of reach for many large-scale research projects which look at a subject pool in the tens of thousands. A budget request of $10,000 to examine 200 subjects sounds more efficient than a similar request to examine four subjects.

Ethical Considerations

Researchers conducting case studies should consider certain ethical issues. For example, many educational case studies are often financed by people who have, either directly or indirectly, power over both those being studied and those conducting the investigation (1985). This conflict of interests can hinder the credibility of the study.

The personal integrity, sensitivity, and possible prejudices and/or biases of the investigators need to be taken into consideration as well. Personal biases can creep into how the research is conducted, alternative research methods used, and the preparation of surveys and questionnaires.

A common complaint in case study research is that investigators change direction during the course of the study unaware that their original research design was inadequate for the revised investigation. Thus, the researchers leave unknown gaps and biases in the study. To avoid this, researchers should report preliminary findings so that the likelihood of bias will be reduced.

Concerns about Reliability, Validity, and Generalizability

Merriam (1985) offers several suggestions for how case study researchers might actively combat the popular attacks on the validity, reliability, and generalizability of case studies:

• Prolong the Processes of Data Gathering on Site: This will help to insure the accuracy of the findings by providing the researcher with more concrete information upon which to formulate interpretations.
• Employ the Process of "Triangulation": Use a variety of data sources as opposed to relying solely upon one avenue of observation. One example of such a data check would be what McClintock, Brannon, and Maynard (1985) refer to as a "case cluster method," that is, when a single unit within a larger case is randomly sampled, and that data treated quantitatively." For instance, in Emig's (1971) study, the case cluster method was employed, singling out the productivity of a single student named Lynn. This cluster profile included an advanced case history of the subject, specific examination and analysis of individual compositions and protocols, and extensive interview sessions. The seven remaining students were then compared with the case of Lynn, to ascertain if there are any shared, or unique dimensions to the composing process engaged in by these eight students.
• Conduct Member Checks: Initiate and maintain an active corroboration on the interpretation of data between the researcher and those who provided the data. In other words, talk to your subjects.
• Collect Referential Materials: Complement the file of materials from the actual site with additional document support. For example, Emig (1971) supports her initial propositions with historical accounts by writers such as T.S. Eliot, James Joyce, and D.H. Lawrence. Emig also cites examples of theoretical research done with regards to the creative process, as well as examples of empirical research dealing with the writing of adolescents. Specific attention is then given to the four stages description of the composing process delineated by Helmoltz, Wallas, and Cowley, as it serves as the focal point in this study.
• Engage in Peer Consultation: Prior to composing the final draft of the report, researchers should consult with colleagues in order to establish validity through pooled judgment.

Although little can be done to combat challenges concerning the generalizability of case studies, "most writers suggest that qualitative research should be judged as credible and confirmable as opposed to valid and reliable" (Merriam 1985). Likewise, it has been argued that "rather than transplanting statistical, quantitative notions of generalizability and thus finding qualitative research inadequate, it makes more sense to develop an understanding of generalization that is congruent with the basic characteristics of qualitative inquiry" (1985). After all, criticizing the case study method for being ungeneralizable is comparable to criticizing a washing machine for not being able to tell the correct time. In other words, it is unjust to criticize a method for not being able to do something which it was never originally designed to do in the first place.

Annotated Bibliography

Armisted, C. (1984). How Useful are Case Studies. Training and Development Journal, 38 (2), 75-77.

This article looks at eight types of case studies, offers pros and cons of using case studies in the classroom, and gives suggestions for successfully writing and using case studies.

Bardovi-Harlig, K. (1997). Beyond Methods: Components of Second Language Teacher Education . New York: McGraw-Hill.

A compilation of various research essays which address issues of language teacher education. Essays included are: "Non-native reading research and theory" by Lee, "The case for Psycholinguistics" by VanPatten, and "Assessment and Second Language Teaching" by Gradman and Reed.

Bartlett, L. (1989). A Question of Good Judgment; Interpretation Theory and Qualitative Enquiry Address. 70th Annual Meeting of the American Educational Research Association. San Francisco.

Bartlett selected "quasi-historical" methodology, which focuses on the "truth" found in case records, as one that will provide "good judgments" in educational inquiry. He argues that although the method is not comprehensive, it can try to connect theory with practice.

Baydere, S. et. al. (1993). Multimedia conferencing as a tool for collaborative writing: a case study in Computer Supported Collaborative Writing. New York: Springer-Verlag.

The case study by Baydere et. al. is just one of the many essays in this book found in the series "Computer Supported Cooperative Work." Denley, Witefield and May explore similar issues in their essay, "A case study in task analysis for the design of a collaborative document production system."

Berkenkotter, C., Huckin, T., N., & Ackerman J. (1988). Conventions, Conversations, and the Writer: Case Study of a Student in a Rhetoric Ph.D. Program. Research in the Teaching of English, 22, 9-44.

The authors focused on how the writing of their subject, Nate or Ackerman, changed as he became more acquainted or familiar with his field's discourse community.

Berninger, V., W., and Gans, B., M. (1986). Language Profiles in Nonspeaking Individuals of Normal Intelligence with Severe Cerebral Palsy. Augmentative and Alternative Communication, 2, 45-50.

Argues that generalizations about language abilities in patients with severe cerebral palsy (CP) should be avoided. Standardized tests of different levels of processing oral language, of processing written language, and of producing written language were administered to 3 male participants (aged 9, 16, and 40 yrs).

Bockman, J., R., and Couture, B. (1984). The Case Method in Technical Communication: Theory and Models. Texas: Association of Teachers of Technical Writing.

Examines the study and teaching of technical writing, communication of technical information, and the case method in terms of those applications.

Boehrer, J. (1990). Teaching With Cases: Learning to Question. New Directions for Teaching and Learning, 42 41-57.

This article discusses the origins of the case method, looks at the question of what is a case, gives ideas about learning in case teaching, the purposes it can serve in the classroom, the ground rules for the case discussion, including the role of the question, and new directions for case teaching.

Bowman, W. R. (1993). Evaluating JTPA Programs for Economically Disadvantaged Adults: A Case Study of Utah and General Findings . Washington: National Commission for Employment Policy.

"To encourage state-level evaluations of JTPA, the Commission and the State of Utah co-sponsored this report on the effectiveness of JTPA Title II programs for adults in Utah. The technique used is non-experimental and the comparison group was selected from registrants with Utah's Employment Security. In a step-by-step approach, the report documents how non-experimental techniques can be applied and several specific technical issues can be addressed."

Boyce, A. (1993) The Case Study Approach for Pedagogists. Annual Meeting of the American Alliance for Health, Physical Education, Recreation and Dance. (Address). Washington DC.

This paper addresses how case studies 1) bridge the gap between teaching theory and application, 2) enable students to analyze problems and develop solutions for situations that will be encountered in the real world of teaching, and 3) helps students to evaluate the feasibility of alternatives and to understand the ramifications of a particular course of action.

Carson, J. (1993) The Case Study: Ideal Home of WAC Quantitative and Qualitative Data. Annual Meeting of the Conference on College Composition and Communication. (Address). San Diego.

"Increasingly, one of the most pressing questions for WAC advocates is how to keep [WAC] programs going in the face of numerous difficulties. Case histories offer the best chance for fashioning rhetorical arguments to keep WAC programs going because they offer the opportunity to provide a coherent narrative that contextualizes all documents and data, including what is generally considered scientific data. A case study of the WAC program, . . . at Robert Morris College in Pittsburgh demonstrates the advantages of this research method. Such studies are ideal homes for both naturalistic and positivistic data as well as both quantitative and qualitative information."

---. (1991). A Cognitive Process Theory of Writing. College Composition and Communication. 32. 365-87.

No abstract available.

Cromer, R. (1994) A Case Study of Dissociations Between Language and Cognition. Constraints on Language Acquisition: Studies of Atypical Children . Hillsdale: Lawrence Erlbaum Associates, 141-153.

Crossley, M. (1983) Case Study in Comparative and International Education: An Approach to Bridging the Theory-Practice Gap. Proceedings of the 11th Annual Conference of the Australian Comparative and International Education Society. Hamilton, NZ.

Case study research, as presented here, helps bridge the theory-practice gap in comparative and international research studies of education because it focuses on the practical, day-to-day context rather than on the national arena. The paper asserts that the case study method can be valuable at all levels of research, formation, and verification of theories in education.

Daillak, R., H., and Alkin, M., C. (1982). Qualitative Studies in Context: Reflections on the CSE Studies of Evaluation Use . California: EDRS

The report shows how the Center of the Study of Evaluation (CSE) applied qualitative techniques to a study of evaluation information use in local, Los Angeles schools. It critiques the effectiveness and the limitations of using case study, evaluation, field study, and user interview survey methodologies.

Davey, L. (1991). The Application of Case Study Evaluations. ERIC/TM Digest.

This article examines six types of case studies, the type of evaluation questions that can be answered, the functions served, some design features, and some pitfalls of the method.

Deutch, C. E. (1996). A course in research ethics for graduate students. College Teaching, 44, 2, 56-60.

This article describes a one-credit discussion course in research ethics for graduate students in biology. Case studies are focused on within the four parts of the course: 1) major issues, 2 )practical issues in scholarly work, 3) ownership of research results, and 4) training and personal decisions.

DeVoss, G. (1981). Ethics in Fieldwork Research. RIE 27p. (ERIC)

This article examines four of the ethical problems that can happen when conducting case study research: acquiring permission to do research, knowing when to stop digging, the pitfalls of doing collaborative research, and preserving the integrity of the participants.

Driscoll, A. (1985). Case Study of a Research Intervention: the University of Utah’s Collaborative Approach . San Francisco: Far West Library for Educational Research Development.

Paper presented at the annual meeting of the American Association of Colleges of Teacher Education, Denver, CO, March 1985. Offers information of in-service training, specifically case studies application.

Ellram, L. M. (1996). The Use of the Case Study Method in Logistics Research. Journal of Business Logistics, 17, 2, 93.

This article discusses the increased use of case study in business research, and the lack of understanding of when and how to use case study methodology in business.

Emig, J. (1971) The Composing Processes of Twelfth Graders . Urbana: NTCE.

This case study uses observation, tape recordings, writing samples, and school records to show that writing in reflexive and extensive situations caused different lengths of discourse and different clusterings of the components of the writing process.

Feagin, J. R. (1991). A Case For the Case Study . Chapel Hill: The University of North Carolina Press.

This book discusses the nature, characteristics, and basic methodological issues of the case study as a research method.

Feldman, H., Holland, A., & Keefe, K. (1989) Language Abilities after Left Hemisphere Brain Injury: A Case Study of Twins. Topics in Early Childhood Special Education, 9, 32-47.

"Describes the language abilities of 2 twin pairs in which 1 twin (the experimental) suffered brain injury to the left cerebral hemisphere around the time of birth and1 twin (the control) did not. One pair of twins was initially assessed at age 23 mo. and the other at about 30 mo.; they were subsequently evaluated in their homes 3 times at about 6-mo intervals."

Fidel, R. (1984). The Case Study Method: A Case Study. Library and Information Science Research, 6.

The article describes the use of case study methodology to systematically develop a model of online searching behavior in which study design is flexible, subject manner determines data gathering and analyses, and procedures adapt to the study's progressive change.

Flower, L., & Hayes, J. R. (1984). Images, Plans and Prose: The Representation of Meaning in Writing. Written Communication, 1, 120-160.

Explores the ways in which writers actually use different forms of knowing to create prose.

Frey, L. R. (1992). Interpreting Communication Research: A Case Study Approach Englewood Cliffs, N.J.: Prentice Hall.

The book discusses research methodologies in the Communication field. It focuses on how case studies bridge the gap between communication research, theory, and practice.

Gilbert, V. K. (1981). The Case Study as a Research Methodology: Difficulties and Advantages of Integrating the Positivistic, Phenomenological and Grounded Theory Approaches . The Annual Meeting of the Canadian Association for the Study of Educational Administration. (Address) Halifax, NS, Can.

This study on an innovative secondary school in England shows how a "low-profile" participant-observer case study was crucial to the initial observation, the testing of hypotheses, the interpretive approach, and the grounded theory.

Gilgun, J. F. (1994). A Case for Case Studies in Social Work Research. Social Work, 39, 4, 371-381.

This article defines case study research, presents guidelines for evaluation of case studies, and shows the relevance of case studies to social work research. It also looks at issues such as evaluation and interpretations of case studies.

Glennan, S. L., Sharp-Bittner, M. A. & Tullos, D. C. (1991). Augmentative and Alternative Communication Training with a Nonspeaking Adult: Lessons from MH. Augmentative and Alternative Communication, 7, 240-7.

"A response-guided case study documented changes in a nonspeaking 36-yr-old man's ability to communicate using 3 trained augmentative communication modes. . . . Data were collected in videotaped interaction sessions between the nonspeaking adult and a series of adult speaking."

Graves, D. (1981). An Examination of the Writing Processes of Seven Year Old Children. Research in the Teaching of English, 15, 113-134.

Hamel, J. (1993). Case Study Methods . Newbury Park: Sage. .

"In a most economical fashion, Hamel provides a practical guide for producing theoretically sharp and empirically sound sociological case studies. A central idea put forth by Hamel is that case studies must "locate the global in the local" thus making the careful selection of the research site the most critical decision in the analytic process."

Karthigesu, R. (1986, July). Television as a Tool for Nation-Building in the Third World: A Post-Colonial Pattern, Using Malaysia as a Case-Study. International Television Studies Conference. (Address). London, 10-12.

"The extent to which Television Malaysia, as a national mass media organization, has been able to play a role in nation building in the post-colonial period is . . . studied in two parts: how the choice of a model of nation building determines the character of the organization; and how the character of the organization influences the output of the organization."

Kenny, R. (1984). Making the Case for the Case Study. Journal of Curriculum Studies, 16, (1), 37-51.

The article looks at how and why the case study is justified as a viable and valuable approach to educational research and program evaluation.

Knirk, F. (1991). Case Materials: Research and Practice. Performance Improvement Quarterly, 4 (1 ), 73-81.

The article addresses the effectiveness of case studies, subject areas where case studies are commonly used, recent examples of their use, and case study design considerations.

Klos, D. (1976). Students as Case Writers. Teaching of Psychology, 3.2, 63-66.

This article reviews a course in which students gather data for an original case study of another person. The task requires the students to design the study, collect the data, write the narrative, and interpret the findings.

Leftwich, A. (1981). The Politics of Case Study: Problems of Innovation in University Education. Higher Education Review, 13.2, 38-64.

The article discusses the use of case studies as a teaching method. Emphasis is on the instructional materials, interdisciplinarity, and the complex relationships within the university that help or hinder the method.

Mabrito, M. (1991, Oct.). Electronic Mail as a Vehicle for Peer Response: Conversations of High and Low Apprehensive Writers. Written Communication, 509-32.

McCarthy, S., J. (1955). The Influence of Classroom Discourse on Student Texts: The Case of Ella . East Lansing: Institute for Research on Teaching.

A look at how students of color become marginalized within traditional classroom discourse. The essay follows the struggles of one black student: Ella.

Matsuhashi, A., ed. (1987). Writing in Real Time: Modeling Production Processes Norwood, NJ: Ablex Publishing Corporation.

Investigates how writers plan to produce discourse for different purposes to report, to generalize, and to persuade, as well as how writers plan for sentence level units of language. To learn about planning, an observational measure of pause time was used" (ERIC).

Merriam, S. B. (1985). The Case Study in Educational Research: A Review of Selected Literature. Journal of Educational Thought, 19.3, 204-17.

The article examines the characteristics of, philosophical assumptions underlying the case study, the mechanics of conducting a case study, and the concerns about the reliability, validity, and generalizability of the method.

---. (1988). Case Study Research in Education: A Qualitative Approach San Francisco: Jossey Bass.

Merry, S. E., & Milner, N. eds. (1993). The Possibility of Popular Justice: A Case Study of Community Mediation in the United States . Ann Arbor: U of Michigan.

". . . this volume presents a case study of one experiment in popular justice, the San Francisco Community Boards. This program has made an explicit claim to create an alternative justice, or new justice, in the midst of a society ordered by state law. The contributors to this volume explore the history and experience of the program and compare it to other versions of popular justice in the United States, Europe, and the Third World."

Merseth, K. K. (1991). The Case for Cases in Teacher Education. RIE. 42p. (ERIC).

This monograph argues that the case method of instruction offers unique potential for revitalizing the field of teacher education.

Michaels, S. (1987). Text and Context: A New Approach to the Study of Classroom Writing. Discourse Processes, 10, 321-346.

"This paper argues for and illustrates an approach to the study of writing that integrates ethnographic analysis of classroom interaction with linguistic analysis of written texts and teacher/student conversational exchanges. The approach is illustrated through a case study of writing in a single sixth grade classroom during a single writing assignment."

Milburn, G. (1995). Deciphering a Code or Unraveling a Riddle: A Case Study in the Application of a Humanistic Metaphor to the Reporting of Social Studies Teaching. Theory and Research in Education, 13.

This citation serves as an example of how case studies document learning procedures in a senior-level economics course.

Milley, J. E. (1979). An Investigation of Case Study as an Approach to Program Evaluation. 19th Annual Forum of the Association for Institutional Research. (Address). San Diego.

The case study method merged a narrative report focusing on the evaluator as participant-observer with document review, interview, content analysis, attitude questionnaire survey, and sociogram analysis. Milley argues that case study program evaluation has great potential for widespread use.

Minnis, J. R. (1985, Sept.). Ethnography, Case Study, Grounded Theory, and Distance Education Research. Distance Education, 6.2.

This article describes and defines the strengths and weaknesses of ethnography, case study, and grounded theory.

Nunan, D. (1992). Collaborative language learning and teaching . New York: Cambridge University Press.

Included in this series of essays is Peter Sturman’s "Team Teaching: a case study from Japan" and David Nunan’s own "Toward a collaborative approach to curriculum development: a case study."

Nystrand, M., ed. (1982). What Writers Know: The Language, Process, and Structure of Written Discourse . New York: Academic Press.

Owenby, P. H. (1992). Making Case Studies Come Alive. Training, 29, (1), 43-46. (ERIC)

This article provides tips for writing more effective case studies.

---. (1981). Pausing and Planning: The Tempo of Writer Discourse Production. Research in the Teaching of English, 15 (2),113-34.

Perl, S. (1979). The Composing Processes of Unskilled College Writers. Research in the Teaching of English, 13, 317-336.

"Summarizes a study of five unskilled college writers, focusing especially on one of the five, and discusses the findings in light of current pedagogical practice and research design."

Pilcher J. and A. Coffey. eds. (1996). Gender and Qualitative Research . Brookfield: Aldershot, Hants, England.

This book provides a series of essays which look at gender identity research, qualitative research and applications of case study to questions of gendered pedagogy.

Pirie, B. S. (1993). The Case of Morty: A Four Year Study. Gifted Education International, 9 (2), 105-109.

This case study describes a boy from kindergarten through third grade with above average intelligence but difficulty in learning to read, write, and spell.

Popkewitz, T. (1993). Changing Patterns of Power: Social Regulation and Teacher Education Reform. Albany: SUNY Press.

Popkewitz edits this series of essays that address case studies on educational change and the training of teachers. The essays vary in terms of discipline and scope. Also, several authors include case studies of educational practices in countries other than the United States.

---. (1984). The Predrafting Processes of Four High- and Four Low Apprehensive Writers. Research in the Teaching of English, 18, (1), 45-64.

Rasmussen, P. (1985, March) A Case Study on the Evaluation of Research at the Technical University of Denmark. International Journal of Institutional Management in Higher Education, 9 (1).

This is an example of a case study methodology used to evaluate the chemistry and chemical engineering departments at the University of Denmark.

Roth, K. J. (1986). Curriculum Materials, Teacher Talk, and Student Learning: Case Studies in Fifth-Grade Science Teaching . East Lansing: Institute for Research on Teaching.

Roth offers case studies on elementary teachers, elementary school teaching, science studies and teaching, and verbal learning.

Selfe, C. L. (1985). An Apprehensive Writer Composes. When a Writer Can't Write: Studies in Writer's Block and Other Composing-Process Problems . (pp. 83-95). Ed. Mike Rose. NMY: Guilford.

Smith-Lewis, M., R. and Ford, A. (1987). A User's Perspective on Augmentative Communication. Augmentative and Alternative Communication, 3, 12-7.

"During a series of in-depth interviews, a 25-yr-old woman with cerebral palsy who utilized augmentative communication reflected on the effectiveness of the devices designed for her during her school career."

St. Pierre, R., G. (1980, April). Follow Through: A Case Study in Metaevaluation Research . 64th Annual Meeting of the American Educational Research Association. (Address).

The three approaches to metaevaluation are evaluation of primary evaluations, integrative meta-analysis with combined primary evaluation results, and re-analysis of the raw data from a primary evaluation.

Stahler, T., M. (1996, Feb.) Early Field Experiences: A Model That Worked. ERIC.

"This case study of a field and theory class examines a model designed to provide meaningful field experiences for preservice teachers while remaining consistent with the instructor's beliefs about the role of teacher education in preparing teachers for the classroom."

Stake, R. E. (1995). The Art of Case Study Research. Thousand Oaks: Sage Publications.

This book examines case study research in education and case study methodology.

Stiegelbauer, S. (1984) Community, Context, and Co-curriculum: Situational Factors Influencing School Improvements in a Study of High Schools. Presented at the annual meeting of the American Educational Research Association, New Orleans, LA.

Discussion of several case studies: one looking at high school environments, another examining educational innovations.

Stolovitch, H. (1990). Case Study Method. Performance And Instruction, 29, (9), 35-37.

This article describes the case study method as a form of simulation and presents guidelines for their use in professional training situations.

Thaller, E. (1994). Bibliography for the Case Method: Using Case Studies in Teacher Education. RIE. 37 p.

