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Case Study – Methods, Examples and Guide

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

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

Types of Case Study

Types and Methods of Case Study are as follows:

Single-Case Study

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

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

Multiple-Case Study

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

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

Exploratory Case Study

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

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

Descriptive Case Study

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

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

Instrumental Case Study

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

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

Case Study Data Collection Methods

Here are some common data collection methods for case studies:

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

Observations

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

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

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

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

How to conduct Case Study Research

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

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

Examples of Case Study

Here are some examples of case study research:

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

Application of Case Study

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

Business and Management

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

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

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

Social Sciences

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

Law and Ethics

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

Purpose of Case Study

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

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

Case studies can also serve other purposes, including:

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

Advantages of Case Study Research

There are several advantages of case study research, including:

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

Limitations of Case Study Research

There are several limitations of case study research, including:

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

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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.

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

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

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

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

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

Research question

• Conceptual framework
• Conceptual vs. theoretical framework

Data collection

• Qualitative research methods
• Focus groups
• Observational research

What is a case study?

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

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

Case studies

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

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

Definition of a case study

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

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

Characteristics of case studies

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

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

The role of case studies in research

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

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

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

What is the purpose of a case study?

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

Why use case studies in qualitative research?

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

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

The explanatory, exploratory, and descriptive roles of case studies

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

The impact of case studies on knowledge development

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

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

Types of case studies

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

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

Exploratory case studies

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

Descriptive case studies

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

Explanatory case studies

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

Intrinsic, instrumental, and collective case studies

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

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

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

Critical information systems research

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

Health research

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

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

Asthma research studies

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

Other fields

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

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

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

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

Propositions

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

Units of analysis

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

Argumentation

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

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

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

Defining the research question

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

Selecting and defining the case

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

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

Developing a detailed case study protocol

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

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

Collecting data

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

Analyzing and interpreting data

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

Writing the case study report

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

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

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

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

Observations

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

Documents and artifacts

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

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

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

Ensuring the quality of data collection

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

Data analysis

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

Organizing the data

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

Categorizing and coding the data

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

Identifying patterns and themes

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

Interpreting the data

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

Verification of the data

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

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

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

Benefits include the following:

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

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

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

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

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Research Writing and Analysis

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• Step 2: Explain
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Writing a Case Study

What is a case study?

A Case study is: 

• An in-depth research design that primarily uses a qualitative methodology but sometimes​​ includes quantitative methodology.
• Used to examine an identifiable problem confirmed through research.
• Used to investigate an individual, group of people, organization, or event.
• Used to mostly answer "how" and "why" questions.

What are the different types of case studies?

Note: These are the primary case studies. As you continue to research and learn

about case studies you will begin to find a robust list of different types. 

Who are your case study participants?

What is triangulation ? 

Validity and credibility are an essential part of the case study. Therefore, the researcher should include triangulation to ensure trustworthiness while accurately reflecting what the researcher seeks to investigate.

How to write a Case Study?

When developing a case study, there are different ways you could present the information, but remember to include the five parts for your case study.

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Qualitative study design: Case Studies

• Qualitative study design
• Phenomenology
• Grounded theory
• Ethnography
• Narrative inquiry
• Action research

Case Studies

• Field research
• Focus groups
• Observation
• Surveys & questionnaires
• Study Designs Home

In depth description of the experience of a single person, a family, a group, a community or an organisation.

An example of a qualitative case study is a life history which is the story of one specific person.  A case study may be done to highlight a specific issue by telling a story of one person or one group. 

• Oral recording

Ability to explore and describe, in depth, an issue or event. 

Develop an understanding of health, illness and health care in context. 

Single case can be used to develop or disprove a theory. 

Can be used as a model or prototype .  

Limitations

Labour intensive and generates large diverse data sets which can be hard to manage. 

Case studies are seen by many as a weak methodology because they only look at one person or one specific group and aren’t as broad in their participant selection as other methodologies. 

Example questions

This methodology can be used to ask questions about a specific drug or treatment and its effects on an individual.

• Does thalidomide cause birth defects?
• Does exposure to a pesticide lead to cancer?