This bibliography presents approximately 450 citations on the use of case studies in teacher education from 1921-1993.

Thrane, T. (1986). On Delimiting the Senses of Near-Synonyms in Historical Semantics: A Case Study of Adjectives of 'Moral Sufficiency' in the Old English Andreas. Linguistics Across Historical and Geographical Boundaries: In Honor of Jacek Fisiak on the Occasion of his Fiftieth Birthday . Berlin: Mouton de Gruyter.

United Nations. (1975). Food and Agriculture Organization. Report on the FAO/UNFPA Seminar on Methodology, Research and Country: Case Studies on Population, Employment and Productivity . Rome: United Nations.

This example case study shows how the methodology can be used in a demographic and psychographic evaluation. At the same time, it discusses the formation and instigation of the case study methodology itself.

Van Vugt, J. P., ed. (1994). Aids Prevention and Services: Community Based Research . Westport: Bergin and Garvey.

"This volume has been five years in the making. In the process, some of the policy applications called for have met with limited success, such as free needle exchange programs in a limited number of American cities, providing condoms to prison inmates, and advertisements that depict same-sex couples. Rather than dating our chapters that deal with such subjects, such policy applications are verifications of the type of research demonstrated here. Furthermore, they indicate the critical need to continue community based research in the various communities threatened by acquired immuno-deficiency syndrome (AIDS) . . . "

Welch, W., ed. (1981, May). Case Study Methodology in Educational Evaluation. Proceedings of the Minnesota Evaluation Conference. Minnesota. (Address).

The four papers in these proceedings provide a comprehensive picture of the rationale, methodology, strengths, and limitations of case studies.

Williams, G. (1987). The Case Method: An Approach to Teaching and Learning in Educational Administration. RIE, 31p.

This paper examines the viability of the case method as a teaching and learning strategy in instructional systems geared toward the training of personnel of the administration of various aspects of educational systems.

Yin, R. K. (1993). Advancing Rigorous Methodologies: A Review of 'Towards Rigor in Reviews of Multivocal Literatures.' Review of Educational Research, 61, (3).

"R. T. Ogawa and B. Malen's article does not meet its own recommended standards for rigorous testing and presentation of its own conclusions. Use of the exploratory case study to analyze multivocal literatures is not supported, and the claim of grounded theory to analyze multivocal literatures may be stronger."

---. (1989). Case Study Research: Design and Methods. London: Sage Publications Inc.

This book discusses in great detail, the entire design process of the case study, including entire chapters on collecting evidence, analyzing evidence, composing the case study report, and designing single and multiple case studies.

Related Links

Consider the following list of related Web sites for more information on the topic of case study research. Note: although many of the links cover the general category of qualitative research, all have sections that address issues of case studies.

• Sage Publications on Qualitative Methodology: Search here for a comprehensive list of new books being published about "Qualitative Methodology" http://www.sagepub.co.uk/
• The International Journal of Qualitative Studies in Education: An on-line journal "to enhance the theory and practice of qualitative research in education." On-line submissions are welcome. http://www.tandf.co.uk/journals/tf/09518398.html
• Qualitative Research Resources on the Internet: From syllabi to home pages to bibliographies. All links relate somehow to qualitative research. http://www.nova.edu/ssss/QR/qualres.html

Becker, Bronwyn, Patrick Dawson, Karen Devine, Carla Hannum, Steve Hill, Jon Leydens, Debbie Matuskevich, Carol Traver, & Mike Palmquist. (2005). Case Studies. Writing@CSU . Colorado State University. https://writing.colostate.edu/guides/guide.cfm?guideid=60

Have a language expert improve your writing

Run a free plagiarism check in 10 minutes, automatically generate references for free.

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

Case Study | Definition, Examples & Methods

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

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

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

Table of contents

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

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

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

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

Prevent plagiarism, run a free check.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Cite this Scribbr article

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

McCombes, S. (2023, January 30). Case Study | Definition, Examples & Methods. Scribbr. Retrieved 18 September 2024, from https://www.scribbr.co.uk/research-methods/case-studies/

Is this article helpful?

Shona McCombes

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

• All Categories
• Marketing Analytics Software

What Is a Case Study? How to Write, Examples, and Template

In this post

How to write a case study

Case study template, case study examples, types of case studies, what are the benefits of case studies , what are the limitations of case studies , case study vs. testimonial.

In today's marketplace, conveying your product's value through a compelling narrative is crucial to genuinely connecting with your customers.

Your business can use marketing analytics tools to understand what customers want to know about your product. Once you have this information, the next step is to showcase your product and its benefits to your target audience. This strategy involves a mix of data, analysis, and storytelling. Combining these elements allows you to create a narrative that engages your audience. So, how can you do this effectively?

What is a case study? 

A case study is a powerful tool for showcasing a business's success in helping clients achieve their goals. It's a form of storytelling that details real-world scenarios where a business implemented its solutions to deliver positive results for a client.

In this article, we explore the concept of a case study , including its writing process, benefits, various types, challenges, and more.

Understanding how to write a case study is an invaluable skill. You'll need to embrace decision-making – from deciding which customers to feature to designing the best format to make them as engaging as possible.  This can feel overwhelming in a hurry, so let's break it down.

Step 1: Reach out to the target persona

If you've been in business for a while, you have no shortage of happy customers. But w ith limited time and resources, you can't choose everyone.  So, take some time beforehand to flesh out your target buyer personas. 

Once you know precisely who you're targeting, go through your stable of happy customers to find a buyer representative of the audience you're trying to reach. The closer their problems, goals, and industries align, the more your case study will resonate.

What if you have more than one buyer persona? No problem. This is a common situation for companies because buyers comprise an entire committee. You might be marketing to procurement experts, executives, engineers, etc. Try to develop a case study tailored to each key persona. This might be a long-term goal, and that's fine. The better you can personalize the experience for each stakeholder, the easier it is to keep their attention.  

Here are a few considerations to think about before research:

• Products/services of yours the customer uses (and how familiar they are with them)
• The customer's brand recognition in the industry
• Whether the results they've achieved are specific and remarkable
• Whether they've switched from a competitor's product/service
• How closely aligned they are with your target audience

These items are just a jumping-off point as you develop your criteria.  Once you have a list, run each customer through it to determine your top targets. Approach the ones on the top (your "dream" case study subjects) and work your way down as needed.

Who to interview

You should consider interviewing top-level managers or executives because those are high-profile positions. But consider how close they are to your product and its results.

Focusing on an office manager or engineer who uses your product daily would be better. Look for someone with a courtside view of the effects.

The ways to request customer participation in case studies can vary, but certain principles can improve your chances:

• Make it easy for customers to work with you, respecting their valuable time. Be well-prepared and minimize their involvement.
• Emphasize how customers will benefit through increased publicity, revenue opportunities, or recognition for their success. 
• Acknowledge their contributions and showcase their achievements.
• Standardizing the request process with a script incorporating these principles can help your team consistently secure case study approvals and track performance.

Step 2: Prepare for the interview

Case study interviews are like school exams. The more prepared you are for them, the better they turn out. Preparing thoroughly also shows participants that you value their time. You don't waste precious minutes rehashing things you should have already known. You focus on getting the information you need as efficiently as possible.

You can conduct your case study interview in multiple formats, from exchanging emails to in-person interviews. This isn't a trivial decision.  As you'll see in the chart below, each format has its unique advantages and disadvantages. 

You'll also have to consider who will ask and answer the questions during your case study interview. It's wise to consider this while considering the case study format.  The number of participants factors into which format will work best. Pulling off an in-person interview becomes much harder if you're trying to juggle four or five people's busy schedules. Try a video conference instead.

Before interviewing your case study participant, it is crucial to identify the specific questions that need to be asked.  It's essential to thoroughly evaluate your collaboration with the client and understand how your product's contributions impact the company. 

Remember that structuring your case study is akin to crafting a compelling narrative. To achieve this, follow a structured approach:

• Beginning of your story. Delve into the customer's challenge that ultimately led them to do business with you. What were their problems like? What drove them to make a decision finally? Why did they choose you?
• The middle of the case study.  Your audience also wants to know about the experience of working with you. Your customer has taken action to address their problems. What happened once you got on board?
• An ending that makes you the hero.  Describe the specific results your company produced for the customer. How has the customer's business (and life) changed once they implemented your solution?

Sample questions for the case study interview

If you're preparing for a case study interview, here are some sample case study research questions to help you get started:

• What challenges led you to seek a solution?
• When did you realize the need for immediate action? Was there a tipping point?
• How did you decide on the criteria for choosing a B2B solution, and who was involved?
• What set our product or service apart from others you considered?
• How was your experience working with us post-purchase?
• Were there any pleasant surprises or exceeded expectations during our collaboration?
• How smoothly did your team integrate our solution into their workflows?
• How long before you started seeing positive results?
• How have you benefited from our products or services?
• How do you measure the value our product or service provides?

Step 3: Conduct the interview

Preparing for case study interviews can be different from everyday conversations. Here are some tips to keep in mind:

• Create a comfortable atmosphere.  Before diving into the discussion, talk about their business and personal interests. Ensure everyone is at ease, and address any questions or concerns.
• Prioritize key questions.  Lead with your most crucial questions to respect your customer's time. Interview lengths can vary, so starting with the essentials ensures you get the vital information.
• Be flexible.  Case study interviews don't have to be rigid. If your interviewee goes "off script," embrace it. Their spontaneous responses often provide valuable insights.
• Record the interview.  If not conducted via email, ask for permission to record the interview. This lets you focus on the conversation and capture valuable quotes without distractions.

Step 4: Figure out who will create the case study

When creating written case studies for your business, deciding who should handle the writing depends on cost, perspective, and revisions.

Outsourcing might be pricier, but it ensures a professionally crafted outcome. On the other hand, in-house writing has its considerations, including understanding your customers and products. 

Technical expertise and equipment are needed for video case studies, which often leads companies to consider outsourcing due to production and editing costs. 

Tip: When outsourcing work, it's essential to clearly understand pricing details to avoid surprises and unexpected charges during payment.

Step 5: Utilize storytelling

Understanding and applying storytelling elements can make your case studies unforgettable, offering a competitive edge. 

Source: The Framework Bank

Every great study follows a narrative arc (also called a "story arc"). This arc represents how a character faces challenges, struggles against raising stakes, and encounters a formidable obstacle before the tension resolves.

In a case study narrative, consider:

• Exposition. Provide background information about the company, revealing their "old life" before becoming your customer.
• Inciting incident. Highlight the problem that drove the customer to seek a solution, creating a sense of urgency.
• Obstacles (rising action). Describe the customer's journey in researching and evaluating solutions, building tension as they explore options.
• Midpoint. Explain what made the business choose your product or service and what set you apart.
• Climax. Showcase the success achieved with your product.
• Denouement. Describe the customer's transformed business and end with a call-to-action for the reader to take the next step.

Step 6: Design the case study

The adage "Don't judge a book by its cover" is familiar, but people tend to do just that quite often!

A poor layout can deter readers even if you have an outstanding case study. To create an engaging case study, follow these steps:

• Craft a compelling title. Just like you wouldn't read a newspaper article without an eye-catching headline, the same goes for case studies. Start with a title that grabs attention.
• Organize your content. Break down your content into different sections, such as challenges, results, etc. Each section can also include subsections. This case study approach divides the content into manageable portions, preventing readers from feeling overwhelmed by lengthy blocks of text.
• Conciseness is key. Keep your case study as concise as possible. The most compelling case studies are precisely long enough to introduce the customer's challenge, experience with your solution, and outstanding results. Prioritize clarity and omit any sections that may detract from the main storyline.
• Utilize visual elements. To break up text and maintain reader interest, incorporate visual elements like callout boxes, bulleted lists, and sidebars.
• Include charts and images. Summarize results and simplify complex topics by including pictures and charts. Visual aids enhance the overall appeal of your case study.
• Embrace white space. Avoid overwhelming walls of text to prevent reader fatigue. Opt for plenty of white space, use shorter paragraphs, and employ subsections to ensure easy readability and navigation.
• Enhance video case studies. In video case studies, elements like music, fonts, and color grading are pivotal in setting the right tone. Choose music that complements your message and use it strategically throughout your story. Carefully select fonts to convey the desired style, and consider how lighting and color grading can influence the mood. These elements collectively help create the desired tone for your video case study.

Step 7: Edits and revisions

Once you've finished the interview and created your case study, the hardest part is over. Now's the time for editing and revision. This might feel frustrating for impatient B2B marketers, but it can turn good stories into great ones.

Ideally, you'll want to submit your case study through two different rounds of editing and revisions:

• Internal review. Seek feedback from various team members to ensure your case study is captivating and error-free. Gather perspectives from marketing, sales, and those in close contact with customers for well-rounded insights. Use patterns from this feedback to guide revisions and apply lessons to future case studies.
• Customer feedback. Share the case study with customers to make them feel valued and ensure accuracy. Let them review quotes and data points, as they are the "heroes" of the story, and their logos will be prominently featured. This step maintains positive customer relationships.

Case study mistakes to avoid

• Ensure easy access to case studies on your website.
• Spotlight the customer, not just your business.
• Tailor each case study to a specific audience.
• Avoid excessive industry jargon in your content.

Step 8: Publishing

Take a moment to proofread your case study one more time carefully. Even if you're reasonably confident you've caught all the errors, it's always a good idea to check. Your case study will be a valuable marketing tool for years, so it's worth the investment to ensure it's flawless. Once done, your case study is all set to go!

Consider sharing a copy of the completed case study with your customer as a thoughtful gesture. They'll likely appreciate it; some may want to keep it for their records. After all, your case study wouldn't have been possible without their help, and they deserve to see the final product.

Where you publish your case study depends on its role in your overall marketing strategy. If you want to reach as many people as possible with your case study, consider publishing it on your website and social media platforms. 

Tip: Some companies prefer to keep their case studies exclusive, making them available only to those who request them. This approach is often taken to control access to valuable information and to engage more deeply with potential customers who express specific interests. It can create a sense of exclusivity and encourage interested parties to engage directly with the company.

Step 9: Case study distribution

When sharing individual case studies, concentrate on reaching the audience with the most influence on purchasing decisions

Here are some common distribution channels to consider:

• Sales teams. Share case studies to enhance customer interactions, retention , and upselling among your sales and customer success teams. Keep them updated on new studies and offer easily accessible formats like PDFs or landing page links.
• Company website. Feature case studies on your website to establish authority and provide valuable information to potential buyers. Organize them by categories such as location, size, industry, challenges, and products or services used for effective presentation.
• Events. Use live events like conferences and webinars to distribute printed case study copies, showcase video case studies at trade show booths, and conclude webinars with links to your case study library. This creative approach blends personal interactions with compelling content.
• Industry journalists. Engage relevant industry journalists to gain media coverage by identifying suitable publications and journalists covering related topics. Building relationships is vital, and platforms like HARO (Help A Reporter Out) can facilitate connections, especially if your competitors have received coverage before.

Want to learn more about Marketing Analytics Software? Explore Marketing Analytics products.

It can seem daunting to transform the information you've gathered into a cohesive narrative.  We’ve created a versatile case study template that can serve as a solid starting point for your case study.

With this template, your business can explore any solutions offered to satisfied customers, covering their background, the factors that led them to choose your services, and their outcomes.

The template boasts a straightforward design, featuring distinct sections that guide you in effectively narrating your and your customer's story. However, remember that limitless ways to showcase your business's accomplishments exist.

To assist you in this process, here's a breakdown of the recommended sections to include in a case study:

• Title.  Keep it concise. Create a brief yet engaging project title summarizing your work with your subject. Consider your title like a newspaper headline; do it well, and readers will want to learn more. 
• Subtitle . Use this section to elaborate on the achievement briefly. Make it creative and catchy to engage your audience.
• Executive summary.  Use this as an overview of the story, followed by 2-3 bullet points highlighting key success metrics.
• Challenges and objectives. This section describes the customer's challenges before adopting your product or service, along with the goals or objectives they sought to achieve.
• How product/service helped.  A paragraph explaining how your product or service addressed their problem.
• Testimonials.  Incorporate short quotes or statements from the individuals involved in the case study, sharing their perspectives and experiences.
• Supporting visuals.  Include one or two impactful visuals, such as graphs, infographics, or highlighted metrics, that reinforce the narrative.
• Call to action (CTA).  If you do your job well, your audience will read (or watch) your case studies from beginning to end. They are interested in everything you've said. Now, what's the next step they should take to continue their relationship with you? Give people a simple action they can complete. 

Case studies are proven marketing strategies in a wide variety of B2B industries. Here are just a few examples of a case study:

• Amazon Web Services, Inc.  provides companies with cloud computing platforms and APIs on a metered, pay-as-you-go basis. This case study example illustrates the benefits Thomson Reuters experienced using AWS.
• LinkedIn Marketing Solutions combines captivating visuals with measurable results in the case study created for BlackRock. This case study illustrates how LinkedIn has contributed to the growth of BlackRock's brand awareness over the years. 
• Salesforce , a sales and marketing automation SaaS solutions provider, seamlessly integrates written and visual elements to convey its success stories with Pepe Jeans. This case study effectively demonstrates how Pepe Jeans is captivating online shoppers with immersive and context-driven e-commerce experiences through Salesforce.
• HubSpot offers a combination of sales and marketing tools. Their case study demonstrates the effectiveness of its all-in-one solutions. These typically focus on a particular client's journey and how HubSpot helped them achieve significant results.

There are two different types of case studies that businesses might utilize:

Written case studies 

Written case studies offer readers a clear visual representation of data, which helps them quickly identify and focus on the information that matters most. 

Printed versions of case studies find their place at events like trade shows, where they serve as valuable sales collateral to engage prospective clients.  Even in the digital age, many businesses provide case studies in PDF format or as web-based landing pages, improving accessibility for their audience. 

Note: Landing pages , in particular, offer the flexibility to incorporate rich multimedia content, including images, charts, and videos. This flexibility in design makes landing pages an attractive choice for presenting detailed content to the audience.

Written case study advantages

Here are several significant advantages to leveraging case studies for your company:

• Hyperlink accessibility.  Whether in PDF or landing page format, written case studies allow for embedded hyperlinks, offering prospects easy access to additional information and contact forms.
• Flexible engagement.  Unlike video case studies, which may demand in-person arrangements, written case studies can be conducted via phone or video streaming, reducing customer commitment and simplifying scheduling.
• Efficient scanning . Well-structured written case studies with a scannable format cater to time-strapped professionals. Charts and callout boxes with key statistics enhance the ease of information retrieval.
• Printable for offline use.  Written case studies can be effortlessly printed and distributed at trade shows, sales meetings, and live events. This tangible format accommodates those who prefer physical materials and provides versatility in outreach, unlike video content, which is less portable.

Written case study disadvantages

Here are some drawbacks associated with the use of case studies:

• Reduced emotional impact.  Written content lacks the emotional punch of live video testimonials, which engage more senses and emotions, making a stronger connection.
• Consider time investment.  Creating a compelling case study involves editing, proofreading, and design collaboration, with multiple revisions commonly required before publication.
• Challenges in maintaining attention.  Attention spans are short in today's ad-saturated world. Using graphics, infographics, and videos more often is more powerful to incite the right emotions in customers.

Video case studies

Video case studies are the latest marketing trend. Unlike in the past, when video production was costly, today's tools make it more accessible for users to create and edit their videos. However, specific technical requirements still apply.

Like written case studies, video case studies delve into a specific customer's challenges and how your business provides solutions. Yet, the video offers a more profound connection by showcasing the person who faced and conquered the problem.

Video case studies can boost brand exposure when shared on platforms like YouTube. For example, Slack's engaging case study video with Sandwich Video illustrates how Slack transformed its workflow and adds humor, which can be challenging in written case studies focused on factual evidence.

Source : YouTube

This video case study has garnered nearly a million views on YouTube.

Video case study advantages

Here are some of the top advantages of video case studies. While video testimonials take more time, the payoff can be worth it. 

• Humanization and authenticity.  Video case studies connect viewers with real people, adding authenticity and fostering a stronger emotional connection.
• Engaging multiple senses.  They engage both auditory and visual senses, enhancing credibility and emotional impact. Charts, statistics, and images can also be incorporated.
• Broad distribution.  Videos can be shared on websites, YouTube, social media, and more, reaching diverse audiences and boosting engagement, especially on social platforms.

Video case study disadvantages

Before fully committing to video testimonials, consider the following:

• Technical expertise and equipment.  Video production requires technical know-how and equipment, which can be costly. Skilled video editing is essential to maintain a professional image. While technology advances, producing amateurish videos may harm your brand's perception.
• Viewer convenience.  Some prospects prefer written formats due to faster reading and ease of navigation. Video typically requires sound, which can be inconvenient for viewers in specific settings. Many people may not have headphones readily available to watch your content.
• Demand on case study participants.  On-camera interviews can be time-consuming and location-dependent, making scheduling challenging for case study participants. Additionally, being on screen for a global audience may create insecurities and performance pressure.
• Comfort on camera.  Not everyone feels at ease on camera. Nervousness or a different on-screen persona can impact the effectiveness of the testimonial, and discovering this late in the process can be problematic.

Written or video case studies: Which is right for you?

Now that you know the pros and cons of each, how do you choose which is right for you?

One of the most significant factors in doing video case studies can be the technical expertise and equipment required for a high level of production quality. Whether you have the budget to do this in-house or hire a production company can be one of the major deciding factors.

Still, written or video doesn't have to be an either-or decision. Some B2B companies are using both formats. They can complement each other nicely, minimizing the downsides mentioned above and reaching your potential customers where they prefer.

Let's say you're selling IT network security. What you offer is invaluable but complicated. You could create a short (three- or four-minute) video case study to get attention and touch on the significant benefits of your services. This whets the viewer's appetite for more information, which they could find in a written case study that supplements the video.

Should you decide to test the water in video case studies, test their effectiveness among your target audience. See how well they work for your company and sales team. And, just like a written case study, you can always find ways to improve your process as you continue exploring video case studies.

Case studies offer several distinctive advantages, making them an ideal tool for businesses to market their products to customers. However, their benefits extend beyond these qualities. 

Here's an overview of all the advantages of case studies:

Valuable sales support

Case studies serve as a valuable resource for your sales endeavors. Buyers frequently require additional information before finalizing a purchase decision. These studies provide concrete evidence of your product or service's effectiveness, assisting your sales representatives in closing deals more efficiently, especially with customers with lingering uncertainties.

Validating your value

Case studies serve as evidence of your product or service's worth or value proposition , playing a role in building trust with potential customers. By showcasing successful partnerships, you make it easier for prospects to place trust in your offerings. This effect is particularly notable when the featured customer holds a reputable status.

Unique and engaging content

By working closely with your customer success teams, you can uncover various customer stories that resonate with different prospects. Case studies allow marketers to shape product features and benefits into compelling narratives. 

Each case study's distinctiveness, mirroring the uniqueness of every customer's journey, makes them a valuable source of relatable and engaging content. Storytelling possesses the unique ability to connect with audiences on an emotional level, a dimension that statistics alone often cannot achieve. 

Spotlighting valuable customers

Case studies provide a valuable platform for showcasing your esteemed customers. Featuring them in these studies offers a chance to give them visibility and express your gratitude for the partnership, which can enhance customer loyalty . Depending on the company you are writing about, it can also demonstrate the caliber of your business.

Now is the time to get SaaS-y news and entertainment with our 5-minute newsletter,   G2 Tea , featuring inspiring leaders, hot takes, and bold predictions. Subscribe below!

It's important to consider limitations when designing and interpreting the results of case studies. Here's an overview of the limitations of case studies:

Challenges in replication

Case studies often focus on specific individuals, organizations, or situations, making generalizing their findings to broader populations or contexts challenging. 

Time-intensive process

Case studies require a significant time investment. The extensive data collection process and the need for comprehensive analysis can be demanding, especially for researchers who are new to this method.

Potential for errors

Case studies can be influenced by memory and judgment, potentially leading to inaccuracies. Depending on human memory to reconstruct a case's history may result in variations and potential inconsistencies in how individuals recall past events. Additionally, bias may emerge, as individuals tend to prioritize what they consider most significant, which could limit their consideration of alternative perspectives.

Challenges in verification

Confirming results through additional research can present difficulties. This complexity arises from the need for detailed and extensive data in the initial creation of a case study. Consequently, this process requires significant effort and a substantial amount of time.

While looking at case studies, you may have noticed a quote. This type of quote is considered a testimonial, a key element of case studies.

If a customer's quote proves that your brand does what it says it will or performs as expected, you may wonder: 'Aren't customer testimonials and case studies the same thing?' Not exactly.

Testimonials are brief endorsements designed to establish trust on a broad scale. In contrast, case studies are detailed narratives that offer a comprehensive understanding of how a product or service addresses a specific problem, targeting a more focused audience. 

Crafting case studies requires more resources and a structured approach than testimonials. Your selection between the two depends on your marketing objectives and the complexity of your product or service.

Case in point!

Case studies are among a company's most effective tools. You're  well on your way to mastering them.

Today's buyers are tackling much of the case study research methodology independently. Many are understandably skeptical before making a buying decision. By connecting them with multiple case studies, you can prove you've gotten the results you say you can. There's hardly a better way to boost your credibility and persuade them to consider your solution.

Case study formats and distribution methods might change as technology evolves. However, the fundamentals that make them effective—knowing how to choose subjects, conduct interviews, and structure everything to get attention—will serve you for as long as you're in business. 

We covered a ton of concepts and resources, so go ahead and bookmark this page. You can refer to it whenever you have questions or need a refresher.

Dive into market research to uncover customer preferences and spending habits.

Kristen McCabe

Kristen’s is a former senior content marketing specialist at G2. Her global marketing experience extends from Australia to Chicago, with expertise in B2B and B2C industries. Specializing in content, conversions, and events, Kristen spends her time outside of work time acting, learning nature photography, and joining in the #instadog fun with her Pug/Jack Russell, Bella. (she/her/hers)

Explore More G2 Articles

What Is a Case Study and Why You Should Use Them

Case studies can provide more insights into your business while helping you conduct further research with robust qualitative data analysis to learn more.

If you're in charge of running a company, then you're likely always looking for new ways to run your business more efficiently and increase your customer base while streamlining as many processes as possible.

Unfortunately, it can sometimes be difficult to determine how to go about implementing the proper program in order to be successful. This is why many business owners opt to conduct a case study, which can help significantly. Whether you've been struggling with brand consistency or some other problem, the right case study can identify why your problem exists as well as provide a way to rectify it.

A case study is a great tool that many businesses aren't even aware exists, and there are marketing experts like Mailchimp who can provide you with step-by-step assistance with implementing a plan with a case study. Many companies discover that not only do they need to start a blog in order to improve business, but they also need to create specific and relevant blog titles.

If your company already has a blog, then optimizing your blog posts may be helpful. Regardless of the obstacles that are preventing you from achieving all your professional goals, a case study can work wonders in helping you reverse this issue.

What is a case study?

A case study is a comprehensive report of the results of theory testing or examining emerging themes of a business in real life context. Case studies are also often used in the healthcare industry, conducting health services research with primary research interest around routinely collected healthcare data.

However, for businesses, the purpose of a case study is to help small business owners or company leaders identify the issues and conduct further research into what may be preventing success through information collection, client or customer interviews, and in-depth data analysis.

Knowing the case study definition is crucial for any business owner. By identifying the issues that are hindering a company from achieving all its goals, it's easier to make the necessary corrections to promote success through influenced data collection.

Why are case studies important?

Now that we've answered the questions, "what is a case study?" Why are case studies important? Some of the top reasons why case studies are important include:

• Understand complex issues: Even after you conduct a significant amount of market research , you might have a difficult time understanding exactly what it means. While you might have the basics down, conducting a case study can help you see how that information is applied. Then, when you see how the information can make a difference in business decisions, it could make it easier to understand complex issues.
• Collect data: A case study can also help with data tracking . A case study is a data collection method that can help you describe the information that you have available to you. Then, you can present that information in a way the reader can understand.
• Conduct evaluations: As you learn more about how to write a case study, remember that you can also use a case study to conduct evaluations of a specific situation. A case study is a great way to learn more about complex situations, and you can evaluate how various people responded in that situation. By conducting a case study evaluation, you can learn more about what has worked well, what has not, and what you might want to change in the future.
• Identify potential solutions: A case study can also help you identify solutions to potential problems. If you have an issue in your business that you are trying to solve, you may be able to take a look at a case study where someone has dealt with a similar situation in the past. For example, you may uncover data bias in a specific solution that you would like to address when you tackle the issue on your own. If you need help solving a difficult problem, a case study may be able to help you.

Remember that you can also use case studies to target your audience . If you want to show your audience that you have a significant level of expertise in a field, you may want to publish some case studies that you have handled in the past. Then, when your audience sees that you have had success in a specific area, they may be more likely to provide you with their business. In essence, case studies can be looked at as the original method of social proof, showcasing exactly how you can help someone solve their problems.

What are the benefits of writing a business case study?

Although writing a case study can seem like a tedious task, there are many benefits to conducting one through an in depth qualitative research process.

• Industry understanding: First of all, a case study can give you an in-depth understanding of your industry through a particular conceptual framework and help you identify hidden problems that are preventing you from transcending into the business world.
• Develop theories: If you decide to write a business case study, it provides you with an opportunity to develop new theories. You might have a theory about how to solve a specific problem, but you need to write a business case study to see exactly how that theory has unfolded in the past. Then, you can figure out if you want to apply your theory to a similar issue in the future.
• Evaluate interventions: When you write a business case study that focuses on a specific situation you have been through in the past, you can uncover whether that intervention was truly helpful. This can make it easier to figure out whether you want to use the same intervention in a similar situation in the future.
• Identify best practices: If you want to stay on top of the best practices in your field, conducting case studies can help by allowing you to identify patterns and trends and develop a new list of best practices that you can follow in the future.
• Versatility: Writing a case study also provides you with more versatility. If you want to expand your business applications, you need to figure out how you respond to various problems. When you run a business case study, you open the door to new opportunities, new applications, and new techniques that could help you make a difference in your business down the road.
• Solve problems: Writing a great case study can dramatically improve your chances of reversing your problem and improving your business.
• These are just a few of the biggest benefits you might experience if you decide to publish your case studies. They can be an effective tool for learning, showcasing your talents, and teaching some of your other employees. If you want to grow your audience , you may want to consider publishing some case studies.

What are the limitations of case studies?

Case studies can be a wonderful tool for any business of any size to use to gain an in-depth understanding of their clients, products, customers, or services, but there are limitations.

One limitation of case studies is the fact that, unless there are other recently published examples, there is nothing to compare them to since, most of the time, you are conducting a single, not multiple, case studies.

Another limitation is the fact that most case studies can lack scientific evidence.

Types of case studies

There are specific types of case studies to choose from, and each specific type will yield different results. Some case study types even overlap, which is sometimes more favorable, as they provide even more pertinent data.

Here are overviews of the different types of case studies, each with its own theoretical framework, so you can determine which type would be most effective for helping you meet your goals.

Explanatory case studies

Explanatory case studies are pretty straightforward, as they're not difficult to interpret. This type of case study is best if there aren't many variables involved because explanatory case studies can easily answer questions like "how" and "why" through theory development.

Exploratory case studies

An exploratory case study does exactly what its name implies: it goes into specific detail about the topic at hand in a natural, real-life context with qualitative research.

The benefits of exploratory case studies are limitless, with the main one being that it offers a great deal of flexibility. Having flexibility when writing a case study is important because you can't always predict what obstacles might arise during the qualitative research process.

Collective case studies

Collective case studies require you to study many different individuals in order to obtain usable data.

Case studies that involve an investigation of people will involve many different variables, all of which can't be predicted. Despite this fact, there are many benefits of collective case studies, including the fact that it allows an ongoing analysis of the data collected.

Intrinsic case studies

This type of study differs from the others as it focuses on the inquiry of one specific instance among many possibilities.

Many people prefer these types of case studies because it allows them to learn about the particular instance that they wish to investigate further.

Instrumental case studies

An instrumental case study is similar to an intrinsic one, as it focuses on a particular instance, whether it's a person, organization, or something different.

One thing that differentiates instrumental case studies from intrinsic ones is the fact that instrumental case studies aren't chosen merely because a person is interested in learning about a specific instance.

Tips for writing a case study

If you have decided to write case studies for your company, then you may be unsure of where to start or which type to conduct.

However, it doesn't have to be difficult or confusing to begin conducting a case study that will help you identify ways to improve your business.

Here are some helpful tips for writing your case studies:

1. Your case study must be written in the proper format

When writing a case study, the format that you should be similar to this:

Administrative summary

The executive summary is an overview of what your report will contain, written in a concise manner while providing real-life context.

Despite the fact that the executive summary should appear at the beginning of your case studies, it shouldn't be written until you've completed the entire report because if you write it before you finish the report, this summary may not be completely accurate.

Key problem statement

In this section of your case study, you will briefly describe the problem that you hope to solve by conducting the study. You will have the opportunity to elaborate on the problem that you're focusing on as you get into the breadth of the report.

Problem exploration

This part of the case study isn't as brief as the other two, and it goes into more detail about the problem at hand. Your problem exploration must include why the identified problem needs to be solved as well as the urgency of solving it.

Additionally, it must include justification for conducting the problem-solving, as the benefits must outweigh the efforts and costs.

Proposed resolution

This case study section will also be lengthier than the first two. It must include how you propose going about rectifying the problem. The "recommended solution" section must also include potential obstacles that you might experience, as well as how these will be managed.

Furthermore, you will need to list alternative solutions and explain the reason the chosen solution is best. Charts can enhance your report and make it easier to read, and provide as much proof to substantiate your claim as possible.

Overview of monetary consideration

An overview of monetary consideration is essential for all case studies, as it will be used to convince all involved parties why your project should be funded. You must successfully convince them that the cost is worth the investment it will require. It's important that you stress the necessity for this particular case study and explain the expected outcome.

Execution timeline

In the execution times of case studies, you explain how long you predict it will take to implement your study. The shorter the time it will take to implement your plan, the more apt it is to be approved. However, be sure to provide a reasonable timeline, taking into consideration any additional time that might be needed due to obstacles.

Always include a conclusion in your case study. This is where you will briefly wrap up your entire proposal, stressing the benefits of completing the data collection and data analysis in order to rectify your problem.

2. Make it clear and comprehensive

You want to write your case studies with as much clarity as possible so that every aspect of the report is understood. Be sure to double-check your grammar, spelling, punctuation, and more, as you don't want to submit a poorly-written document.

Not only would a poorly-written case study fail to prove that what you are trying to achieve is important, but it would also increase the chances that your report will be tossed aside and not taken seriously.

3. Don't rush through the process

Writing the perfect case study takes time and patience. Rushing could result in your forgetting to include information that is crucial to your entire study. Don't waste your time creating a study that simply isn't ready. Take the necessary time to perform all the research necessary to write the best case study possible.

Depending on the case study, conducting case study research could mean using qualitative methods, quantitative methods, or both. Qualitative research questions focus on non-numerical data, such as how people feel, their beliefs, their experiences, and so on.

Meanwhile, quantitative research questions focus on numerical or statistical data collection to explain causal links or get an in-depth picture.

It is also important to collect insightful and constructive feedback. This will help you better understand the outcome as well as any changes you need to make to future case studies. Consider using formal and informal ways to collect feedback to ensure that you get a range of opinions and perspectives.

4. Be confident in your theory development

While writing your case study or conducting your formal experimental investigation, you should have confidence in yourself and what you're proposing in your report. If you took the time to gather all the pertinent data collected to complete the report, don't second-guess yourself or doubt your abilities. If you believe your report will be amazing, then it likely will be.

5. Case studies and all qualitative research are long

It's expected that multiple case studies are going to be incredibly boring, and there is no way around this. However, it doesn't mean you can choose your language carefully in order to keep your audience as engaged as possible.

If your audience loses interest in your case study at the beginning, for whatever reason, then this increases the likelihood that your case study will not be funded.

Case study examples

If you want to learn more about how to write a case study, it might be beneficial to take a look at a few case study examples. Below are a few interesting case study examples you may want to take a closer look at.

• Phineas Gage by John Martin Marlow : One of the most famous case studies comes from the medical field, and it is about the story of Phineas Gage, a man who had a railroad spike driven through his head in 1848. As he was working on a railroad, an explosive charge went off prematurely, sending a railroad rod through his head. Even though he survived this incident, he lost his left eye. However, Phineas Gage was studied extensively over the years because his experiences had a significant, lasting impact on his personality. This served as a case study because his injury showed different parts of the brain have different functions.
• Kitty Genovese and the bystander effect : This is a tragic case study that discusses the murder of Kitty Genovese, a woman attacked and murdered in Queens, New York City. Shockingly, while numerous neighbors watched the scene, nobody called for help because they assumed someone else would. This case study helped to define the bystander effect, which is when a person fails to intervene during an emergency because other people are around.
• Henry Molaison and the study of memory : Henry Molaison lost his memory and suffered from debilitating amnesia. He suffered from childhood epilepsy, and medical professionals attempted to remove the part of his brain that was causing his seizures. He had a portion of his brain removed, but it completely took away his ability to hold memories. Even though he went on to live until the age of 82, he was always forced to live in the present moment, as he was completely unable to form new memories.

Case study FAQs

When should you do a case study.

There are several scenarios when conducting a case study can be beneficial. Case studies are often used when there's a "why" or "how" question that needs to be answered. Case studies are also beneficial when trying to understand a complex phenomenon, there's limited research on a topic, or when you're looking for practical solutions to a problem.

How can case study results be used to make business decisions?

You can use the results from a case study to make future business decisions if you find yourself in a similar situation. As you assess the results of a case study, you can identify best practices, evaluate the effectiveness of an intervention, generate new and creative ideas, or get a better understanding of customer needs.

How are case studies different from other research methodologies?

When compared to other research methodologies, such as experimental or qualitative research methodology, a case study does not require a representative sample. For example, if you are performing quantitative research, you have a lot of subjects that expand your sample size. If you are performing experimental research, you may have a random sample in front of you. A case study is usually designed to deliberately focus on unusual situations, which allows it to shed new light on a specific business research problem.

Writing multiple case studies for your business

If you're feeling overwhelmed by the idea of writing a case study and it seems completely foreign, then you aren't alone. Writing a case study for a business is a very big deal, but fortunately, there is help available because an example of a case study doesn't always help.

Mailchimp, a well-known marketing company that provides comprehensive marketing support for all sorts of businesses, can assist you with your case study, or you can review one of their own recently published examples.

Mailchimp can assist you with developing the most effective content strategy to increase your chances of being as successful as possible. Mailchimp's content studio is a great tool that can help your business immensely.

• 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

798k Accesses

1122 Citations

43 Altmetric

Metrics details

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.

Peer Review reports

Introduction

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

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

This paper is structured around the following main questions: What is a case study? What are case studies used for? How are case studies conducted? What are the potential pitfalls and how can these be avoided? We draw in particular on four of our own recently published examples of case studies (see Tables 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.

Yin RK: Case study research, design and method. 2009, London: Sage Publications Ltd., 4

Google Scholar  

Keen J, Packwood T: Qualitative research; case study evaluation. BMJ. 1995, 311: 444-446.

Article   CAS   PubMed   PubMed Central   Google Scholar  

Sheikh A, Halani L, Bhopal R, Netuveli G, Partridge M, Car J, et al: Facilitating the Recruitment of Minority Ethnic People into Research: Qualitative Case Study of South Asians and Asthma. PLoS Med. 2009, 6 (10): 1-11.

Article   Google Scholar  

Pinnock H, Huby G, Powell A, Kielmann T, Price D, Williams S, et al: The process of planning, development and implementation of a General Practitioner with a Special Interest service in Primary Care Organisations in England and Wales: a comparative prospective case study. Report for the National Co-ordinating Centre for NHS Service Delivery and Organisation R&D (NCCSDO). 2008, [ http://www.sdo.nihr.ac.uk/files/project/99-final-report.pdf ]

Robertson A, Cresswell K, Takian A, Petrakaki D, Crowe S, Cornford T, et al: Prospective evaluation of the implementation and adoption of NHS Connecting for Health's national electronic health record in secondary care in England: interim findings. BMJ. 2010, 41: c4564-

Pearson P, Steven A, Howe A, Sheikh A, Ashcroft D, Smith P, the Patient Safety Education Study Group: Learning about patient safety: organisational context and culture in the education of healthcare professionals. J Health Serv Res Policy. 2010, 15: 4-10. 10.1258/jhsrp.2009.009052.

Article   PubMed   Google Scholar  

van Harten WH, Casparie TF, Fisscher OA: The evaluation of the introduction of a quality management system: a process-oriented case study in a large rehabilitation hospital. Health Policy. 2002, 60 (1): 17-37. 10.1016/S0168-8510(01)00187-7.

Stake RE: The art of case study research. 1995, London: Sage Publications Ltd.

Sheikh A, Smeeth L, Ashcroft R: Randomised controlled trials in primary care: scope and application. Br J Gen Pract. 2002, 52 (482): 746-51.

PubMed   PubMed Central   Google Scholar  

King G, Keohane R, Verba S: Designing Social Inquiry. 1996, Princeton: Princeton University Press

Doolin B: Information technology as disciplinary technology: being critical in interpretative research on information systems. Journal of Information Technology. 1998, 13: 301-311. 10.1057/jit.1998.8.

George AL, Bennett A: Case studies and theory development in the social sciences. 2005, Cambridge, MA: MIT Press

Eccles M, the Improved Clinical Effectiveness through Behavioural Research Group (ICEBeRG): Designing theoretically-informed implementation interventions. Implementation Science. 2006, 1: 1-8. 10.1186/1748-5908-1-1.

Article   PubMed Central   Google Scholar  

Netuveli G, Hurwitz B, Levy M, Fletcher M, Barnes G, Durham SR, Sheikh A: Ethnic variations in UK asthma frequency, morbidity, and health-service use: a systematic review and meta-analysis. Lancet. 2005, 365 (9456): 312-7.

Sheikh A, Panesar SS, Lasserson T, Netuveli G: Recruitment of ethnic minorities to asthma studies. Thorax. 2004, 59 (7): 634-

CAS   PubMed   PubMed Central   Google Scholar  

Hellström I, Nolan M, Lundh U: 'We do things together': A case study of 'couplehood' in dementia. Dementia. 2005, 4: 7-22. 10.1177/1471301205049188.

Som CV: Nothing seems to have changed, nothing seems to be changing and perhaps nothing will change in the NHS: doctors' response to clinical governance. International Journal of Public Sector Management. 2005, 18: 463-477. 10.1108/09513550510608903.

Lincoln Y, Guba E: Naturalistic inquiry. 1985, Newbury Park: Sage Publications

Barbour RS: Checklists for improving rigour in qualitative research: a case of the tail wagging the dog?. BMJ. 2001, 322: 1115-1117. 10.1136/bmj.322.7294.1115.

Mays N, Pope C: Qualitative research in health care: Assessing quality in qualitative research. BMJ. 2000, 320: 50-52. 10.1136/bmj.320.7226.50.

Mason J: Qualitative researching. 2002, London: Sage

Brazier A, Cooke K, Moravan V: Using Mixed Methods for Evaluating an Integrative Approach to Cancer Care: A Case Study. Integr Cancer Ther. 2008, 7: 5-17. 10.1177/1534735407313395.

Miles MB, Huberman M: Qualitative data analysis: an expanded sourcebook. 1994, CA: Sage Publications Inc., 2

Pope C, Ziebland S, Mays N: Analysing qualitative data. Qualitative research in health care. BMJ. 2000, 320: 114-116. 10.1136/bmj.320.7227.114.