Example studies

• Choi, T. S. T., Walker, K. Z., & Palermo, C. (2018). Diabetes management in a foreign land: A case study on Chinese Australians. Health & Social Care in the Community, 26(2), e225-e232. 
• Reade, I., Rodgers, W., & Spriggs, K. (2008). New Ideas for High Performance Coaches: A Case Study of Knowledge Transfer in Sport Science.  International Journal of Sports Science & Coaching , 3(3), 335-354. 
• Wingrove, K., Barbour, L., & Palermo, C. (2017). Exploring nutrition capacity in Australia's charitable food sector.  Nutrition & Dietetics , 74(5), 495-501. 
• Green, J., & Thorogood, N. (2018). Qualitative methods for health research (4th ed.). London: SAGE. 
• University of Missouri-St. Louis. Qualitative Research Designs. Retrieved from http://www.umsl.edu/~lindquists/qualdsgn.html     
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• Open access
• Published: 27 June 2011

The case study approach

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

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

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

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Introduction

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

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

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

What is a case study?

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

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

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

What are case studies used for?

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

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

How are case studies conducted?

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

Defining the case

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

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

Selecting the case(s)

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

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

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

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

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

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

Collecting the data

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

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

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

Analysing, interpreting and reporting case studies

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

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

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

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

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

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

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

Conclusions

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

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Acknowledgements

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

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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

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Correspondence to Sarah Crowe .

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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.

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

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Received : 29 November 2010

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

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22 Case Study Research: In-Depth Understanding in Context

Helen Simons, School of Education, University of Southampton

• Published: 01 July 2014
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This chapter explores case study as a major approach to research and evaluation. After first noting various contexts in which case studies are commonly used, the chapter focuses on case study research directly Strengths and potential problematic issues are outlined and then key phases of the process. The chapter emphasizes how important it is to design the case, to collect and interpret data in ways that highlight the qualitative, to have an ethical practice that values multiple perspectives and political interests, and to report creatively to facilitate use in policy making and practice. Finally, it explores how to generalize from the single case. Concluding questions center on the need to think more imaginatively about design and the range of methods and forms of reporting requiredto persuade audiences to value qualitative ways of knowing in case study research.

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What is case study research?

Last updated

8 February 2023

Reviewed by

Cathy Heath

Short on time? Get an AI generated summary of this article instead

Suppose a company receives a spike in the number of customer complaints, or medical experts discover an outbreak of illness affecting children but are not quite sure of the reason. In both cases, carrying out a case study could be the best way to get answers.

Organization

Case studies can be carried out across different disciplines, including education, medicine, sociology, and business.

Most case studies employ qualitative methods, but quantitative methods can also be used. Researchers can then describe, compare, evaluate, and identify patterns or cause-and-effect relationships between the various variables under study. They can then use this knowledge to decide what action to take. 

Another thing to note is that case studies are generally singular in their focus. This means they narrow focus to a particular area, making them highly subjective. You cannot always generalize the results of a case study and apply them to a larger population. However, they are valuable tools to illustrate a principle or develop a thesis.

Analyze case study research

Dovetail streamlines case study research to help you uncover and share actionable insights

• What are the different types of case study designs?

Researchers can choose from a variety of case study designs. The design they choose is dependent on what questions they need to answer, the context of the research environment, how much data they already have, and what resources are available.

Here are the common types of case study design:

Explanatory

An explanatory case study is an initial explanation of the how or why that is behind something. This design is commonly used when studying a real-life phenomenon or event. Once the organization understands the reasons behind a phenomenon, it can then make changes to enhance or eliminate the variables causing it. 

Here is an example: How is co-teaching implemented in elementary schools? The title for a case study of this subject could be “Case Study of the Implementation of Co-Teaching in Elementary Schools.”

Descriptive

An illustrative or descriptive case study helps researchers shed light on an unfamiliar object or subject after a period of time. The case study provides an in-depth review of the issue at hand and adds real-world examples in the area the researcher wants the audience to understand. 

The researcher makes no inferences or causal statements about the object or subject under review. This type of design is often used to understand cultural shifts.

Here is an example: How did people cope with the 2004 Indian Ocean Tsunami? This case study could be titled "A Case Study of the 2004 Indian Ocean Tsunami and its Effect on the Indonesian Population."

Exploratory

Exploratory research is also called a pilot case study. It is usually the first step within a larger research project, often relying on questionnaires and surveys . Researchers use exploratory research to help narrow down their focus, define parameters, draft a specific research question , and/or identify variables in a larger study. This research design usually covers a wider area than others, and focuses on the ‘what’ and ‘who’ of a topic.

Here is an example: How do nutrition and socialization in early childhood affect learning in children? The title of the exploratory study may be “Case Study of the Effects of Nutrition and Socialization on Learning in Early Childhood.”

An intrinsic case study is specifically designed to look at a unique and special phenomenon. At the start of the study, the researcher defines the phenomenon and the uniqueness that differentiates it from others. 

In this case, researchers do not attempt to generalize, compare, or challenge the existing assumptions. Instead, they explore the unique variables to enhance understanding. Here is an example: “Case Study of Volcanic Lightning.”

This design can also be identified as a cumulative case study. It uses information from past studies or observations of groups of people in certain settings as the foundation of the new study. Given that it takes multiple areas into account, it allows for greater generalization than a single case study. 

The researchers also get an in-depth look at a particular subject from different viewpoints.  Here is an example: “Case Study of how PTSD affected Vietnam and Gulf War Veterans Differently Due to Advances in Military Technology.”

Critical instance

A critical case study incorporates both explanatory and intrinsic study designs. It does not have predetermined purposes beyond an investigation of the said subject. It can be used for a deeper explanation of the cause-and-effect relationship. It can also be used to question a common assumption or myth. 

The findings can then be used further to generalize whether they would also apply in a different environment.  Here is an example: “What Effect Does Prolonged Use of Social Media Have on the Mind of American Youth?”

Instrumental

Instrumental research attempts to achieve goals beyond understanding the object at hand. Researchers explore a larger subject through different, separate studies and use the findings to understand its relationship to another subject. This type of design also provides insight into an issue or helps refine a theory. 

For example, you may want to determine if violent behavior in children predisposes them to crime later in life. The focus is on the relationship between children and violent behavior, and why certain children do become violent. Here is an example: “Violence Breeds Violence: Childhood Exposure and Participation in Adult Crime.”

Evaluation case study design is employed to research the effects of a program, policy, or intervention, and assess its effectiveness and impact on future decision-making. 

For example, you might want to see whether children learn times tables quicker through an educational game on their iPad versus a more teacher-led intervention. Here is an example: “An Investigation of the Impact of an iPad Multiplication Game for Primary School Children.” 

• When do you use case studies?

Case studies are ideal when you want to gain a contextual, concrete, or in-depth understanding of a particular subject. It helps you understand the characteristics, implications, and meanings of the subject.

They are also an excellent choice for those writing a thesis or dissertation, as they help keep the project focused on a particular area when resources or time may be too limited to cover a wider one. You may have to conduct several case studies to explore different aspects of the subject in question and understand the problem.

• What are the steps to follow when conducting a case study?

1. Select a case

Once you identify the problem at hand and come up with questions, identify the case you will focus on. The study can provide insights into the subject at hand, challenge existing assumptions, propose a course of action, and/or open up new areas for further research.

2. Create a theoretical framework

While you will be focusing on a specific detail, the case study design you choose should be linked to existing knowledge on the topic. This prevents it from becoming an isolated description and allows for enhancing the existing information. 

It may expand the current theory by bringing up new ideas or concepts, challenge established assumptions, or exemplify a theory by exploring how it answers the problem at hand. A theoretical framework starts with a literature review of the sources relevant to the topic in focus. This helps in identifying key concepts to guide analysis and interpretation.

3. Collect the data

Case studies are frequently supplemented with qualitative data such as observations, interviews, and a review of both primary and secondary sources such as official records, news articles, and photographs. There may also be quantitative data —this data assists in understanding the case thoroughly.

4. Analyze your case

The results of the research depend on the research design. Most case studies are structured with chapters or topic headings for easy explanation and presentation. Others may be written as narratives to allow researchers to explore various angles of the topic and analyze its meanings and implications.

In all areas, always give a detailed contextual understanding of the case and connect it to the existing theory and literature before discussing how it fits into your problem area.

• What are some case study examples?

What are the best approaches for introducing our product into the Kenyan market?

How does the change in marketing strategy aid in increasing the sales volumes of product Y?

How can teachers enhance student participation in classrooms?

How does poverty affect literacy levels in children?

Case study topics

Case study of product marketing strategies in the Kenyan market

Case study of the effects of a marketing strategy change on product Y sales volumes

Case study of X school teachers that encourage active student participation in the classroom

Case study of the effects of poverty on literacy levels in children

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From: http://www.emeraldgrouppublishing.com/products/case_studies/index.htm

What is a case study?