Cresswell KM, Worth A, Sheikh A: Actor-Network Theory and its role in understanding the implementation of information technology developments in healthcare. BMC Med Inform Decis Mak. 2010, 10 (1): 67-10.1186/1472-6947-10-67.

Article   PubMed   PubMed Central   Google Scholar  

Malterud K: Qualitative research: standards, challenges, and guidelines. Lancet. 2001, 358: 483-488. 10.1016/S0140-6736(01)05627-6.

Article   CAS   PubMed   Google Scholar  

Yin R: Case study research: design and methods. 1994, Thousand Oaks, CA: Sage Publishing, 2

Yin R: Enhancing the quality of case studies in health services research. Health Serv Res. 1999, 34: 1209-1224.

Green J, Thorogood N: Qualitative methods for health research. 2009, Los Angeles: Sage, 2

Howcroft D, Trauth E: Handbook of Critical Information Systems Research, Theory and Application. 2005, Cheltenham, UK: Northampton, MA, USA: Edward Elgar

Book   Google Scholar  

Blakie N: Approaches to Social Enquiry. 1993, Cambridge: Polity Press

Doolin B: Power and resistance in the implementation of a medical management information system. Info Systems J. 2004, 14: 343-362. 10.1111/j.1365-2575.2004.00176.x.

Bloomfield BP, Best A: Management consultants: systems development, power and the translation of problems. Sociological Review. 1992, 40: 533-560.

Shanks G, Parr A: Positivist, single case study research in information systems: A critical analysis. Proceedings of the European Conference on Information Systems. 2003, Naples

Pre-publication history

The pre-publication history for this paper can be accessed here: http://www.biomedcentral.com/1471-2288/11/100/prepub

Download references

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.

Author information

Authors and affiliations.

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

Sarah Crowe & Anthony Avery

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

Kathrin Cresswell, Ann Robertson & Aziz Sheikh

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

You can also search for this author in PubMed   Google Scholar

Corresponding author

Correspondence to Sarah Crowe .

Additional information

Competing interests.

The authors declare that they have no competing interests.

Authors' contributions

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

Rights and permissions

This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/2.0 ), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Reprints and permissions

About this article

Cite this article.

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

Download citation

Received : 29 November 2010

Accepted : 27 June 2011

Published : 27 June 2011

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

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Case Study Approach
• Electronic Health Record System
• Case Study Design
• Case Study Site
• Case Study Report

BMC Medical Research Methodology

ISSN: 1471-2288

• General enquiries: [email protected]

Case Studies

Collections of case studies.

• Databases of Scholarly Articles

Your Librarian

• National Center for Case Study Teaching in Science Hundreds of case studies in many different areas of science. Faculty members will need to purchase a personal subscription to use these cases. Search or browse by topic or date. Some supplemental teaching resources are freely available. Created by the National Center for Case Study Teaching in Science at the University of Buffalo. Managed by the National Science Teachers Association.
• The Case Centre The Case Centre is an international clearing house of cases for business education. Create a personal account to access a curated collection of free cases on health and medical care, entrepreneurship, arts management, responsible management, social responsibility, technologies and more.
• Socio-Environmental Synthesis Center: Case Studies This collection focuses on case studies that take an interdisciplinary approach to environmental studies: synthesizing socio-environmental research, policies and data.
• MIT Sloan School: LearningEdge Case Studies A collection of teaching business case studies that focus on entrepreneurship, leadership/ethics, operations management, strategy and sustainability.
• PharmacyLibrary: Case Studies The APhA PharmacyLibrary includes over 450 cases for preparing for patient care in practice settings.
• Next: Databases of Scholarly Articles >>
• Last Updated: Aug 27, 2024 10:45 AM
• URL: https://mcphs.libguides.com/casestudies

The case study as a type of qualitative research

• Solution Focused Possibilities

Discover the world's research

• 25+ million members
• 160+ million publication pages
• 2.3+ billion citations

• Doni Wahyu Prabowo
• Bramastia Bramastia
• Sarwanto Sarwanto
• James Cohen

• Meenakshi Gandhi

• Dina Sidani

• Michael Hankins

• Asrul Mustaqim

• John W. Creswell

• Gary Thomas
• S. B. Merriam

• Sharan B. Merriam
• Recruit researchers
• Join for free
• Login Email Tip: Most researchers use their institutional email address as their ResearchGate login Password Forgot password? Keep me logged in Log in or Continue with Google Welcome back! Please log in. Email · Hint Tip: Most researchers use their institutional email address as their ResearchGate login Password Forgot password? Keep me logged in Log in or Continue with Google No account? Sign up

Case Studies

Case studies are a popular research method in business area. Case studies aim to analyze specific issues within the boundaries of a specific environment, situation or organization.

According to its design, case studies in business research can be divided into three categories: explanatory, descriptive and exploratory.

Explanatory case studies aim to answer ‘how’ or ’why’ questions with little control on behalf of researcher over occurrence of events. This type of case studies focus on phenomena within the contexts of real-life situations. Example: “An investigation into the reasons of the global financial and economic crisis of 2008 – 2010.”

Descriptive case studies aim to analyze the sequence of interpersonal events after a certain amount of time has passed. Studies in business research belonging to this category usually describe culture or sub-culture, and they attempt to discover the key phenomena. Example: “Impact of increasing levels of multiculturalism on marketing practices: A case study of McDonald’s Indonesia.”

Exploratory case studies aim to find answers to the questions of ‘what’ or ‘who’. Exploratory case study data collection method is often accompanied by additional data collection method(s) such as interviews, questionnaires, experiments etc. Example: “A study into differences of leadership practices between private and public sector organizations in Atlanta, USA.”

Advantages of case study method include data collection and analysis within the context of phenomenon, integration of qualitative and quantitative data in data analysis, and the ability to capture complexities of real-life situations so that the phenomenon can be studied in greater levels of depth. Case studies do have certain disadvantages that may include lack of rigor, challenges associated with data analysis and very little basis for generalizations of findings and conclusions.

John Dudovskiy

An official website of the United States government

The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

• Publications
• Account settings

The PMC website is updating on October 15, 2024. Learn More or Try it out now .

• Advanced Search
• Journal List
• Int J Qual Stud Health Well-being

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.

• Adamson S, Holloway M. Negotiating sensitivities and grappling with intangibles: Experiences from a study of spirituality and funerals. Qualitative Research. 2012; 12 (6):735–752. doi: 10.1177/1468794112439008. [ CrossRef ] [ Google Scholar ]
• Ajodhia-Andrews A, Berman R. Exploring school life from the lens of a child who does not use speech to communicate. Qualitative Inquiry. 2009; 15 (5):931–951. doi: 10.1177/1077800408322789. [ CrossRef ] [ Google Scholar ]
• Alexander B. K, Moreira C, Kumar H. S. Resisting (resistance) stories: A tri-autoethnographic exploration of father narratives across shades of difference. Qualitative Inquiry. 2012; 18 (2):121–133. doi: 10.1177/1077800411429087. [ CrossRef ] [ Google Scholar ]
• Austin W, Park C, Goble E. From interdisciplinary to transdisciplinary research: A case study. Qualitative Health Research. 2008; 18 (4):557–564. doi: 10.1177/1049732307308514. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Ayres L, Kavanaugh K, Knafl K. A. Within-case and across-case approaches to qualitative data analysis. Qualitative Health Research. 2003; 13 (6):871–883. doi: 10.1177/1049732303013006008. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Barone T. L. Culturally sensitive care 1969–2000: The Indian Chicano Health Center. Qualitative Health Research. 2010; 20 (4):453–464. doi: 10.1177/1049732310361893. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Bassey M. A solution to the problem of generalisation in educational research: Fuzzy prediction. Oxford Review of Education. 2001; 27 (1):5–22. doi: 10.1080/03054980123773. [ CrossRef ] [ Google Scholar ]
• Bronken B. A, Kirkevold M, Martinsen R, Kvigne K. The aphasic storyteller: Coconstructing stories to promote psychosocial well-being after stroke. Qualitative Health Research. 2012; 22 (10):1303–1316. doi: 10.1177/1049732312450366. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Broyles L. M, Rodriguez K. L, Price P. A, Bayliss N. K, Sevick M. A. Overcoming barriers to the recruitment of nurses as participants in health care research. Qualitative Health Research. 2011; 21 (12):1705–1718. doi: 10.1177/1049732311417727. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Buckley C. A, Waring M. J. Using diagrams to support the research process: Examples from grounded theory. Qualitative Research. 2013; 13 (2):148–172. doi: 10.1177/1468794112472280. [ CrossRef ] [ Google Scholar ]
• Buzzanell P. M, D'Enbeau S. Stories of caregiving: Intersections of academic research and women's everyday experiences. Qualitative Inquiry. 2009; 15 (7):1199–1224. doi: 10.1177/1077800409338025. [ CrossRef ] [ Google Scholar ]
• Carter S. M, Little M. Justifying knowledge, justifying method, taking action: Epistemologies, methodologies, and methods in qualitative research. Qualitative Health Research. 2007; 17 (10):1316–1328. doi: 10.1177/1049732307306927. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Cheek J, Garnham B, Quan J. What's in a number? Issues in providing evidence of impact and quality of research(ers) Qualitative Health Research. 2006; 16 (3):423–435. doi: 10.1177/1049732305285701. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Colón-Emeric C. S, Plowman D, Bailey D, Corazzini K, Utley-Smith Q, Ammarell N, et al. Regulation and mindful resident care in nursing homes. Qualitative Health Research. 2010; 20 (9):1283–1294. doi: 10.1177/1049732310369337. [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Coltart C, Henwood K. On paternal subjectivity: A qualitative longitudinal and psychosocial case analysis of men's classed positions and transitions to first-time fatherhood. Qualitative Research. 2012; 12 (1):35–52. doi: 10.1177/1468794111426224. [ CrossRef ] [ Google Scholar ]
• Creswell J. W. Five qualitative approaches to inquiry. In: Creswell J. W, editor. Qualitative inquiry and research design: Choosing among five approaches. 3rd ed. Thousand Oaks, CA: Sage; 2013a. pp. 53–84. [ Google Scholar ]
• Creswell J. W. Qualitative inquiry and research design: Choosing among five approaches. 3rd ed. Thousand Oaks, CA: Sage; 2013b. [ Google Scholar ]
• Crowe S, Cresswell K, Robertson A, Huby G, Avery A, Sheikh A. The case study approach. BMC Medical Research Methodology. 2011; 11 (1):1–9. doi: 10.1186/1471-2288-11-100. [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Cunsolo Willox A, Harper S. L, Edge V. L, ‘My Word’: Storytelling and Digital Media Lab, & Rigolet Inuit Community Government Storytelling in a digital age: Digital storytelling as an emerging narrative method for preserving and promoting indigenous oral wisdom. Qualitative Research. 2013; 13 (2):127–147. doi: 10.1177/1468794112446105. [ CrossRef ] [ Google Scholar ]
• De Haene L, Grietens H, Verschueren K. Holding harm: Narrative methods in mental health research on refugee trauma. Qualitative Health Research. 2010; 20 (12):1664–1676. doi: 10.1177/1049732310376521. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• D'Enbeau S, Buzzanell P. M, Duckworth J. Problematizing classed identities in fatherhood: Development of integrative case studies for analysis and praxis. Qualitative Inquiry. 2010; 16 (9):709–720. doi: 10.1177/1077800410374183. [ CrossRef ] [ Google Scholar ]
• Denzin N. K, Lincoln Y. S. Introduction: Disciplining the practice of qualitative research. In: Denzin N. K, Lincoln Y. S, editors. The SAGE handbook of qualitative research. 4th ed. Thousand Oaks, CA: Sage; 2011a. pp. 1–6. [ Google Scholar ]
• Denzin N. K, Lincoln Y. S, editors. The SAGE handbook of qualitative research. 4th ed. Thousand Oaks, CA: Sage; 2011b. [ Google Scholar ]
• Edwards R, Weller S. Shifting analytic ontology: Using I-poems in qualitative longitudinal research. Qualitative Research. 2012; 12 (2):202–217. doi: 10.1177/1468794111422040. [ CrossRef ] [ Google Scholar ]
• Eisenhardt K. M. Building theories from case study research. The Academy of Management Review. 1989; 14 (4):532–550. doi: 10.2307/258557. [ CrossRef ] [ Google Scholar ]
• Fincham B, Scourfield J, Langer S. The impact of working with disturbing secondary data: Reading suicide files in a coroner's office. Qualitative Health Research. 2008; 18 (6):853–862. doi: 10.1177/1049732307308945. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Flanagan J. Public participation in the design of educational programmes for cancer nurses: A case report. European Journal of Cancer Care. 1999; 8 (2):107–112. doi: 10.1046/j.1365-2354.1999.00141.x. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Flyvbjerg B. Five misunderstandings about case-study research. Qualitative Inquiry. 2006; 12 (2):219–245. doi: 10.1177/1077800405284.363. [ CrossRef ] [ Google Scholar ]
• Flyvbjerg B. Case study. In: Denzin N. K, Lincoln Y. S, editors. The SAGE handbook of qualitative research. 4th ed. Thousand Oaks, CA: Sage; 2011. pp. 301–316. [ Google Scholar ]
• Fourie C. L, Theron L. C. Resilience in the face of fragile X syndrome. Qualitative Health Research. 2012; 22 (10):1355–1368. doi: 10.1177/1049732312451871. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Gallagher N, MacFarlane A, Murphy A. W, Freeman G. K, Glynn L. G, Bradley C. P. Service users’ and caregivers’ perspectives on continuity of care in out-of-hours primary care. Qualitative Health Research. 2013; 23 (3):407–421. doi: 10.1177/1049732312470521. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Gerring J. What is a case study and what is it good for? American Political Science Review. 2004; 98 (2):341–354. doi: 10.1017/S0003055404001182. [ CrossRef ] [ Google Scholar ]
• Gillard A, Witt P. A, Watts C. E. Outcomes and processes at a camp for youth with HIV/AIDS. Qualitative Health Research. 2011; 21 (11):1508–1526. doi: 10.1177/1049732311413907. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Grant M, Booth A. A typology of reviews: An analysis of 14 review types and associated methodologies. Health Information and Libraries Journal. 2009; 26 :91–108. doi: 10.1111/j.1471-1842.2009.00848.x. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Gratton M.-F, O'Donnell S. Communication technologies for focus groups with remote communities: A case study of research with First Nations in Canada. Qualitative Research. 2011; 11 (2):159–175. doi: 10.1177/1468794110394068. [ CrossRef ] [ Google Scholar ]
• Hallberg L. Quality criteria and generalization of results from qualitative studies. International Journal of Qualitative Studies on Health and Wellbeing. 2013; 8 :1. doi: 10.3402/qhw.v8i0.20647. [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Hames I. Committee on Publication Ethics, 1. 2013, March. COPE Ethical guidelines for peer reviewers. Retrieved April 7, 2013, from http://publicationethics.org/resources/guidelines . [ Google Scholar ]
• Hooghe A, Neimeyer R. A, Rober P. “Cycling around an emotional core of sadness”: Emotion regulation in a couple after the loss of a child. Qualitative Health Research. 2012; 22 (9):1220–1231. doi: 10.1177/1049732312449209. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Jackson C. B, Botelho E. M, Welch L. C, Joseph J, Tennstedt S. L. Talking with others about stigmatized health conditions: Implications for managing symptoms. Qualitative Health Research. 2012; 22 (11):1468–1475. doi: 10.1177/1049732312450323. [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Jasper M, Vaismoradi M, Bondas T, Turunen H. Validity and reliability of the scientific review process in nursing journals—time for a rethink? Nursing Inquiry. 2013 doi: 10.1111/nin.12030. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Jensen J. L, Rodgers R. Cumulating the intellectual gold of case study research. Public Administration Review. 2001; 61 (2):235–246. doi: 10.1111/0033-3352.00025. [ CrossRef ] [ Google Scholar ]
• Jorrín-Abellán I. M, Rubia-Avi B, Anguita-Martínez R, Gómez-Sánchez E, Martínez-Mones A. Bouncing between the dark and bright sides: Can technology help qualitative research? Qualitative Inquiry. 2008; 14 (7):1187–1204. doi: 10.1177/1077800408318435. [ CrossRef ] [ Google Scholar ]
• Ledderer L. Understanding change in medical practice: The role of shared meaning in preventive treatment. Qualitative Health Research. 2011; 21 (1):27–40. doi: 10.1177/1049732310377451. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Lincoln Y. S. Emerging criteria for quality in qualitative and interpretive research. Qualitative Inquiry. 1995; 1 (3):275–289. doi: 10.1177/107780049500100301. [ CrossRef ] [ Google Scholar ]
• Luck L, Jackson D, Usher K. Case study: A bridge across the paradigms. Nursing Inquiry. 2006; 13 (2):103–109. doi: 10.1111/j.1440-1800.2006.00309.x. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Mawn B, Siqueira E, Koren A, Slatin C, Devereaux Melillo K, Pearce C, et al. Health disparities among health care workers. Qualitative Health Research. 2010; 20 (1):68–80. doi: 10.1177/1049732309355590. [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Merriam S. B. Qualitative research: A guide to design and implementation. 3rd ed. San Francisco, CA: Jossey-Bass; 2009. [ Google Scholar ]
• Meyer C. B. A case in case study methodology. Field Methods. 2001; 13 (4):329–352. doi: 10.1177/1525822x0101300402. [ CrossRef ] [ Google Scholar ]
• Morse J. M. Mixing qualitative methods. Qualitative Health Research. 2009; 19 (11):1523–1524. doi: 10.1177/1049732309349360. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Morse J. M. Molding qualitative health research. Qualitative Health Research. 2011; 21 (8):1019–1021. doi: 10.1177/1049732311404706. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Morse J. M, Dimitroff L. J, Harper R, Koontz A, Kumra S, Matthew-Maich N, et al. Considering the qualitative–quantitative language divide. Qualitative Health Research. 2011; 21 (9):1302–1303. doi: 10.1177/1049732310392386. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Nagar-Ron S, Motzafi-Haller P. “My life? There is not much to tell”: On voice, silence and agency in interviews with first-generation Mizrahi Jewish women immigrants to Israel. Qualitative Inquiry. 2011; 17 (7):653–663. doi: 10.1177/1077800411414007. [ CrossRef ] [ Google Scholar ]
• Nairn K, Panelli R. Using fiction to make meaning in research with young people in rural New Zealand. Qualitative Inquiry. 2009; 15 (1):96–112. doi: 10.1177/1077800408318314. [ CrossRef ] [ Google Scholar ]
• Nespor J. The afterlife of “teachers’ beliefs”: Qualitative methodology and the textline. Qualitative Inquiry. 2012; 18 (5):449–460. doi: 10.1177/1077800412439530. [ CrossRef ] [ Google Scholar ]
• Piekkari R, Welch C, Paavilainen E. The case study as disciplinary convention: Evidence from international business journals. Organizational Research Methods. 2009; 12 (3):567–589. doi: 10.1177/1094428108319905. [ CrossRef ] [ Google Scholar ]
• Ragin C. C, Becker H. S. What is a case?: Exploring the foundations of social inquiry. Cambridge: Cambridge University Press; 1992. [ Google Scholar ]
• Roscigno C. I, Savage T. A, Kavanaugh K, Moro T. T, Kilpatrick S. J, Strassner H. T, et al. Divergent views of hope influencing communications between parents and hospital providers. Qualitative Health Research. 2012; 22 (9):1232–1246. doi: 10.1177/1049732312449210. [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Rosenberg J. P, Yates P. M. Schematic representation of case study research designs. Journal of Advanced Nursing. 2007; 60 (4):447–452. doi: 10.1111/j.1365-2648.2007.04385.x. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Rytterström P, Unosson M, Arman M. Care culture as a meaning- making process: A study of a mistreatment investigation. Qualitative Health Research. 2013; 23 :1179–1187. doi: 10.1177/1049732312470760. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Sandelowski M. Whatever happened to qualitative description? Research in Nursing & Health. 2000; 23 (4):334–340. doi: 10.1002/1098-240X. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Sandelowski M. What's in a name? Qualitative description revisited. Research in Nursing & Health. 2010; 33 (1):77–84. doi: 10.1002/nur.20362. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Sandelowski M, Barroso J. Reading qualitative studies. International Journal of Qualitative Methods. 2002; 1 (1):74–108. [ Google Scholar ]
• Snyder-Young D. “Here to tell her story”: Analyzing the autoethnographic performances of others. Qualitative Inquiry. 2011; 17 (10):943–951. doi: 10.1177/1077800411425149. [ CrossRef ] [ Google Scholar ]
• Stake R. E. The case study method in social inquiry. Educational Researcher. 1978; 7 (2):5–8. [ Google Scholar ]
• Stake R. E. The art of case study research. Thousand Oaks, CA: Sage; 1995. [ Google Scholar ]
• Stake R. E. Case studies. In: Denzin N. K, Lincoln Y. S, editors. Strategies of qualitative inquiry. Thousand Oaks, CA: Sage; 1998. pp. 86–109. [ Google Scholar ]
• Sumsion J. Opening up possibilities through team research: Investigating infants’ experiences of early childhood education and care. Qualitative Research. 2013; 14 (2):149–165. doi: 10.1177/1468794112468471.. [ CrossRef ] [ Google Scholar ]
• Thomas G. Doing case study: Abduction not induction, phronesis not theory. Qualitative Inquiry. 2010; 16 (7):575–582. doi: 10.1177/1077800410372601. [ CrossRef ] [ Google Scholar ]
• Thomas G. A typology for the case study in social science following a review of definition, discourse, and structure. Qualitative Inquiry. 2011; 17 (6):511–521. doi: 10.1177/1077800411409884. [ CrossRef ] [ Google Scholar ]
• Tight M. The curious case of case study: A viewpoint. International Journal of Social Research Methodology. 2010; 13 (4):329–339. doi: 10.1080/13645570903187181. [ CrossRef ] [ Google Scholar ]
• Wager E, Kleinert S. Responsible research publication: International standards for authors. A position statement developed at the 2nd World Conference on Research Integrity, Singapore, July 22–24, 2010. In: Mayer T, Steneck N, editors. Promoting research integrity in a global environment. Singapore: Imperial College Press/World Scientific; 2010a. pp. 309–316. [ Google Scholar ]
• Wager E, Kleinert S. Responsible research publication: International standards for editors. A position statement developed at the 2nd World Conference on Research Integrity, Singapore, July 22–24, 2010. In: Mayer T, Steneck N, editors. Promoting research integrity in a global environment. Singapore: Imperial College Press/World Scientific; 2010b. pp. 317–328. [ Google Scholar ]
• Webb C, Kevern J. Focus groups as a research method: A critique of some aspects of their use in nursing research. Journal of Advanced Nursing. 2000; 33 (6):798–805. doi: 10.1046/j.1365-2648.2001.01720.x. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Wimpenny K, Savin-Baden M. Exploring and implementing participatory action synthesis. Qualitative Inquiry. 2012; 18 (8):689–698. doi: 10.1177/1077800412452854. [ CrossRef ] [ Google Scholar ]
• Yeh H.-Y. Boundaries, entities, and modern vegetarianism: Examining the emergence of the first vegetarian organization. Qualitative Inquiry. 2013; 19 (4):298–309. doi: 10.1177/1077800412471516. [ CrossRef ] [ Google Scholar ]
• Yin R. K. Enhancing the quality of case studies in health services research. Health Services Research. 1999; 34 (5 Pt 2):1209–1224. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Yin R. K. Case study research: Design and methods. 4th ed. Thousand Oaks, CA: Sage; 2009. [ Google Scholar ]
• Yin R. K. Applications of case study research. 3rd ed. Thousand Oaks, CA: Sage; 2012. [ Google Scholar ]

• Bipolar Disorder
• Therapy Center
• When To See a Therapist
• Types of Therapy
• Best Online Therapy
• Best Couples Therapy
• Managing Stress
• Sleep and Dreaming
• Understanding Emotions
• Self-Improvement
• Healthy Relationships
• Student Resources
• Personality Types
• Sweepstakes
• Guided Meditations
• Verywell Mind Insights
• 2024 Verywell Mind 25
• Mental Health in the Classroom
• Editorial Process
• Meet Our Review Board
• Crisis Support

What Is a Case Study?