• Attempts to shed light on a phenomena by studying a single case example.
• Focuses on an individual person, an event, a group, or an institution.
• Allows for in-depth examination by prolonged engagement or cultural immersion
• Explores processes and outcomes
• Investigates the context and setting of a situation
• Can involve a number of data gathering methods

Duke Resources

• Philanthropy Central from Sanford School of Public Policy Case Study Database Provides real-life case studies of philanthropic initiatives. There are currently more than 600 case studies linked to in the Database.

Suggested Readings

• McNabb, D. (2010).  Case reseach in public management.  NY: M.E.Sharpe.
• Samuels, D. (2013).  Case studies in comparative politics .  NY: Pearson Education.
• Stark, R. (1995). The  art of case study research, Thousand Oaks: Sage.
• Yin, R.K. (2009) Case study research: Design and methods. Los Angeles: Sage.
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• Last Updated: Mar 1, 2024 10:13 AM
• URL: https://guides.library.duke.edu/qualitative-research

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• Volume 21, Issue 1
• What is a case study?
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• Roberta Heale 1 ,
• Alison Twycross 2
• 1 School of Nursing , Laurentian University , Sudbury , Ontario , Canada
• 2 School of Health and Social Care , London South Bank University , London , UK
• Correspondence to Dr Roberta Heale, School of Nursing, Laurentian University, Sudbury, ON P3E2C6, Canada; rheale{at}laurentian.ca

https://doi.org/10.1136/eb-2017-102845

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What is it?

Case study is a research methodology, typically seen in social and life sciences. There is no one definition of case study research. 1 However, very simply… ‘a case study can be defined as an intensive study about a person, a group of people or a unit, which is aimed to generalize over several units’. 1 A case study has also been described as an intensive, systematic investigation of a single individual, group, community or some other unit in which the researcher examines in-depth data relating to several variables. 2

Often there are several similar cases to consider such as educational or social service programmes that are delivered from a number of locations. Although similar, they are complex and have unique features. In these circumstances, the evaluation of several, similar cases will provide a better answer to a research question than if only one case is examined, hence the multiple-case study. Stake asserts that the cases are grouped and viewed as one entity, called the quintain . 6  ‘We study what is similar and different about the cases to understand the quintain better’. 6

The steps when using case study methodology are the same as for other types of research. 6 The first step is defining the single case or identifying a group of similar cases that can then be incorporated into a multiple-case study. A search to determine what is known about the case(s) is typically conducted. This may include a review of the literature, grey literature, media, reports and more, which serves to establish a basic understanding of the cases and informs the development of research questions. Data in case studies are often, but not exclusively, qualitative in nature. In multiple-case studies, analysis within cases and across cases is conducted. Themes arise from the analyses and assertions about the cases as a whole, or the quintain, emerge. 6

Benefits and limitations of case studies

If a researcher wants to study a specific phenomenon arising from a particular entity, then a single-case study is warranted and will allow for a in-depth understanding of the single phenomenon and, as discussed above, would involve collecting several different types of data. This is illustrated in example 1 below.

Using a multiple-case research study allows for a more in-depth understanding of the cases as a unit, through comparison of similarities and differences of the individual cases embedded within the quintain. Evidence arising from multiple-case studies is often stronger and more reliable than from single-case research. Multiple-case studies allow for more comprehensive exploration of research questions and theory development. 6

Despite the advantages of case studies, there are limitations. The sheer volume of data is difficult to organise and data analysis and integration strategies need to be carefully thought through. There is also sometimes a temptation to veer away from the research focus. 2 Reporting of findings from multiple-case research studies is also challenging at times, 1 particularly in relation to the word limits for some journal papers.

Examples of case studies

Example 1: nurses’ paediatric pain management practices.

One of the authors of this paper (AT) has used a case study approach to explore nurses’ paediatric pain management practices. This involved collecting several datasets:

Observational data to gain a picture about actual pain management practices.

Questionnaire data about nurses’ knowledge about paediatric pain management practices and how well they felt they managed pain in children.

Questionnaire data about how critical nurses perceived pain management tasks to be.

These datasets were analysed separately and then compared 7–9 and demonstrated that nurses’ level of theoretical did not impact on the quality of their pain management practices. 7 Nor did individual nurse’s perceptions of how critical a task was effect the likelihood of them carrying out this task in practice. 8 There was also a difference in self-reported and observed practices 9 ; actual (observed) practices did not confirm to best practice guidelines, whereas self-reported practices tended to.