Weighing the pros and cons of this method of research

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

• Statistics Tutorial
• Adjusted R-Squared
• Analysis of Variance
• Arithmetic Mean
• Arithmetic Median
• Arithmetic Mode
• Arithmetic Range
• Best Point Estimation
• Beta Distribution
• Binomial Distribution
• Black-Scholes model
• Central limit theorem
• Chebyshev's Theorem
• Chi-squared Distribution
• Chi Squared table
• Circular Permutation
• Cluster sampling
• Cohen's kappa coefficient
• Combination
• Combination with replacement
• Comparing plots
• Continuous Uniform Distribution
• Continuous Series Arithmetic Mean
• Continuous Series Arithmetic Median
• Continuous Series Arithmetic Mode
• Cumulative Frequency
• Co-efficient of Variation
• Correlation Co-efficient
• Cumulative plots
• Cumulative Poisson Distribution
• Data collection
• Data collection - Questionaire Designing
• Data collection - Observation
• Data collection - Case Study Method
• Data Patterns
• Deciles Statistics
• Discrete Series Arithmetic Mean
• Discrete Series Arithmetic Median
• Discrete Series Arithmetic Mode
• Exponential distribution
• F distribution
• F Test Table
• Frequency Distribution
• Gamma Distribution
• Geometric Mean
• Geometric Probability Distribution
• Goodness of Fit
• Gumbel Distribution
• Harmonic Mean
• Harmonic Number
• Harmonic Resonance Frequency
• Hypergeometric Distribution
• Hypothesis testing
• Individual Series Arithmetic Mean
• Individual Series Arithmetic Median
• Individual Series Arithmetic Mode
• Interval Estimation
• Inverse Gamma Distribution
• Kolmogorov Smirnov Test
• Laplace Distribution
• Linear regression
• Log Gamma Distribution
• Logistic Regression
• Mcnemar Test
• Mean Deviation
• Means Difference
• Multinomial Distribution
• Negative Binomial Distribution
• Normal Distribution
• Odd and Even Permutation
• One Proportion Z Test
• Outlier Function
• Permutation
• Permutation with Replacement
• Poisson Distribution
• Pooled Variance (r)
• Power Calculator
• Probability
• Probability Additive Theorem
• Probability Multiplecative Theorem
• Probability Bayes Theorem
• Probability Density Function
• Process Sigma
• Quadratic Regression Equation
• Qualitative Data Vs Quantitative Data
• Quartile Deviation
• Range Rule of Thumb
• Rayleigh Distribution
• Regression Intercept Confidence Interval
• Relative Standard Deviation
• Reliability Coefficient
• Required Sample Size
• Residual analysis
• Residual sum of squares
• Root Mean Square
• Sample planning
• Sampling methods
• Scatterplots
• Shannon Wiener Diversity Index
• Signal to Noise Ratio
• Simple random sampling
• Standard Deviation
• Standard Error ( SE )
• Standard normal table
• Statistical Significance
• Statistics Formulas
• Statistics Notation
• Stem and Leaf Plot
• Stratified sampling
• Student T Test
• Sum of Square
• T-Distribution Table
• Ti 83 Exponential Regression
• Transformations
• Trimmed Mean
• Type I & II Error
• Venn Diagram
• Weak Law of Large Numbers
• Statistics Useful Resources
• Statistics - Discussion
• Selected Reading
• UPSC IAS Exams Notes
• Developer's Best Practices
• Questions and Answers
• Effective Resume Writing
• HR Interview Questions
• Computer Glossary

Statistics - Data collection - Case Study Method

Case study research is a qualitative research method that is used to examine contemporary real-life situations and apply the findings of the case to the problem under study. Case studies involve a detailed contextual analysis of a limited number of events or conditions and their relationships. It provides the basis for the application of ideas and extension of methods. It helps a researcher to understand a complex issue or object and add strength to what is already known through previous research.

STEPS OF CASE STUDY METHOD

In order to ensure objectivity and clarity, a researcher should adopt a methodical approach to case studies research. The following steps can be followed:

Identify and define the research questions - The researcher starts with establishing the focus of the study by identifying the research object and the problem surrounding it. The research object would be a person, a program, an event or an entity.

Select the cases - In this step the researcher decides on the number of cases to choose (single or multiple), the type of cases to choose (unique or typical) and the approach to collect, store and analyze the data. This is the design phase of the case study method.

Collect the data - The researcher now collects the data with the objective of gathering multiple sources of evidence with reference to the problem under study. This evidence is stored comprehensively and systematically in a format that can be referenced and sorted easily so that converging lines of inquiry and patterns can be uncovered.

Evaluate and analyze the data - In this step the researcher makes use of varied methods to analyze qualitative as well as quantitative data. The data is categorized, tabulated and cross checked to address the initial propositions or purpose of the study. Graphic techniques like placing information into arrays, creating matrices of categories, creating flow charts etc. are used to help the investigators to approach the data from different ways and thus avoid making premature conclusions. Multiple investigators may also be used to examine the data so that a wide variety of insights to the available data can be developed.

Presentation of Results - The results are presented in a manner that allows the reader to evaluate the findings in the light of the evidence presented in the report. The results are corroborated with sufficient evidence showing that all aspects of the problem have been adequately explored. The newer insights gained and the conflicting propositions that have emerged are suitably highlighted in the report.

• { document.getElementById('header-search').focus(); }, 300);"> Search

Search Search

Civic Engagement Case Set

• Authors Gaylen W. Moore, Hollie Russon Gilman, Archon Fung, Jorrit de Jong, LaChaun J. Banks

Last Updated Sep 20, 2024 Topic Collaboration Locations Europe, United States

Complex challenges are driving a growing demand for better engagement between city leaders and residents. In a world without easy answers, how can leaders ground their practices in the essential engagement goals and the fundamental design questions relevant to each situation? This set of teaching cases helps learners explore a range of pathways for public problem-solving.

Introduction

This set of teaching cases features different approaches to civic engagement. The learning objectives for which these cases were developed include:

• Understand the democratic goals of civic engagement
• Ask and answer key design questions for planning engagement efforts
• See the breadth of options for civic engagement and make strategic choices
• Assess and troubleshoot civic engagement efforts

Cases come with educator guides (suggested session plans for use in academic courses) and practitioner guides (suggested session plans for standalone workshops) as they become available. As a set of curricular materials, this collection of cases lends itself well for courses and training on:

• Democratic governance
• Capabilities for social problem-solving
• Public leadership and management in cities
• Social and urban policy
• Organizational culture and design

More than a Contract: Black Self-Determination and People’s Assemblies in Jackson, Mississippi

Protagonists: Safiya Omari, Chief of Staff

Region: United States

Location: Jackson, Mississippi

Operation Pufferfish: Building and Sustaining a Department of Neighborhoods and Citizen Engagement in Lansing, Michigan

Protagonists: DeLisa Fountain, Neighborhood Resource Coordinator, Lansing Department of Neighborhoods and Citizen Engagement

Location: Lansing, Michigan

“Trust the People”: Civic Engagement and Collaborative Imagination in Bologna, Italy

Protagonists: Matteo Lepore, Deputy Mayor for Economic Development and Tourism

Region: Europe

Location: Bologna, Italy

Stay up to date on our latest work to improve cities

Email Address Sign up

The Bloomberg Harvard City Leadership Initiative is located at the Bloomberg Center for Cities at Harvard University.

• Open access
• Published: 19 September 2024

Measuring and optimizing the spatial accessibility of primary health care in remote and rural areas: a case study of Liannan Yao Autonomous County in China

• Lulu Liu 1 , 2 ,
• Yaowen Chen 1 ,
• Haiqing Xiang 3 ,
• Jiawei Zhong 1 ,
• Peng Zhou 1 ,
• Yu Xiao 1 ,
• Lan Wang 1 , 2 &
• Ying Sun 4  

BMC Health Services Research volume  24 , Article number:  1100 ( 2024 ) Cite this article

Metrics details

The need for equitable access to primary healthcare services in the current global context has attracted widespread attention, prompting nations to continuously enhance their grassroots medical service levels. In response, China launched the "Healthy China" initiative, which prioritizes the enhancement of national health as a core goal of the healthcare system and uses this opportunity to deepen reforms aimed at strengthening primary care. However, in remote and rural areas, the optimization of medical resource allocation and the achievement of balanced service development remain critical challenges owing to limited resources. This study selected Liannan Yao Autonomous County, which is situated in the northwestern corner of Guangdong Province, as a case study due to its remote mountainous location, underdeveloped economy, and minority region characteristics. Through field research and interviews, this study thoroughly explored the needs of both supply and demand, factoring in elements such as the service capability of healthcare facilities and residents' travel thresholds to enhance the two-step floating catchment area model, thus making it more applicable to remote villages. By integrating electric bikes and cars, which are the primary means of transportation in rural areas, this study conducted a thorough analysis and comparison of the accessibility of medical services in Liannan Yao Autonomous County (Liannan County) . The results reveal significant disparities in healthcare accessibility, an uneven distribution of medical resources, and varying impacts of transportation conditions and facility service capabilities on accessibility. Notably, the study revealed that improving transportation conditions alone has limited effects in rural areas; the key lies in balancing medical service capabilities and the rationality of overall layouts. From the perspectives of equity and efficiency, this study employs the equitable coverage model and the efficiency-driven model to construct two scenarios, comparing accessibility changes in Liannan County under both conditions and proposing strategies to improve the spatial layout of local healthcare facilities. This research not only deepens the understanding of healthcare service accessibility in rural areas but also provides a scientific basis for optimizing resource allocation and enhancing primary medical services, offering valuable guidance and reference for Liannan County and other similar rural regions.

Peer Review reports

In the current global context, there is a growing recognition of the significance of primary health care, now a shared focus among countries. Various nations have implemented measures to provide high-quality and inclusive primary health care services aimed at safeguarding the health and well-being of their populations [ 1 ]. In 2015, the WHO released a draft for consultation on the WHO Framework on Integrated People-Centred Health Services [ 2 ], which outlined a global strategy to strengthen health systems through more integrated, people-focused health services. In line with this, China introduced the national strategy "Healthy China", primarily aimed at enhancing the overall health of its citizens [ 3 ]. This strategy initiated comprehensive reforms of the healthcare system, particularly emphasizing the strengthening of primary health care services. However, China currently faces challenges in terms of the distribution and allocation of healthcare resources, with only about 30% of these resources being available in towns and townships, and even fewer in remote and rural areas [ 4 ]. Addressing these issues and find solutions to optimize resource allocation and enhance the quality and efficiency of medical services are crucial, especially given the limited availability of resources.

Against this background, research on the accessibility of healthcare facilities has become a crucial approach to addressing this issue [ 5 ]. The accessibility of healthcare facilities is not only directly related to the health status of residents but also serves as an important indicator for measuring social welfare and equity in a region [ 6 ]. In recent years, with the rapid development of Geographic Information System (GIS) technology, research on the accessibility of healthcare facilities has deepened, focusing on several key aspects [ 7 ]. Firstly, in terms of concepts and definitions, accessibility, as a spatio-temporal concept, reflects the ease or difficulty of overcoming various barriers to communication between a starting point and an endpoint in space and time, while also emphasizing the interconnection and interaction among all elements. Since Hansen first introduced the concept of accessibility in 1959 [ 8 ], its meaning has been continuously enriched. For example, Penchansky and Thomas (1981) broke down the broad and somewhat vague concept of accessibility into five dimensions: accessibility, availability, acceptability, affordability, and accommodation [ 9 ]. Khan categorized accessibility into two primary dimensions: potential and revealed (or realized). Each of these dimensions is further divided into spatial and aspatial aspects, resulting in four categories of accessibility [ 10 ]. Although spatial accessibility has long been the core of research, recent years have seen a gradual increase in studies focusing on non-spatial factors, greatly enriching the meaning and application scope of accessibility [ 11 ].

Secondly, in terms of research methods and application models, researchers have introduced various innovations and improvements based on classical models. They have refined and adjusted their approaches to accommodate different groups, research unit scales, modes of transportation, time factors, and types and levels of healthcare facilities [ 12 ]. Common methods for measuring spatial accessibility include the provider-to-population ratio (PPR), distance to the nearest provider, average distance to a group of providers, and gravity models [ 13 , 14 , 15 , 16 , 17 ]. Among these, the two-step floating catchment area (2SFCA) method is the most commonly used approach [ 1 , 24 ], and it has been chosen for this study. The 2SFCA method was initially proposed by Radke et al [ 18 ] and later refined and formally named by Luo et al. [ 19 , 20 ]. Its ease of understanding and operability has led to widespread attention and development [ 21 , 22 , 23 ], culminating in various extended formulas such as the enhanced 2SFCA[ 25 ], Gaussian 2SFCA [ 26 ], kernel density 2SFCA [ 27 ], and gravity 2SFCA [ 28 ]. The improvement of these models and the integration of multi-source data have significantly enhanced research accuracy and expanded their application scenarios [ 29 ].

Furthermore, key factors influencing the accessibility of healthcare facilities have been extensively explored. Factors such as population density, the distribution of medical resources, transportation convenience, quality of medical services, and socioeconomic status all profoundly impact the distribution of healthcare resources and residents' convenience in seeking medical care [ 31 ]. In-depth research into these factors contributes to a comprehensive understanding of the current state and challenges related to healthcare facility accessibility [ 32 ].

However, despite significant progress in the three areas mentioned above, the strategies and recommendations for improving healthcare facility accessibility remain relatively underdeveloped. Current research primarily focuses on status analysis and problem diagnosis, with a greater need for specific improvement strategies. Future studies should focus more on integrating interdisciplinary knowledge and combining it with practical applications.

It is worth noting that existing accessibility studies are mostly concentrated in developed coastal cities and plain areas, with insufficient attention to remote rural and mountainous regions [ 33 ]. Current research is largely limited to the analysis of geographical data and lacks in-depth investigation and consideration of actual conditions. Although the amount of data for rural areas is not large, the real-life complexity and limited availability of online information necessitate using surveys and interviews to study these regions. This approach ensures that the parameters in accessibility evaluation models align more closely with the actual conditions of remote and rural areas, reflecting the primary goal of this study.

Moreover, most existing studies assume that residents rely on a single mode of transportation to access healthcare facilities. This study examines cars and electric bikes—the two most common means of transportation in rural southern China—and analyzes their impact on the accessibility of medical services. It then uses the results of this accessibility evaluation to propose effective recommendations for optimizing the layout of healthcare facilities, representing another innovative effort by this research.

Simultaneously, to address the shortcomings of existing research in providing strategies and recommendations for improving healthcare facility accessibility, this study expands further in this direction. By designing and constructing different development scenarios, this study simulates various resource allocation schemes to predict and evaluate the effects of policy interventions.

In summary, this study has three objectives: (1) To adopt both quantitative analysis and social surveys based on the unique context of remote rural areas and from both the supply and demand perspectives, comprehensively considering factors such as the service capacity of healthcare facilities and residents' travel thresholds, and to improve the accessibility model to more accurately reflect and be applicable to the actual conditions of remote rural areas; (2) To explore the spatial differences in the accessibility of medical resources in Liannan County based on various modes of transportation and healthcare service thresholds, and to analyze the impact of transportation and service capabilities on accessibility through comparative analysis; (3) To design and construct two scenarios based on the current development and future trends of Liannan County, determining which strategy more effectively enhances the accessibility of medical resources through comparative analysis. Based on these findings, targeted strategies and recommendations are proposed to support decision-making for improving the spatial layout of local healthcare facilities. This research not only seeks to increase the standard of medical services in the rural areas of Liannan County, enhancing convenience and efficiency for local residents, but also aims to provide valuable insights for the development of rural healthcare in other similar regions.

Methods and data sources

This article examines Liannan County in China as a case study utilizing the gravity-based two-step floating catchment area (2SFCA) method for assessing accessibility. In presenting the results of the accessibility assessment, the inverse distance weighting interpolation technique is utilized for grading [ 35 ]. Subsequently, based on the accessibility outcomes and their distribution characteristics, two scenarios were designed: one for balanced coverage and the other for enhancing a single core. Correspondingly, the maximization coverage model and the core service capability enhancement calculation are employed to simulate changes in accessibility. This targeted approach proposes optimization strategies for improving medical services in Liannan County (Fig. 1 ).

Method workflow

This study focuses on Liannan County, located in Qingyuan city, Guangdong Province, in the northwestern corner of the province. It is among the least economically developed counties in Guangdong Province (Fig. 2 ). Geographically, it spans from 24°17′16″N to 24°56′2" N in latitude and from 112°2′2″E to 112°29′1" E in longitude. The county administers seven towns—Sanjiang, Sanpai, Zhaigang, Daping, Xiangping, Guoshui, and Damaishan-which comprise 69 administrative villages and 2 communities, totaling 71 residential demand points. In 2022, the county had a total population of 177,521, with more than half comprising the Yao ethnic group. More than 88% of the county's area is mountainous, featuring 161 high mountains exceeding 1000 meters in altitude (Fig. 3 ). Many residents, especially those from the Yao community, maintain the traditional habit of living in mountainous areas, which results in inconvenient transportation for many residential areas (Fig. 4 ). The county experiences a high degree of aging, with 16.74% of the population aged 60 and above. The distributions of the population density and healthcare facilities within the region are illustrated in Table 1 and Fig. 2 , respectively.

Location map and distribution of population and healthcare facilities in Liannan County

Typical terrain of Liannan County

Typical Yao ethnic village in Liannan County

The selection of Liannan County as the focus of this study is based on three main considerations: (1) Liannan County, located in the remote mountainous area of northwestern Guangdong Province, is a typical representative of remote and rural areas.Its unique geographical location and socioeconomic conditions provide a rare case study for researching healthcare accessibility in remote, rural areas. As a region predominantly inhabited by ethnic minorities, Liannan County also faces the challenge of an aging population, making the study of healthcare services in this area more relevant and urgent; (2) Liannan County not only represents remote areas but also reflects the general insufficiency of healthcare resources in rural China, particularly regarding their uneven distribution. This imbalance is especially pronounced in Liannan County, making it an ideal subject for studying healthcare resource allocation in remote and rural areas. This research will conduct a thorough investigation and analysis of data to examine healthcare accessibility and resource allocation issues in this typical area in depth; (3) Against the backdrop of China's ongoing healthcare reform and the implementation of the "Healthy China" strategy, Liannan County, a remote mountainous area that has achieved significant success in healthcare service reform, provides valuable empirical evidence for this study. By taking Liannan County as a representative of remote and rural areas, this study delves into its healthcare accessibility. This approach not only helps improve the quality and accessibility of healthcare services in the local area and other similar remote rural regions but also offers valuable experiences and insights for healthcare reform and resource allocation in remote rural areas globally.

The distribution of medical resources in China is uneven, with significant disparities between rural areas and cities. Cities have ample medical resources, while rural areas are relatively underserved. In rural areas of China, the healthcare system operates as a three-tiered medical service system comprising county hospitals, town health centers (THCs), and village clinics [ 34 ]. China has not yet established a comprehensive hierarchical medical system, permitting residents to seek treatment at any level of medical institution when ill. County hospitals typically represent the highest level of medical care in a county, and many residents, particularly those living nearby, choose to go directly to them. THCs serve as hubs of rural medical network services, providing primary healthcare and public health services while also overseeing and managing village clinics. Every village in Liannan County has a health room, usually within a 15-minute walk, thereby offering good accessibility with little variation among villages. These village health rooms, with their basic equipment, cater to minor ailments of local residents, who generally visit town health centers or the Liannan County People's Hospital for more serious conditions. Hence, this study exclusively focused on the 8 THCs and 1 county hospital in Liannan County, excluding village health rooms. To facilitate the use of medical health facilities and residential demand point locations within geographic information systems(GIS), these locations were digitized into latitudinal and longitudinal points based on points of interest (POI).

Data collection

Population and healthcare-related data were obtained from the Liannan Yao Autonomous County Statistics Bureau and the Liannan Yao Autonomous County Health Bureau. To better understand the healthcare-seeking behavior of rural residents and the practices of doctors, a survey was designed for this study. The survey consisted of two parts: 218 questionnaires for local residents and 42 for healthcare professionals, aiming to gather their opinions and insights. A total of 270 questionnaires were distributed (see Supplementary Files 1 and 2), with 260 valid responses received, resulting in a response rate of 96%. The survey participants comprised local residents and healthcare personnel. Residents were required to be at least 18 years old and to have lived in Liannan County for more than one year. Healthcare personnel comprised doctors, nurses, and other medical staff who had been working in various medical institutions in Liannan County for more than six months. This study employed a random sampling method, with the number of questionnaires distributed controlled according to the population proportion of each town, ensuring that the collected data adequately represented the actual situation of the area.

Gravity-based two-step movement search method

Overall model.

In the traditional 2SFCA method, the first step entails establishing a healthcare supply point \(j\) as the center and utilizing a service threshold \({d}_{0}\) as the radius to delineate the catchment area for that supply point. All demand points \(k\) within this catchment area are then identified and analyzed to calculate the supply-demand ratio \({R}_{j}\) for supply point \(j\) . In the second step, attention shifts to demand point \(i\) . Using the same service threshold \({d}_{0}\) as the service radius, this phase involves calculating the sum of the supply-demand ratios \({R}_{j}\) within the radius of the demand point. This sum determines the accessibility \({A}_{i}\) at demand point \(i\) . The formula is as follows:

Where \(i\) represents the demand point; \(j\) represents the supply point; \({A}_{i}\) represents the accessibility of demand point \(i\) calculated based on the 2SFCA method; \({d}_{ij}\) represents the distance between demand point \(i\) and supply point \(j\) ; \({R}_{j}\) represents the ratio of the facility size of supply point \(j\) to the population served within the search radius ( \({d}_{0}\) ); \({S}_{j}\) represents the supply size of supply point \(j\) ; \({P}_{k}\) represents the demand size of demand point \(k\) [ 36 ].

The gravity-based 2SFCA method applies the distance decay function of the gravity model within the search domain of the 2SFCA method, thereby transforming the discrete distance decay function into a continuous one [ 19 , 30 ]. When the distance is short, accessibility decreases rapidly; as the distance increases, the rate of decline slows, aligning better with the actual conditions of the study area. The formula for the gravity-based 2SFCA method can be expressed as follows, incorporating the decay function into the basic formula ( 1 ):

where \({A}_{i}\) represents the accessibility of demand point \(i, f({d}_{ij})\) is the distance decay functions, and \(\upbeta\) is the distance decay parameter.

Evaluation of the service capacity of healthcare facilities \({S}_j\)

Past studies have typically relied on a single indicator to evaluate the service capacity \({\text{S}}_{\text{j}}\) [ 37 , 38 ] of healthcare facilities, thus failing to capture the variability in service capabilities based on the actual conditions of rural areas. This study initially conducted field observations and questionnaires to collect indicators that represent the service capabilities of healthcare facilities and are in line with the current national medical reform and development trends. For example, indicators such as the number of medical visits and number of patients under family doctor contracts reflect a significant portion of a rural doctor's regular duties. After collecting a set of indicators, these indicators were refined based on data availability and consultations with healthcare professionals. Given the requirements of the SPSS factor analysis, which stipulates that the number of indicators must not exceed the number of supply points, the final selection comprised seven indicators of healthcare service capacity, as listed in Table 2 .

After integrating all the indicator data into the raw dataset, Kaiser–Meyer–Olkin (KMO) and Bartlett's tests were performed to determine whether the original variables were suitable for factor analysis. Generally, a KMO measure above 0.5 and a Bartlett's test p value below 0.05 indicate that factor analysis is appropriate. The results, as shown in Table 3 , confirm that the factor analysis is appropriate.

Based on eigenvalues greater than 1 and a cumulative contribution rate exceeding 85%, two common factors, F1 and F2, were extracted from the seven evaluation variables; these factors are stastistically independent. The cumulative contribution rate of 99.117% demonstrated that the two extracted factors accounted for 99.117% of the variance in the original seven healthcare service capability indicators, providing a comprehensive explanation of the raw data. The factor loading matrix underwent orthogonal rotation, and the factors were subsequently named and interpreted. As shown in Table 4 , variables such as the number of beds, number of practicing physicians, number of medical treatments in 2022, number of nurses, other medical technicians, and number of hospitalizations in 2022 exhibit high loadings on Factor F1, which is interpreted as the level of comprehensive medical resources. This factor had the largest variance contribution rate at 82.311%, indicating that it was the primary influencing factor. The number of family doctor contracts displays a high loading on Factor F2, while the number of nurses also demonstrates a smaller positive correlation with F2, interpreted as primary healthcare service management. This factor contributed 16.806% of the variance, making it a secondary influencing factor.

Finally, to accurately analyse the medical service capabilities of the eight healthcare facilities, the original data were entered into the formula derived from the factor score coefficients, as detailed in Table 5 . Weighted calculations are then conducted using the following factor score functions for Factors F1 and F2:

By utilizing these factor score functions for weighted calculation, comprehensive scores \({S}_{j}\) representing the service capabilities for each healthcare facility were derived, as presented in Table 6 .

Selection of the distance decay coefficient value \(\beta\)

The distance decay coefficient \(\upbeta\) reflects the pattern by which the influence between demand points and supply points diminishes as distance increases. The selection of \(\upbeta\) significantly impacts the outcomes of the gravity-based 2SFCA method. Ideally, this value should be derived from a regression analysis of a large dataset that considers various conditions at supply points. However, the required volume of data for practical verification is substantial, and the associated costs are high, making implementation challenging. According to the literature, the range of values for \(\upbeta\) varies between 0.9 and 2.29 [ 39 , 40 , 41 , 42 ], with common practice setting it at 1.0, 1.2, 1.5, 1.8, or 2.0 [ 43 , 44 , 45 , 46 , 47 ]. To determine the most suitable value, this study conducts a gravity-based 2SFCA model simulation for each of these five values. The travel background is set as car trips, with a healthcare service threshold of 90 minutes, as longer car travel times can better reflect changes in \(\upbeta\) . Finally, the accessibility statistics for different values of are compared to determine the most appropriate value for calculating the accessibility of healthcare facilities in Liannan County (see Table 7 ).

As shown in Fig. 5 , as the value of \(\upbeta\) increases, the high-accessibility areas in Liannan County expand gradually, while the low-accessibility areas shrink correspondingly. This change is particularly evident in the northern and southern peripheral regions of the county. These geographically remote areas, which lack healthcare resources, are more sensitive to changes in the \(\upbeta\) value. In contrast, in the central part of the county, where healthcare facilities are relatively concentrated and residents have more access to medical services, the response of accessibility to changes in the β value is more gradual. Additionally, we conducted an accessibility analysis based on minimum impedance during the study, but due to space limitations, it is not detailed in this paper. This analysis further highlights the significant impact of road distance on motor vehicle travel accessibility. In Liannan County, road conditions directly affect the speed and ease with which residents can reach healthcare facilities. Considering this practical situation, we selected a relatively larger β value to ensure that the accessibility assessment accurately reflects the impact of road distance on accessibility. By comparing the visualized spatial distribution of accessibility under different \(\upbeta\) values, we found that when \(\upbeta\) =1.8, the accessibility assessment results best match the actual conditions. This conclusion is supported not only by the intuitive observation of spatial distribution but also by statistical data analysis. Therefore, we chose β=1.8 as the appropriate distance decay coefficient for assessing healthcare accessibility in Liannan County.

Spatial distribution map of accessibility with different \(\upbeta\) values

Traffic data

Traffic speed.

The survey results indicated that electric bikes and cars are the most common means of transport for rural residents seeking medical care. The shortest travel times from healthcare facilities to administrative villages, and vice versa, can be calculated using the origin-destination (OD) cost matrix function in the network analyst extension and the built-in calculator in GIS.

The basic transportation data for Liannan County, including highways and primary, secondary, tertiary, and quaternary roads, were obtained from the National Geomatics Center of China and digitized in accordance with the requirements of the GIS network model. Based on actual road conditions and the speed regulations for different road types as stipulated in China's "Highway Route Design Regulations" (JTG D20-2017) [ 48 ], the simulated driving speeds in GIS are detailed in Table 8 .

Estimation of healthcare service threshold values

In the survey, the thresholds for acceptable travel time to County People's Hospital and THCs were established at intervals of less than 30 minutes, 30 minutes, 45 minutes, 60 minutes, and more than 90 minutes. The majority of respondents selected "30 minutes" and "over 90 minutes" (Fig. 6 ). Consequently, this study determined the search radius to be 30 minutes and 90 minutes.

Proportional distribution of residents' willingness regarding travel time to different healthcare facilities

Maximized coverage model

During the layout optimization simulation, the Maximization Coverage Model is employed. This model focuses on selecting a specified number of facility locations from a set of potential candidate sites, ensuring that each is strategically placed within the required service radius of the facilities. The primary goal of the maximization coverage model (maximum covering location problem) is to maximize the coverage of facilities. Concerning the distance from demand points to healthcare facilities, the model assumes that any demand point within the service radius receives adequate services. The formulas are as follows:

Where i represents the set of demand points; j represents the set of candidate points; m represents the total number of demand points; n represents the total number of candidate points; p represents the total number of facility points; d represents the distance from demand point i to supply point j; s represents the defined service radius; \({x}_{j}\) is the location variable, indicating whether a healthcare facility is established at candidate point j (if established, \({x}_{j}\) =1; otherwise, \({x}_{j}\) =0); \({y}_{i}\) is the allocation variable, indicating whether demand point i receives service from a community health service center (if received, \({y}_{i}\) =1; otherwise, \({y}_{i}\) =0). The variable \({y}_{j}\) indicates whether candidate point j is selected as a healthcare facility point (if selected, \({y}_{j}\) =1; otherwise, \({y}_{j}\) =0).

Where i represents the set of demand points; j represents the set of candidate points; p represents the total number of facility points; d represents the distance from demand point i to supply point j; s represents the designated service radius; and \({x}_{j}\) is the location variable indicating whether a healthcare facility is established at candidate point j. If established, \({x}_{j}\) =1; otherwise, \({x}_{j}\) =0; and \({y}_{i}\) is the allocation variable indicating whether demand point i accepts services from the community health service center. If accepted, \({y}_{i}\) =1; otherwise, \({y}_{i}\) =0.

Results of overall accessibility

Figure 7 illustrates the spatial distribution of healthcare service accessibility via electric bikes, while Fig. 8 depicts accessibility via cars. The "Inverse Distance Weighting (IDW)" method in GIS classifies accessibility scores into nine levels, with each cell shaded in a different color according to its level. In ArcGIS, the "Inverse Distance Weighting (IDW)" method was used to classify accessibility scores into nine levels, with higher levels indicating better accessibility. Each cell is colored differently according to its level. Within this classification framework, Level 5 represents a relatively balanced state, indicating a medium level of healthcare service accessibility—neither the best nor the worst. This middle level reflects the current situation in Liannan County, where healthcare facilities are limited and unevenly distributed. Therefore, Level 5 can be considered representative of the overall average level of healthcare service accessibility in the region, providing a relatively objective benchmark for evaluation.Although the absolute values in each figure differ, our analysis does not directly compare the specific values of Level 5 in each figure, but rather focuses on their relative positions and meanings across the figures. This approach provides a simple and clear framework for comparison, particularly when basic parameters (such as geographical location, traffic conditions, etc.) are consistent. Adjusting certain parameters (such as service capacity or thresholds) allows for an intuitive observation of the impact of changes in accessibility. Thus, despite the differences in specific values between the figures, this classification method enables a clear comparison of accessibility changes under different scenarios, making horizontal comparisons more straightforward.

Spatial distribution of healthcare service accessibility by electric bike. a 30 min. b  90 min

Spatial distribution of healthcare service accessibility by car. a 30 min. b 90 min

The adopting of a nine-level classification is primarily based on the unique terrain and distribution characteristics of medical resources in Liannan County. In previous studies, classifications exceeding six levels are rare. However, in this study, due to the relatively dispersed distribution of healthcare facilities in Liannan County, it was found through experimentation that dividing accessibility into nine levels more clearly reveals the differences and contrasts between regions, making the trends more evident. This refined classification method not only improves the resolution of the analysis but also significantly enhances the scientific validity and comparability of the research results.

Table 9 details the proportion of healthcare services accessible to residents within different thresholds in Liannan County and the percentage of healthcare facilities throughout the county meeting or exceeding Level 5 accessibility standards. Regardless of the mode of transportation or threshold setting, the proportion of areas in Liannan County achieving above Level 5 is less than 60%, with minimal differences among the four modes of transportation, indicating that the impact of transportation modes on accessibility is relatively limited.

The results revealed a significant disparity between the maximum and minimum values of accessibility within Liannan County, underscoring substantial inequalities in healthcare service accessibility across the region and an uneven distribution of medical resources. Accessibility declines from the central part of the county towards the southwest, exhibiting distinct north‒south and east‒west gradients. The northern and eastern parts of the county demonstrate notably better accessibility compared to the southern and western areas, indicating a more adequate distribution of medical and healthcare facilities in these regions.

The impact of transportation

Extending travel distances with electric bikes has a negligible impact on enhancing accessibility, particularly in regions that are initially the most underserved. These areas, notably the northwestern part of the county, which includes sections of three towns, and the southern area of Damaishan Town, are characterized by low population density, considerable distances between healthcare facilities, substandard medical service capabilities, and limited coverage. Consequently, residents frequently must traverse significant distances within the county to access treatment from hospitals with superior service capabilities. Even after extending the threshold to 90 minutes, no noticeable improvement was observed in these highly underserved areas. Instead, the area of poor accessibility expanded, extending beyond the regions previously calculated for a 30-minute travel time. This demonstrates that increasing the travel distance for electric bikes fails to enhance accessibility in the most disadvantaged areas.

Regarding sensitivity to threshold changes—specifically, the difference in calculated results before and after adjustments in the threshold—electric bikes surpass conventional cars within a certain range. However, beyond a specific threshold, electric bikes prove less effective than conventional cars. A comparison of four maps reveals that within the town domain, the differences in simulated travel outcomes for electric bikes are significant; however, beyond the town domain—especially across two towns—the variations in conventional car travel simulations become considerably more pronounced, particularly in the county’s most peripheral areas.

The impact of service capability

The imbalance in regional accessibility significantly impacts the area and does not necessarily improve with increased travel distances. In this study, changes in the threshold demonstrated polarization in geographic areas, typically causing further deterioration in worse-off areas, while better-served areas improved. The top four healthcare facilities ranked by service capability are all located on the eastern side of the county, resulting in Xiangping Town on the far west becoming the area most affected by the uneven distribution of medical services. The superior medical services accessible to Xiangping Town are the farthest away, so even with an increased threshold, the accessibility around the Xiangping Health Center remains the worst. In contrast, the area around the Zhaigang Health Center on the eastern side consistently boasts the greatest accessibility, which further increases with increasing threshold. This underscores the critical importance of balancing regional service capabilities.

From the maps, the certian areas exhibit a clear improvement in accessibility with increased thresholds, while others experience a reduction in accessibility levels due to the higher threshold. The areas with significant improvements are those with access to the two most robust services—County People's Hospital and Zhaigang Health Center—particularly in Damaishan Town in the southern part of the county. Interviews conducted in Shangdong village and neighboring villages in Damaishan town revealed that with adequate transportation conditions, the majority of villagers opt to travel to the superior Zhaigang Health Center as travel distances increase. Therefore, with the increased service threshold, the accessibility rating for this area improved from Level 5 to Level 6 or higher, closely aligning with actual conditions. In areas where the accessibility rating decreased due to the increased threshold, the cause was exposure to lower-quality resources than before due to the expanded threshold, which lowered the average level of medical services and thus decreased the accessibility results accordingly.

Based on the evaluation of accessibility using various thresholds and transportation methods, it is clear that in remote and rural areas, improvements in transportation alone have a limited effect on enhancing accessibility. Instead, the equitable distribution of medical service capabilities and the optimization of the overall spatial layout are crucial. Given these findings, this paper proposes two improvement scenarios tailored to the specific conditions in Liannan County. Considering the existing economic constraints, the likelihood of adding new healthcare facilities remains low. Therefore, under the premise of maintaining the current number of facilities, this study constructs two scenario simulations designed to explore strategies that enhance accessibility.

The first scenario prioritizes equity. This research identified significant impacts resulting from regional imbalances, necessitating county-wide consideration of balance. Field research has revealed that many health centers consider their locations to be suboptimal and express a desire to relocate. Thus, we use the maximal coverage model to simulate scenarios aimed at maximizing service coverage and fairness.

The second scenario emphasizes efficiency. From an accessibility perspective, the core parameters in the model are transportation and service capability. The proposed hypothesis is that concentrating limited financial resources on a particular medical facility could significantly enhance accessibility. According to previous measurements, Zhaigang and County People's Hospital exert the most substantial impact. Coupled with the county government's three-year development plan, which aims to further enhance the service capacity of Zhaigang Health Center, this facility was selected for the simulation to assess the strategy’s effectiveness.

Regardless of whether they travel by electric bikes or cars, residents can reach at least one healthcare facility within 90 minutes. Therefore, regarding optimization adjustments, we focus solely on ensuring that residents can access at least one primary healthcare service within a 30-minute service radius.

Optimization of the maximum coverage model

To enhance accessibility without increasing public resource investment, this hypothesis is based on the premise that the total number of nine healthcare service facilities remains unchanged, with resources distributed among 71 village residential points as potential new locations. We conducted a simulation analysis using GIS, with specific parameter settings detailed in Fig. 9 . The results show a significant improvement in overall accessibility within the county, regardless of whether travel is by electric bike or car. Specifically, the maximal coverage model for electric bike travel shows that three healthcare facility locations remain unchanged. Prior to the simulation, an accessibility analysis indicated that 11 residential points lacked access to medical services within a 30-minute threshold. However, postsimulation, this number dramatically decreased to only two points: Junliao village in Daping town and Shanlian village in Zhaigang town (Fig. 10 a). Similarly, the maximal coverage model for car travel indicates that two healthcare facility locations remain unchanged under this model setting. Under this hypothetical model, all residential points fall within the service range, whereas the presimulation accessibility analysis identified four villages without service (Fig. 10 b). These results confirm that by optimizing the distribution of existing resources without increasing the number of healthcare facilities, overall accessibility to medical services can be significantly enhanced.

Parameter Settings for the Maximal Coverage Model

Results from the maximal coverage model simulation. a electric bike. b car

Additionally, the simulation results demonstrate high consistency with real-world conditions, thus providing considerable reference value. In simulations that included both modes of transportation, Baimang village and Guoshui village were identified as new sites. This outcome aligns closely with field research and in-depth interviews with the heads of health centers in these towns, and both locations are considered ideal for their respective town health centers. These site selection recommendations are not only theoretically sound but also strongly supported by practical considerations, thus providing important references for future structural adjustments in the county's healthcare service system.

Optimization of the multicore and multiring models

According to the "Liannan Yao Autonomous County Healthcare Service System Plan (2021—2025)", as published by the government, projections indicate that by 2025, the composite ratio of key indicators between primary healthcare facilities and county hospitals will reach 1.7 to 2.4. These data provide a basis for assigning weight to the service capacity expansion at Zhaigang Health Center. The estimated service capability score post-expansion was calculated and is detailed in Table 10 .

The resimulation of the accessibility within a 30-minute travel radius by electric bike demonstrates that with the enhanced service capability of the Zhaigang Health Center (Fig. 11 ) , there has been a significant improvement in the accessibility tiers in the southeastern region, covering nearly one-third of Liannan County's total area. In this region, most areas previously rated as Level 5 have been upgraded to Level 6, signifying that residents can now access healthcare services more easily, particularly in remote villages on the outskirts of Liannan County. This significant improvement considerably alleviates the issue of insufficient medical services.

Simulated spatial distribution of healthcare service accessibility by electric bike. a current situation. b projected

Similarly, the accessibility within a 30-minute travel radius by car was resimulated, as shown in Fig. 12 . The results indicate that the expansion of service capacity at Zhaigang Health Center predominantly affected the southeastern region, which accounts for approximately one-third of Liannan County's area. Notably, given that the time differences in car travel are less significant at short distances, residents closer to Zhaigang Health Center did not exhibit a marked advantage in accessibility assessments. Therefore, improvements in car travel accessibility become more apparent when considering a broader road network and longer driving distances. This finding aligns with the research results mentioned in the Results section, indicating that within a certain range, changes in car travel accessibility are not as pronounced as those with electric bikes.

Simulated spatial distribution of healthcare service accessibility by car. a current situation. b projected

In summary, the model results clearly demonstrate that the enhanced service capacity of the Zhaigang Health Center has positively impacted the accessibility of healthcare services in the southeastern region, underscoring its critical role in Liannan County’s healthcare service network. Although the southeastern region has experienced significant improvements in accessibility, other areas have not experienced comparable enhancements. This suggests that planning the healthcare service network in Liannan County must fully consider regional differences, as reliance on a single central health center is insufficient. Furthermore, future plans should include the establishment of additional central health centers to enhance the accessibility of healthcare services throughout the country.