Example 2: quality of care for complex patients at Nurse Practitioner-Led Clinics (NPLCs)

The other author of this paper (RH) has conducted a multiple-case study to determine the quality of care for patients with complex clinical presentations in NPLCs in Ontario, Canada. 10 Five NPLCs served as individual cases that, together, represented the quatrain. Three types of data were collected including:

Review of documentation related to the NPLC model (media, annual reports, research articles, grey literature and regulatory legislation).

Interviews with nurse practitioners (NPs) practising at the five NPLCs to determine their perceptions of the impact of the NPLC model on the quality of care provided to patients with multimorbidity.

Chart audits conducted at the five NPLCs to determine the extent to which evidence-based guidelines were followed for patients with diabetes and at least one other chronic condition.

The three sources of data collected from the five NPLCs were analysed and themes arose related to the quality of care for complex patients at NPLCs. The multiple-case study confirmed that nurse practitioners are the primary care providers at the NPLCs, and this positively impacts the quality of care for patients with multimorbidity. Healthcare policy, such as lack of an increase in salary for NPs for 10 years, has resulted in issues in recruitment and retention of NPs at NPLCs. This, along with insufficient resources in the communities where NPLCs are located and high patient vulnerability at NPLCs, have a negative impact on the quality of care. 10

These examples illustrate how collecting data about a single case or multiple cases helps us to better understand the phenomenon in question. Case study methodology serves to provide a framework for evaluation and analysis of complex issues. It shines a light on the holistic nature of nursing practice and offers a perspective that informs improved patient care.

• Gustafsson J
• Calanzaro M
• Sandelowski M

Competing interests None declared.

Provenance and peer review Commissioned; internally peer reviewed.

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What is a Case Study? Definition, Research Methods, Sampling and Examples

What is a Case Study?

A case study is defined as an in-depth analysis of a particular subject, often a real-world situation, individual, group, or organization. 

It is a research method that involves the comprehensive examination of a specific instance to gain a better understanding of its complexities, dynamics, and context. 

Case studies are commonly used in various fields such as business, psychology, medicine, and education to explore and illustrate phenomena, theories, or practical applications.

In a typical case study, researchers collect and analyze a rich array of qualitative and/or quantitative data, including interviews, observations, documents, and other relevant sources. The goal is to provide a nuanced and holistic perspective on the subject under investigation.

The information gathered here is used to generate insights, draw conclusions, and often to inform broader theories or practices within the respective field.

Case studies offer a valuable method for researchers to explore real-world phenomena in their natural settings, providing an opportunity to delve deeply into the intricacies of a particular case. They are particularly useful when studying complex, multifaceted situations where various factors interact. 

Additionally, case studies can be instrumental in generating hypotheses, testing theories, and offering practical insights that can be applied to similar situations. Overall, the comprehensive nature of case studies makes them a powerful tool for gaining a thorough understanding of specific instances within the broader context of academic and professional inquiry.

Key Characteristics of Case Study

Case studies are characterized by several key features that distinguish them from other research methods. Here are some essential characteristics of case studies:

• In-depth Exploration: Case studies involve a thorough and detailed examination of a specific case or instance. Researchers aim to explore the complexities and nuances of the subject under investigation, often using multiple data sources and methods to gather comprehensive information.
• Contextual Analysis: Case studies emphasize the importance of understanding the context in which the case unfolds. Researchers seek to examine the unique circumstances, background, and environmental factors that contribute to the dynamics of the case. Contextual analysis is crucial for drawing meaningful conclusions and generalizing findings to similar situations.
• Holistic Perspective: Rather than focusing on isolated variables, case studies take a holistic approach to studying a phenomenon. Researchers consider a wide range of factors and their interrelationships, aiming to capture the richness and complexity of the case. This holistic perspective helps in providing a more complete understanding of the subject.
• Qualitative and/or Quantitative Data: Case studies can incorporate both qualitative and quantitative data, depending on the research question and objectives. Qualitative data often include interviews, observations, and document analysis, while quantitative data may involve statistical measures or numerical information. The combination of these data types enhances the depth and validity of the study.
• Longitudinal or Retrospective Design: Case studies can be designed as longitudinal studies, where the researcher follows the case over an extended period, or retrospective studies, where the focus is on examining past events. This temporal dimension allows researchers to capture changes and developments within the case.
• Unique and Unpredictable Nature: Each case study is unique, and the findings may not be easily generalized to other situations. The unpredictable nature of real-world cases adds a layer of authenticity to the study, making it an effective method for exploring complex and dynamic phenomena.
• Theory Building or Testing: Case studies can serve different purposes, including theory building or theory testing. In some cases, researchers use case studies to develop new theories or refine existing ones. In others, they may test existing theories by applying them to real-world situations and assessing their explanatory power.