The quality of medical services in remote and rural areas, a critical component of the primary healthcare system, has long been underemphasized in academic research. This study employs a multifaceted approach by integrating GIS, field research, and expert interviews and enhances the 2SFCA method to conduct empirical research in Liannan County. The goal is to explore the current layout and optimization strategies of primary healthcare facilities in remote and rural areas, focusing on accessibility. By assessing the impacts of various transportation methods and thresholds, our study shows that simple improvements in transportation modes, such as the use of electric vehicles and cars, have certain limitations in enhancing the accessibility of healthcare services in remote and rural areas. Furthermore, the imbalance in regional development is a key factor limiting the improvement of healthcare service quality, requiring a comprehensive strategy to address, including but not limited to enhancing transportation infrastructure and service capacity. Based on the current development status of Liannan County, we propose two optimization strategies that provide practical suggestions for enhancing regional medical services. This research not only guides the spatial layout and resource optimization of healthcare facilities in Liannan County but also establishes new research paths and methodologies for studying healthcare facilities accessibility in remote and rural areas. We hope these results will serve as valuable references for improving rural medical services and promoting the health and well-being of rural residents.

At the innovation level, we achieved the following results: First, we refined the traditional 2SFCA model based on the unique characteristics of remote rural areas, allowing for a more accurate reflection of the actual supply and demand situation in these regions. Second, by effectively integrating qualitative and quantitative research, we successfully overcame the challenges of data collection in remote areas, ensuring that the evaluation criteria are both comprehensive and precise. Third, we conducted an innovative comparative analysis of multiple transportation modes, offering a broader perspective for the optimal allocation of healthcare resources. Lastly, by integrating multidisciplinary knowledge, we expanded the scope of the research further and, through scenario simulation and strategy optimization, provided robust scientific support for decision-makers.

This study is predicated on the assumption that residents exclusively seek medical treatment within Liannan County and that local medical resources are dedicated solely to those within the specified research area. However, it does not consider the medical practices of residents in bordering areas or the impact of neighboring regions on the accessibility of medical services. Additionally, the behaviors associated with seeking medical treatment across administrative boundaries have not been thoroughly examined. Future research should investigate these questions more deeply. Furthermore, subsequent in-depth studies should monitor and validate the actual effects of the two proposed recommendations, undertaking more extensive analyzes that integrate various geographic and socioeconomic factors. Such an approach would enhance the theoretical foundation and practical guidance necessary for optimizing global rural medical services.

Availability of data and materials

The basic transportation data for Liannan Yao Autonomous County were obtained from the National Geomatics Center of China(NGCC): https://www.ngcc.cn/ . Population and healthcare-related data were sourced from the Liannan Yao Autonomous County Statistics Bureau and the Liannan Yao Autonomous County Health Bureau. However, restrictions apply to the availability of these data, which were used under licence for the current study and so are not publicly available. The data are, however, available from the authors upon reasonable request and with the permission of the Liannan Yao Autonomous County Statistics Bureau and the Liannan Yao Autonomous County Health Bureau.

Abbreviations

World Health Organisation

Two-step floating catchment area

Town Health Center

Geographic Information System

Points of Interest

Allan DP. Catchments of general practice in different countries– a literature review. Int J Health Geograph. 2014;13(32). https://doi.org/10.1186/1476-072X-13-32 .

World Health Organization. WHO global strategy on integrated people-centred health services 2016-2026 Executive Summary. Available at: https://iris.who.int/bitstream/handle/10665/180984/WHO_HIS_SDS_2015.20_eng.pdf?sequence=1%20 . Accessed 22 Apr 2024.

Wu C, Tu Y, Li Z, et al. An early assessment of the County Medical Community reform in China: a case study of Zhejiang province. J Chinese Gov. 2021;6(4):463–85.

Article   Google Scholar  

Yao Q, Liu C, Ferrier JA, et al. Urban‒rural inequality regarding drug prescriptions in primary care facilities – a pre-post comparison of the National Essential Medicines Scheme of China. Int J Equity Health, 2015.

Liu L, Zhao Y, Lyu H, Chen S, Tu Y, Huang S. Spatial Accessibility and Equity Evaluation of Medical Facilities Based on Improved 2SFCA: A Case Study in Xi’an, China. Int J Environ Res Public Health. 2023;20(3):2076.

Article   PubMed   PubMed Central   Google Scholar  

Liu S, Qin Y, Xu Y. Inequality and Influencing Factors of Spatial Accessibility of Medical Facilities in Rural Areas of China: A Case Study of Henan Province. Int J Environ Res Public Health. 2019;16(10):1833.

Marwal A, Silva E. Literature review of accessibility measures and models used in land use and transportation planning in last 5 years. J Geograph Sci. 2022;32(3):560–84.

Hansen W. How Accessibility Shapes Land Use. J Am Plan Assoc. 1959;25(2):73–76.

Penchansky R, Thomas JW. The concept of access: definition and relationship to consumer satisfaction. Med Care. 1981;19(2):127–40.

Khan AA. An integrated approach to measuring potential spatial access to health care services. Socio-Econ Plan Sci. 1992;26(4):275–87.

Article   CAS   Google Scholar  

Yang L, Liang Y, He B, Yang H, Lin D. COVID-19 moderates the association between to-metro and by-metro accessibility and house prices. Transportation Research Part D-Transport and Environment, 2023, 114.

Guo C, Liang J. Accessibility analysis of medical facilities based on multiple transportation modes of network map. J Geo-information Sci, 2022,24(3):483-494(In Chinese).

Guagliardo MF. Spatial accessibility of primary care: concepts, methods and challenges. Int J Health Geograph, 2004, 3(3).

Hu R, Dong S, Zhao Y, et al. Assessing potential spatial accessibility of health services in rural China: a case study of Donghai county. Int J Equity Health. 2013;12(35). https://doi.org/10.1186/1475-9276-12-35 .

Li P, Hua L, Yu Q. Theoretical and methodological review of urban accessibility research. Urban Issues. 2005;01:69–74.

Google Scholar  

Koenig J.G. Indicators of urban accessibility: Theory and application. Transportation, 1980,9(2)(In Chinese).

Yang T, Guo X. New Concept of Urban Travel Accessability and its Application. China J Highway Transport. 1995;02:25–30 (In Chinese).

CAS   Google Scholar  

Radke J, Mu L. Spatial Decompositions, Modelling and Mapping Service Regions to Predict Access to Social Programs. Annals of GIS. 2000;6(2):105–12.

Luo W, Wang F. Measures of Spatial Accessibility to Health Care in a GIS Environment: Synthesis and a Case Study in the Chicago Region. Environment and Planning B: Planning and Design. 2003;30(6):865–84.

Wachs M, Kumagai TG. Physical accessibility as a social indicator. Socio-Econ Plann Sci. 1973;7(5):437–56.

Joseph AE, Bantock PR. Measuring potential physical accessibility to general practitioners in rural areas: a method and case study. Soc Sci Med (1982). 1982;16(1):85–90.

Ding Q, Zhu L, Luo J. Analysing spatial accessibility to residential care facilities in Wuhan. Human Geography. 2016;31(02):36–42 (In Chinese).

Song Z, Chen W, Zhang G, Zhang L. Spatial Accessibility to Public Service Facilities and Its Measurement Approaches. Progress in Geography. 2010;29(10):1217–24 (In Chinese).

Zhang J, Han P, Sun P, Zhao J, Yang L. Assessing Spatial Accessibility to Primary Health Care Services in Beijing. China: Int J Environ Res Public Health; 2021;18(24): 13182.

Luo W, Qi Y. An enhanced two-step floating catchment area (E2SFCA) method for measuring spatial accessibility to primary care physicians. Health Place. 2009;15(4):1100–7.

Article   PubMed   Google Scholar  

Dai D. Racial/ethnic and socioeconomic disparities in urban green space accessibility: Where to intervene?. Landscape and Urban Plann. 2011;102(4):234–44.

Dai D, Wang F. Geographic Disparities in Accessibility to Food Stores in Southwest Mississippi. Environment and Planning B: Planning and Design, 2011, 38(4).

Wang F, Tang Q. Planning toward Equal Accessibility to Services: A Quadratic Programming Approach. Environment and Planning B: Planning and Design. 2013;40(2):195–212.

Xing L, Liu Y, Wang B, Wang Y, Liu H. An environmental justice study on spatial access to parks for youth by using an improved 2SFCA method in Wuhan, China. Cities. 2020, 96.

Wang F. Measurement, Optimization, and Impact of Health Care Accessibility: A Methodological Review. Annals Assoc Am Geographers. 2012;102(5):1104–12.

Lu C, Zhang Z, Lan X. Impact of China's referral reform on the equity and spatial accessibility of healthcare resources: A case study of Beijing. Soc Sci Med. 2019:1-9.

Cheng J, Cheng J, Lu Y, Huang Z, Cao F. Spatial inequity in access to healthcare facilities at a county level in a developing country: a case study of Deqing County, Zhejiang, China. Int J Equity Health, 2015.

Liu Y, Gu H, Shi Y. Spatial Accessibility Analysis of Medical Facilities Based on Public Transportation Networks. International J Environ Res Public Health. 2022;19:16224.

Gu X, Zhang L, Tao S, Xie B. Spatial Accessibility to Healthcare Services in Metropolitan Suburbs: The Case of Qingpu, Shanghai. Int J Environ Res Public Health. 2022;16:225.

Wang X, Yang H, Duan Z, et al. Spatial accessibility of primary health care in China: A case study in Sichuan Province. Soc Sci Med. 2018;209:14–24.

Liu G, Wang Y, Wang Y. Impact of inverse distance weighted interpolation factors on interpolation error. China Sciencepaper, 2010,5(11):879-884(In Chinese).

Tao Z, Chen Y, Dai T. Measuring spatial accessibility to residential care facilities in Beijing. Progress in Geography. 2014;33(05):616–24 (In Chinese).

Hang J, Chen M, Li Y, Peng M. The Evaluation and Optimization of the Quality of Medical and Health Service Facilities in Wuhan Based on Optimal Path Analysis and Two-Step Floating Catchment Area Method. Modern Urban Res. 2019;08:25–34 (In Chinese).

Xu B, Qin Q, Wei X, Li J, Lin Y, et al. Spatial Accessibility to the Primary Healthcare Services of Community Healthcare Centers in Nanning City: Gaussian Two-step Floating Catchment Area Approach. Chin J Health Stat. 2021;38(06):852–9 (In Chinese).

Berens W, Körling FJ. Estimating road distances by mathematical functions. Eur J Operational Res. 1985;21(1):54–6.

Brimberg J, Love RF. General Considerations on the Use of the Weighted lp Norm as an Empirical Distance Measure. Transportation Sci. 1993;27(4):341–9.

Peeters D, Thomas I. Distance predicting functions and applied location-allocation models. J Geograph Syst. 2000;2(2):167–84.

Love RF, Morris JG. Mathematical Models of Road Travel Distances. Manag Sci. 1979;25(2):130–9.

Wang F . Quantitative methods and applications in GIS. Commercial Press, 2009 (In Chinese).

Siegel M, Koller D, Vogt V, et al. Developing a composite index of spatial accessibility across different health care sectors: A German example. Health policy (Amsterdam). 2016;120(2):205–12.

Wang Q. Accessibility analysis of medical services in Shanghai based on improved two-step mobile search method. Natural Geography of Wuhan University, 2019 (In Chinese).

Tao H, Chen X, Li X. Research on Spatial Accessibility to Health Service——A Case Study in the Haizhu District of Guangzhou. Geomatics & Spatial Information Technology. 2007;01:1–5 (In Chinese).

Ministry of Transport of the People’s Republic of China. Design Specification for Highway Alignment Available at: https://xxgk.mot.gov.cn/2020/jigou/glj/202006/t20200623_3312660.html . Accessed 22 Apr 2024 (In Chinese).

Download references

Acknowledgements

Not applicable.

This research was supported by the philosophy and social science foundation of Guangdong province, China[grant number GD22CGL33], Office of the Guangzhou Social Science Planning Leadership Group, China[grant number 2024GZYB22] and Guangzhou Municipal Science and Technology Bureau, China [grant number 202201011084]. The funding bodies did not influence this paper in any way prior to circulation.

Author information

Authors and affiliations.

School of Mechanics and Constructions Engineering, Jinan University, Guangzhou, 510000, China

Lulu Liu, Yaowen Chen, Jiawei Zhong, Peng Zhou, Yu Xiao & Lan Wang

Key Laboratory of Green toughening and safety prevention and control of offshore structures, Guangzhou, China

Lulu Liu & Lan Wang

The First Affiliated Hospital of Guangdong Pharmaceutical University, Guangzhou, 510000, China

Haiqing Xiang

School of culture tourism and geography, Guangdong University of Finance & Economics, Guangzhou, 510000, China

You can also search for this author in PubMed   Google Scholar

Contributions

LL Conceptualized and wrote the first and final draft of the article. YC designed the research methods, analysed the data and wrote the first draft. HX revised the manuscript and reviewed all the literature. JZ and YX participated in field finds and data collection. PZ and LW participated in designing the figures and tables. YS revised the manuscript. All authors read and approved the paper.

Corresponding author

Correspondence to Haiqing Xiang .

Ethics declarations

Ethics approval and consent to participate.

Our study was reviewed and approved by the Ethics Committee of the First Affiliated Hospital of Guangdong Pharmaceutical University [Ethics approval number: (2024) IIT (30)]. The ethics committee reviewed and approved the request for a waiver of written informed consent. All methods were used in accordance with the relevant guidelines and regulations.

Consent for publication

Competing interests.

The authors declare no competing interests.

Additional information

Publisher's note.

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary Information

Supplementary material 1, supplementary material 2, rights and permissions.

Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modified the licensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by-nc-nd/4.0/ .

Reprints and permissions

About this article

Cite this article.

Liu, L., Chen, Y., Xiang, H. et al. Measuring and optimizing the spatial accessibility of primary health care in remote and rural areas: a case study of Liannan Yao Autonomous County in China. BMC Health Serv Res 24 , 1100 (2024). https://doi.org/10.1186/s12913-024-11556-1

Download citation

Received : 16 May 2024

Accepted : 09 September 2024

Published : 19 September 2024

DOI : https://doi.org/10.1186/s12913-024-11556-1

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Spatial accessibility
• Primary health care
• Remote and rural area
• Resource optimization allocation

BMC Health Services Research

ISSN: 1472-6963

• General enquiries: [email protected]

Postmortem CT and autopsy findings in an elevator-related death: a case report

• Images in Forensics
• Open access
• Published: 20 September 2024

Cite this article

You have full access to this open access article

• Giovanni Aulino   ORCID: orcid.org/0000-0003-3071-6504 1 ,
• Michele Rega 1 ,
• Vittoria Rossi 1 ,
• Massimo Zedda 1 &
• Antonio Oliva 1  

Elevator-related fatalities and injuries are rarely discussed. Falls have been identified as the first cause of mortality in the majority of these accidents. Evidence suggests that many elevator accidents may be attributed to inadequate equipment maintenance or malfunctions of the devices. This study examines a case involving an elevator maintenance worker found within an elevator shaft, using postmortem computed tomography (PMCT) along with a full autopsy. The autopsy revealed that the cause of death was severe polytrauma resulting from dragging, compression, and crushing mechanisms, which resulted in a dislocated skull and multiple thoraco-abdominal injuries, including exposed organs and viscera. Detailed examination identified a cranio-encephalic crush, leading to a significant alteration in the physiognomy of the facial structures. Additionally, PMCT revealed complex spinal fractures, such as a Jefferson fracture and a complete Chance fracture at the D6 vertebra, accompanied by spinal deviation proximal to the fracture site. Autopsy findings corroborated these PMCT results. A multidisciplinary approach, including PMCT, is proposed as a strategic method for the comprehensive reconstruction of such accidents, facilitating the collection of extensive data.

Similar content being viewed by others

Transverse process fractures of the thoracic vertebrae—the significance of this injury in the context of medicolegal opinions on high-energy trauma cases

Traumatic Chest Wall Injuries

Sledding injuries a practice-based study is it time to raise awareness.

Avoid common mistakes on your manuscript.

Introduction

Elevator-related fatalities and injuries are infrequently addressed in literature. Between 1992 and 2009, there were 443 reported fatalities associated with elevators in the United States [ 1 ]. Conversely, injuries attributed to elevators are believed to occur more frequently within the United States, impacting both children and the elderly [ 2 , 3 ]. In cases involving fall-related trauma, PMCT has facilitated a more accurate reconstruction of the accident and provided a detailed characterization of the injuries sustained, as corroborated by subsequent autopsy examinations [ 4 ].

In our institution, PMCT is utilized in specific forensic cases, including those involving extensive carbonization, gunshot wounds, and drowning. This technique was applied to assess a workplace accident involving an elevator, in which the victim was found motionless within the elevator shaft [ 5 , 6 , 7 , 8 , 9 ]. The injuries sustained from the precipitating event were significantly overshadowed by the presence of severe polytrauma, which led to cranio-encephalic displacement and multiple thoracic and abdominal injuries, including exposed organs and viscera. Consequently, this study aims to provide a comprehensive description of the fractures sustained, integrating evidence from the accident scene with radiological and autopsy findings.

Case report

Case presentation.

A 35-year-old elevator maintenance worker was discovered in a prone position at the base of the elevator shaft where he had conducted maintenance the preceding day. He had been reported missing since the previous evening. The individual was found wearing a bloodstained shirt and trousers that were partially lowered to just above the knees, along with work shoes, of which only the left shoe was worn. Additionally, longitudinal streaks of blood were noted on the walls of the upper compartment at the scene.

External examination

Upon examination of the head, a cranio-encephalic crush was identified, characterized by significant disruption of the facial structure, including disrupted eyes and destruction of the bony elements of the cranial vault. Comminuted fragments of cerebral parenchyma were also present (Fig.  1 a-c).

External examination and PMCT findings of the craniofacial region. a, b, c : Cranio-encephalic injury characterized by significant loss of facial structure, including ocular rupture and destruction of the bony components of the cranial vault. d, e : PMCT 3D-rendered images depicting the bone structure of the craniofacial area

Two parallel ecchymotic and excoriated bands were observed: one in the mid-sternal region and another laterally adjacent, each approximately 1 cm thick and diffusely over the anterior thorax and abdomen. Additionally, lacerated and contused wounds affecting the anterior trunk were observed (Fig.  2 a).

External examination findings of the thoraco-abdominal region. a: Two parallel ecchymotic and excoriated bands measuring 1 cm in thickness, located in the mid-sternal region and adjacent laterally. b: A lacerated-contused wound with exposure of underlying musculoskeletal tissue and homolateral lung parenchyma in the right thoracic region. c: A lacerated-contused wound with a longer transverse axis, exposing abdominal viscera in the left flank

In the right thoracic region, a lacerated contusion was identified, associated with multiple dislodged rib fractures and leakage of lung parenchyma. A similarly sized injury was found on the left flank, with exposure of the abdominal viscera (Fig.  2 b, c). Finally, a full-thickness fracture of the thoracic vertebra was documented (Fig.  3 a).

External examination and PMCT findings of the spinal column. a: Full-thickness fracture of the thoracic spine demonstrated. b: PMCT 3D-rendered image of the spinal column’s bone tissue. c: Frontal view of the spine as observed on the PMCT scan

Post-mortem CT

Prior to the autopsy, and following the external examination of the decedent, PMCT was conducted using a Somatom Sensation 16 CT scanner (Siemens ® , Munich, Germany). The examination settings included 140 kVp, 160 mAs, 24-mm feed/rotation, 1-mm slice collimation, 1-mm slice width, and reconstruction kernels of 10, 30, 40, 70, and 80.

Subsequent to data processing, axial, coronal, and sagittal two-dimensional (2D) reconstructions, along with a three-dimensional (3D) volume rendering (VR) and shaded surface display (SSD), were performed. The resultant images were reviewed by a board-certified radiologist with over 10 years of experience in forensic imaging. The findings from the external examination were communicated to the radiologist prior to the review.

PMCT confirmed fractures in the craniofacial region (Fig.  1 d, e) and revealed complex fractures of the spine, including a Jefferson fracture and a complete Chance fracture at the D6 level, with spinal deviation proximal to the fracture (Fig.  3 b, c). Numerous fractures were also identified in all four limbs as well as in the thoracic cage. Additionally, a diaphragmatic rupture and mediastinal dislocation were noted.

Autopsy findings

All radiological findings were corroborated by the forensic autopsy. The macroscopic examination revealed multiple lacerations of the thoracic and abdominal viscera. On sectioning, pronounced pallor of the organs was observed. Moreover, no significant findings identified that would suggest the presence of underlying pathologies capable of contributing to the determination of death.

Elevator accidents, while infrequent, can lead to fatalities and severe injuries [ 10 ]. Despite being one of the safest forms of transportation, the high volume of elevator traffic can contribute to serious incidents [ 2 ]. According to McCann, 20.5% of elevator passengers were not engaged in work at the time of their accidents, while 20.1% were performing work-related duties, such as clerical, stock handling, and janitorial tasks. Notably, the remaining cases (59.4%) involved construction workers who were in or near elevator shafts [ 1 ].

Reconstructing elevator-related accidents is crucial for both safety improvement and legal accountability [ 4 ]. The majority of these accidents can often be attributed to inadequate maintenance or malfunctioning equipment [ 6 ]. The nature of injuries sustained in elevator incidents varies according to the specific circumstances surrounding each case. Prahlow et al. highlighted that falls from heights were the leading cause of elevator-related fatalities, followed closely by severe asphyxia, crushing injuries, and pressure-related injuries, which placed third [ 11 ].

In this case, the cause of death was determined to be severe polytrauma resulting from dragging, compression, and crushing injuries that led to a dislocated skull and multiple thoraco-abdominal injuries, exposing internal organs and viscera. The most plausible scenario suggests that the victim experienced compression between the elevator shaft wall and the elevator, followed by a fall that resulted in further crushing as the elevator descended.

Evidence supporting this hypothesis includes blood found on the wall adjacent to the elevator, facial lacerations, longitudinal bruising on the anterior chest, and multiple fractures identified through PMCT. It has demonstrated not only exceptional sensitivity and specificity in recognizing and classifying various types of fractures, but it also allows for the identification of injuries to soft tissues and organs [ 12 , 13 , 14 , 15 , 16 ].

A systematic review of 15 studies comparing PMCT and autopsy findings in cases of traumatic death indicated an agreement rate ranging from 50 to 100% in determining the cause of death, with enhanced concordance noted specifically in gunshot-related fatalities [ 17 ]. Additionally, a subsequent large-scale study revealed an almost perfect correlation between PMCT and autopsy results in the detection of craniofacial injuries and gunshot-related deaths [ 18 ]. Thus, PMCT was instrumental in characterizing fractures that would have been challenging to analyze during a standard autopsy, thereby providing critical insights into the dynamics of the accident [ 19 ]. Indeed, PMCT has enabled the description and reconstruction of fractures in the craniofacial region and has revealed complex spinal fractures, including a Jefferson fracture and a complete Chance fracture at the D6 level, along with spinal deviation proximal to the fracture.

The autopsy further confirmed the absence of any pre-existing pathological conditions that could have contributed to the victim’s injuries. To maximize data collection, a multidisciplinary approach incorporating PMCT is essential [ 20 ]. Nevertheless, the autopsy remains a key component in establishing the cause of death and ruling out any underlying health issues that may have played a role in the injuries sustained.

In conclusion, the circumstances of the accident and the height of the fall significantly influence the severity of injuries and the likelihood of a fatal outcome in elevator incidents. Precise reconstruction of these accidents is essential for forensic investigations, as it aids in understanding the dynamics involved, especially in industrial contexts. Additionally, PMCT has proven to be a valuable, rapid, and non-invasive tool for the documentation and reconstruction of traumatic injuries, enhancing the overall forensic analysis.

Data availability

My manuscript has associated data in a data repository.

McCann M. Deaths and injuries involving elevators and escalators (2013). https://www.cpwr.com/sites/default/files/publications/elevator_escalator_BLSapproved_2.pdf (accessed 17 Aug 2019).

O’Neil J, Steele GK, Huisingh C, Smith GA. Elevator-related injuries to children in the United States, 1990 through 2004. Clin Pediatr (Phila). 2007;46(7):619–25. https://doi.org/10.1177/0009922807300232 .

Article   PubMed   Google Scholar  

Steele GK, O’Neil J, Huisingh C, Smith GA. Elevator-related injuries to older adults in the United States, 1990 to 2006. J Trauma. 2010;68(1):188–92. https://doi.org/10.1097/TA.0b013e3181b2302b .

Jacobsen C, Schön CA, Kneubuehl B, Thali MJ, Aghayev E. Unusually extensive head trauma in a hydraulic elevator accident: post-mortem MSCT findings, autopsy results and scene reconstruction. J Forensic Leg Med. 2008;15(7):462–6. https://doi.org/10.1016/j.jflm.2008.03.006 .

Cascini F, Polacco M, Cittadini F, Paliani GB, Oliva A, Rossi R. Post-mortem computed tomography for forensic applications: a systematic review of gunshot deaths. Med Sci Law. 2020;60(1):54–62. https://doi.org/10.1177/0025802419883164 .

Coty JB, Nedelcu C, Yahya S, Dupont V, Rougé-Maillart C, Verschoore M, Ridereau Zins C, Aubé C. Burned bodies: post-mortem computed tomography, an essential tool for modern forensic medicine. Insights Imaging. 2018;9(5):731–43. https://doi.org/10.1007/s13244-018-0633-2 .

Article   PubMed   PubMed Central   Google Scholar  

Hourscht C, Christe A, Diers S, Thali MJ, Ruder TD. Learning from the living to diagnose the dead - parallels between CT findings after survived drowning and fatal drowning. Forensic Sci Med Pathol. 2019;15(2):249–51. https://doi.org/10.1007/s12024-018-0081-9 .

Cittadini F, Polacco M, D’Alessio P, Tartaglione T, De Giorgio F, Oliva A, Zobel B, Pascali VL. Virtual autopsy with multidetector computed tomography of three cases of charred bodies. Med Sci Law. 2010;50(4):211–6. https://doi.org/10.1258/msl.2010.010116 .

Oliva A, Grassi S, Zedda M, Calistri L, Cazzato F, Masini V, Polacco M, Maiolatesi F, Bianchi I, Defraia B, Grifoni R, Filograna L, Natale L, Focardi M, Pinchi V. Forensic significance and inferential value of PMCT features in charred bodies: a bicentric study. Forensic Imaging. 2024;37:200590. https://doi.org/10.1016/j.fri.2024.200590 .

Article   Google Scholar  

Khaji A, Ghodsi SM. Trend of elevator-related accidents in Tehran. Arch Bone Jt Surg. 2014;2(2):117–20.

PubMed   PubMed Central   Google Scholar  

Prahlow JA, Ashraf Z, Plaza N, Rogers C, Ferreira P, Fowler DR, Blessing MM, Wolf DA, Graham MA, Sandberg K, Brown TT, Lantz PE. Elevator-related deaths. J Forensic Sci. 2020;65(3):823–32. https://doi.org/10.1111/1556-4029.14235 .

Di Paolo M, Maiese A, dell’Aquila M, Filomena C, Turco S, Giaconi C, Turillazzi E. Role of post mortem CT (PMCT) in high energy traumatic deaths. Clin Ter. 2020;171(6):e490–500. https://doi.org/10.7417/CT.2020.2263 .

Henningsen MJ, Larsen ST, Jacobsen C, Villa C. Sensitivity and specificity of post-mortem computed tomography in skull fracture detection-a systematic review and meta-analysis. Int J Legal Med. 2022;136(5):1363–77. https://doi.org/10.1007/s00414-022-02803-3 .

Mondello C, Baldino G, Bottari A, Sapienza D, Perri F, Argo A, Asmundo A, Ventura Spagnolo E. The role of PMCT for the assessment of the cause of death in natural disaster (landslide and flood): a sicilian experience. Int J Legal Med. 2022;136(1):237–44. https://doi.org/10.1007/s00414-021-02683-z .

Ampanozi G, Halbheer D, Ebert LC, Thali MJ, Held U. Postmortem imaging findings and cause of death determination compared with autopsy: a systematic review of diagnostic test accuracy and meta-analysis. Int J Legal Med. 2020;134(1):321–37. https://doi.org/10.1007/s00414-019-02140-y .

Kranioti EF, Nathena D, Spanakis K, Karantanas A, Bouhaidar R, McLaughlin S, Thali MJ, Ampanozi G. Unenhanced PMCT in the diagnosis of fatal traumatic brain injury in a charred body. J Forensic Leg Med. 2021;77:102093. https://doi.org/10.1016/j.jflm.2020.102093 .

Scholing M, Saltzherr TP, Fung Kon Jin PH, Ponsen KJ, Reitsma JB, Lameris JS, Goslings JC. The value of postmortem computed tomography as an alternative for autopsy in trauma victims: a systematic review. Eur Radiol. 2009;19(10):2333–41. https://doi.org/10.1007/s00330-009-1440-4 .

Article   CAS   PubMed   PubMed Central   Google Scholar  

Le Blanc-Louvry I, Thureau S, Duval C, Papin-Lefebvre F, Thiebot J, Dacher JN, Gricourt C, Touré E, Proust B. Post-mortem computed tomography compared to forensic autopsy findings: a French experience. Eur Radiol. 2013;23(7):1829–35. https://doi.org/10.1007/s00330-013-2779-0 .

Filograna L, Manenti G, Grassi S, Zedda M, Ryan Collen P, Floris R, Oliva A. Health Technology Assessment (HTA) of virtual autopsy through PMCT with particular focus on Italy. Forensic Imaging. 2022;30:200516. https://doi.org/10.1016/j.fri.2022.200516 .

Filograna L, Manenti G, Micillo A, Chirico F, Carini A, Gigliotti PE, Floris R, Malizia A, Oliva A. Post-mortem imaging: a tool to improve post-mortem analysis and case management during terrorist attacks. Forensic Imaging. 2023;34:200551. https://doi.org/10.1016/j.fri.2023.200551 .

Download references

Acknowledgements

We would like to extend our heartfelt gratitude to Dr. Valentina Masini for her exceptional work in reconstructing the PMCT images for this study. Her expertise and meticulous attention to detail significantly enhanced the quality of our analysis. We appreciate her collaborative spirit and contributions, which were invaluable to the success of our research.

Open access funding provided by Università Cattolica del Sacro Cuore within the CRUI-CARE Agreement. This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Author information

Authors and affiliations.

Department of Health Surveillance and Bioethics, Section of Legal Medicine, Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo Francesco Vito, 1, Rome, 00168, Italy

Giovanni Aulino, Michele Rega, Vittoria Rossi, Massimo Zedda & Antonio Oliva

You can also search for this author in PubMed   Google Scholar

Contributions

Giovanni Aulino: Conceptualization, Methodology, Writing -original draft; Michele Rega: Writing -original draft; Writing – review & editing. Vittoria Rossi: Writing -original draft; Writing – review & editing. Massimo Zedda: Writing -original draft; Writing – review & editing. Antonio Oliva: Conceptualization, Writing -original draft; Writing – review & editing; All authors approved the final version of the manuscript.

Corresponding author

Correspondence to Giovanni Aulino .

Ethics declarations

Competing interests.

The authors declare they have no conflict of interest.

Article classification

10: Forensics.

10.010: Pathology.

10.190: Autopsy.

Ethical approval and consent to participate

This article does not contain any studies with animals. Informed consent is not necessary in this work because it was a judicial autopsy case. The report does not contain personal data. In any case, all data are covered by the Italian Law—Data Protection Authority (Official Gazette no. 72 of March 26, 2012)—for scientific research purposes.

Additional information

Publisher’s note.

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/ .

Reprints and permissions

About this article

Aulino, G., Rega, M., Rossi, V. et al. Postmortem CT and autopsy findings in an elevator-related death: a case report. Forensic Sci Med Pathol (2024). https://doi.org/10.1007/s12024-024-00896-3

Download citation

Accepted : 09 September 2024

Published : 20 September 2024

DOI : https://doi.org/10.1007/s12024-024-00896-3

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Forensic radiology
• Elevator accident

Advertisement

• Find a journal
• Publish with us
• Track your research

Disclaimer: Early release articles are not considered as final versions. Any changes will be reflected in the online version in the month the article is officially released.

Volume 30, Number 10—October 2024

Investigation of a Human Case of Francisella tularensis Infection, United Kingdom, 2023

Suggested citation for this article

Tularemia, caused by Francisella tularensis , is not known to occur in the United Kingdom. We report a case of tularemia diagnosed in July 2023 in a UK patient with no travel in the 6 weeks before symptom onset. We describe the subsequent multiagency investigation into possible routes of acquisition.

Tularemia is a zoonotic disease caused by Franciscella tularensis , currently considered absent from the United Kingdom. We report a human case of F. tularensis subspecies holarctica infection diagnosed in the United Kingdom and the resulting cross-agency investigations. We obtained written consent from the patient for publication of our findings.

In May 2023, a 47-year-old man sought treatment at a primary care facility 48 hours after he had fever and cervical lymphadenopathy developed. The working diagnosis was a dental infection, but there was no response to the oral antimicrobial drugs amoxicillin/clavulanic acid and metronidazole or to subsequent dental extraction. The patient was referred to the otorhinolaryngology department for further investigation. Over the next few weeks, the lymph nodes became suppurative, but there was no growth on routine bacterial culture. We aspirated his lymph nodes in June 2023 but found no growth on bacterial or mycobacterial cultures and sent the sample for 16S rRNA gene PCR (16S PCR) and sequencing. F. tularensis was identified on 16S PCR and confirmed by subsequent Francisella -specific PCR at the UK Health Security Agency (UKHSA) Rare and Imported Pathogens Laboratory.

We initially assumed that the infection had been acquired during a trip to Sweden. However, after the F. tularensis diagnosis was confirmed, we obtained a detailed travel and exposure history from the patient. The patient’s symptoms had manifested 6 weeks before the trip to Sweden and remained unchanged after the trip. His only other relevant overseas travel was a 4-day trip to southern Portugal in March 2023, >6 weeks before symptom onset. Before that time, he had not left the United Kingdom since 2019.

The patient had 3 pet degus, chinchilla-like rodents originating in Chile, bought in the United Kingdom 6 years earlier. One degu had died suddenly in early July 2023, two months after the patient’s symptom onset. The corpse of the animal was disposed of without examination. A second degu became unwell with jaw swelling a few days later. Cytological examination of the swelling was in keeping with inflammation and infection, but no samples were sent for bacteriology. The patient reported no other animal contact apart from occasional contact with dogs of a family member. Those dogs were fed commercial nonraw pet food and had had no recent illnesses.

The patient lived near a nature reserve in the northwest of England where he took regular walks; he had not seen any lagomorphs or rodents or noticed any insect bites. He had no history of drinking contaminated water or consuming raw meat, lagomorphs, or rodents and had not handled any animal carcasses. The patient was examined again by the local infection team. Because of ongoing discharge from the neck lesions, antimicrobial drugs were changed from doxycycline to ciprofloxacin.

We collected additional swab and serum samples for F. tularensis antibody testing. F. tularensis subsp. holarctica subtype was confirmed by specific PCR as using an in-house multitarget real-time TaqMan PCR differentiation assay developed as described elsewhere ( 1 ). We submitted the PCR product for next-generation sequencing, which confirmed subspecies identification. Unfortunately, we could not culture the organism from either the original or later swab samples. A commercial assay (Seramun Diagnostica, https://www.seramun.com ) was positive for combined F. tularensis IgG/IgM. We took samples from the surviving degus and the bedding and food. All tested negative for F. tularensis by specific PCR, and the bacterium was not isolated on culture.

The United Kingdom has many potential mammal reservoirs of F. tularensis , including the brown hare ( Lepus europaeus ), black rat ( Rattus rattus ), and several mice and vole species, but the organism has never been isolated from animals in the United Kingdom. The Animal and Plant Health Agency through its Diseases of Wildlife Scheme conducts passive surveillance for wildlife diseases; no local wildlife dieoffs had been reported. Rewilding programs reintroducing beavers ( Castor fiber ) into the United Kingdom present another possible source; however, no beavers had been released near the patient’s locale, and imported beavers must test negative for F. tularensis as a condition of release.

Tickborne transmission of F. tularensis subsp. holarctica has been described for Ixodes ricinus and Dermacentor reticulatus ticks, both present in the United Kingdom. Although the likely date of the patient’s tularemia acquisition was compatible with seasonal activity of I. ricinus ticks, there were no records of that tick in the local area, based on 15 years of passive surveillance data ( 2 ). Similarly, D. reticulatus ticks are not known to be present in that area. Mosquitoes represent another potential vector. Data from national mosquito surveillance indicates that potential mosquito vectors, such as Aedes cinereus , are present in the United Kingdom but would have been active 2 weeks after symptom onset. However, no nuisance biting was reported in the area at that time.

Site visits were conducted by the UKHSA Medical Entomology and Zoonoses Ecology team in August 2023 and May 2024. We found no evidence of active tick populations after sampling. Mosquito traps did not yield any human-biting species.

Although the patient’s travel dates made acquisition in Portugal highly unlikely, we notified authorities in that country using its National International Health Regulations Focal Point in accordance with the World Health Organization International Health Regulations (2005) ( 11 ). The Portugal authorities have reported no recent imported or autochthonous cases of tularemia. European Centre for Disease Prevention and Control tick surveillance data show that both I. ricinus and D. reticulatus ticks are present in southern Portugal ( 3 , 4 ). A surveillance study project conducted in northern Portugal detected F. tularensis DNA in 1 human and 1 tick ( 5 ). Both imported ( 6 ) and autochthonous ( 7 ) cases of tularemia have been described in Portugal, although the autochthonous case was diagnosed by agglutination testing only. If the patient did acquire the infection in Portugal, the incubation period would have been substantially longer than usual because he returned from Portugal 47 days before symptom onset ( 8 ). The longest incubation period reported is 43 days in 1 case report ( 9 ).

Several hypotheses have been proposed and investigated to explain the transmission route for the case-patient. Whereas acquisition in Portugal was a possibility, the unusually long incubation period and reported local absence of F. tularensis in both humans and wildlife makes that scenario unlikely. Similarly, the patient was unlikely to have acquired the infection from his companion animals given the timelines and negative testing of the animals. We cannot rule out acquisition within the United Kingdom, potentially from an as-yet unidentified environmental reservoir, with the possibility that it was transmitted by a biting arthropod. Following antimicrobial treatment, the patient’s systemic symptoms resolved. The lymph nodes ceased suppurating but remained enlarged, although without pain.

Conclusions

UKHSA issued a briefing note ( 10 ) to inform clinicians of the possible presence of F. tularensis in the United Kingdom. Passive surveillance for reports of wildlife dieoffs in the area will continue, and the nature reserve will be incorporated into a nationwide mosquito surveillance project. F. tularensis testing will be conducted on ticks collected as part of ongoing surveillance and research.

This multidisciplinary investigation demonstrates the difficulties of establishing the origin of a cryptic infection. Clinicians should be aware of tularemia and consider it in differential diagnoses of patients with compatible clinical syndromes, even in the absence of a recent relevant history of travel.

Dr. Thompson is an infectious diseases and medical microbiology trainee in the United Kingdom, currently working at the UK Health Security Agency’s Rare and Imported Pathogens Laboratory, Porton Down. Clinical interests include leptospirosis, imported infection, and tuberculosis.

Acknowledgment

Many thanks to the other members of the investigating team: Jane Osborne, Richard Vipond, Clare Warrell, Daniel Bailey, Wendi Shepherd, Zoe Gibney, Eva Emanuel, Shivaj Bhardwaj, Elizabeth Stratford, Adrienne Mackintosh, Paul Holmes, Megan Rawlins, and Susannah Penney.

• Versage  JL , Severin  DD , Chu  MC , Petersen  JM . Development of a multitarget real-time TaqMan PCR assay for enhanced detection of Francisella tularensis in complex specimens. J Clin Microbiol . 2003 ; 41 : 5492 – 9 . DOI PubMed Google Scholar
• Hansford  KM , Gandy  SL , Gillingham  EL , McGinley  L , Cull  B , Johnston  C , et al. Mapping and monitoring tick (Acari, Ixodida) distribution, seasonality, and host associations in the United Kingdom between 2017 and 2020. Med Vet Entomol . 2023 ; 37 : 152 – 63 . DOI PubMed Google Scholar
• European Centre for Disease Prevention and Control . Ixodes ricinus —current known distribution: October 2023 [ cited 2023 Dec 8 ]. https://www.ecdc.europa.eu/en/publications-data/ixodes-ricinus-current-known-distribution-october-2023
• European Centre for Disease Prevention and Control . Dermacentor reticulatus —current known distribution: October 2023 [ cited 2023 Dec 8 ]. https://www.ecdc.europa.eu/en/publications-data/dermacentor-reticulatus-current-known-distribution-october-2023
• de Carvalho  IL , Escudero  R , Garcia-Amil  C , Falcão  H , Anda  P , Núncio  MS . Francisella tularensis , Portugal. Emerg Infect Dis . 2007 ; 13 : 666 – 7 . DOI PubMed Google Scholar
• Lopes de Carvalho  I , Nascimento  P , Núncio  MS , Toscano Rico  M . First case of tularemia reported in Portugal: probably of imported origin. Front Public Health . 2018 ; 6 : 325 . DOI PubMed Google Scholar
• Cunha  F , Lopes de Carvalho  I , Torres  C , Gonçalves  R . A multidisciplinary approach to the first autochthonous case of tularemia reported in Portugal. Acta Med Port. 2022 ;35. PubMed Google Scholar
• Maurin  M , Gyuranecz  M . Tularaemia: clinical aspects in Europe. Lancet Infect Dis . 2016 ; 16 : 113 – 24 . DOI PubMed Google Scholar
• Darmon-Curti  A , Darmon  F , Edouard  S , Hennebique  A , Guimard  T , Martin-Blondel  G , et al. Tularemia: a case series of patients diagnosed at the National Reference Center for Rickettsioses from 2008 to 2017. Open Forum Infect Dis. 2020 ;7:ofaa440. PubMed Google Scholar
• UK Health Security Agency . UKHSA Briefing Note 2023/038. Changing epidemiology of zoonotic and vector borne infections. 2023 .
• World Health Organization . International Health Regulations. 3rd edition. Geneva: The Organization; 2005 .

Suggested citation for this article : Thompson A, Brooks T, Houlihan C, Rampling T, Umpleby H, Hansford K, et al. Investigation of a human case of Francisella tularensis infection, United Kingdom, 2023. Emerg Infect Dis. 2024 Oct [ date cited ]. https://doi.org/10.3201/eid3010.240479

DOI: 10.3201/eid3010.240479

Original Publication Date: September 18, 2024

Table of Contents – Volume 30, Number 10—October 2024

Please use the form below to submit correspondence to the authors or contact them at the following address:

Ameeka Thompson, Rare and Imported Pathogens Laboratory, UK Health Security Agency, Manor Farm Road, Porton Down, Salisbury SP40JG, UK;
email: [email protected]

Comment submitted successfully, thank you for your feedback.

There was an unexpected error. Message not sent.

Metric Details

Article views: 97.

Data is collected weekly and does not include downloads and attachments. View data is from .

What is the Altmetric Attention Score?

The Altmetric Attention Score for a research output provides an indicator of the amount of attention that it has received. The score is derived from an automated algorithm, and represents a weighted count of the amount of attention Altmetric picked up for a research output.