Understanding these key characteristics is essential for researchers and practitioners using case studies as a methodological approach, as it helps guide the design, implementation, and analysis of the study.

Key Components of a Case Study

A well-constructed case study typically consists of several key components that collectively provide a comprehensive understanding of the subject under investigation. Here are the key components of a case study:

• Provide an overview of the context and background information relevant to the case. This may include the history, industry, or setting in which the case is situated.
• Clearly state the purpose and objectives of the case study. Define what the study aims to achieve and the questions it seeks to answer.
• Clearly identify the subject of the case study. This could be an individual, a group, an organization, or a specific event.
• Define the boundaries and scope of the case study. Specify what aspects will be included and excluded from the investigation.
• Provide a brief review of relevant theories or concepts that will guide the analysis. This helps place the case study within the broader theoretical context.
• Summarize existing literature related to the subject, highlighting key findings and gaps in knowledge. This establishes the context for the current case study.
• Describe the research design chosen for the case study (e.g., exploratory, explanatory, descriptive). Justify why this design is appropriate for the research objectives.
• Specify the methods used to gather data, whether through interviews, observations, document analysis, surveys, or a combination of these. Detail the procedures followed to ensure data validity and reliability.
• Explain the criteria for selecting the case and any sampling considerations. Discuss why the chosen case is representative or relevant to the research questions.
• Describe how the collected data will be coded and categorized. Discuss the analytical framework or approach used to identify patterns, themes, or trends.
• If multiple data sources or methods are used, explain how they complement each other to enhance the credibility and validity of the findings.
• Present the key findings in a clear and organized manner. Use tables, charts, or quotes from participants to illustrate the results.
• Interpret the results in the context of the research objectives and theoretical framework. Discuss any unexpected findings and their implications.
• Provide a thorough interpretation of the results, connecting them to the research questions and relevant literature.
• Acknowledge the limitations of the study, such as constraints in data collection, sample size, or generalizability.
• Highlight the contributions of the case study to the existing body of knowledge and identify potential avenues for future research.
• Summarize the key findings and their significance in relation to the research objectives.
• Conclude with a concise summary of the case study, its implications, and potential practical applications.
• Provide a complete list of all the sources cited in the case study, following a consistent citation style.
• Include any additional materials or supplementary information, such as interview transcripts, survey instruments, or supporting documents.

By including these key components, a case study becomes a comprehensive and well-rounded exploration of a specific subject, offering valuable insights and contributing to the body of knowledge in the respective field.

Sampling in a Case Study Research

Sampling in case study research involves selecting a subset of cases or individuals from a larger population to study in depth. Unlike quantitative research where random sampling is often employed, case study sampling is typically purposeful and driven by the specific objectives of the study. Here are some key considerations for sampling in case study research:

• Criterion Sampling: Cases are selected based on specific criteria relevant to the research questions. For example, if studying successful business strategies, cases may be selected based on their demonstrated success.
• Maximum Variation Sampling: Cases are chosen to represent a broad range of variations related to key characteristics. This approach helps capture diversity within the sample.
• Selecting Cases with Rich Information: Researchers aim to choose cases that are information-rich and provide insights into the phenomenon under investigation. These cases should offer a depth of detail and variation relevant to the research objectives.
• Single Case vs. Multiple Cases: Decide whether the study will focus on a single case (single-case study) or multiple cases (multiple-case study). The choice depends on the research objectives, the complexity of the phenomenon, and the depth of understanding required.
• Emergent Nature of Sampling: In some case studies, the sampling strategy may evolve as the study progresses. This is known as theoretical sampling, where new cases are selected based on emerging findings and theoretical insights from earlier analysis.
• Data Saturation: Sampling may continue until data saturation is achieved, meaning that collecting additional cases or data does not yield new insights or information. Saturation indicates that the researcher has adequately explored the phenomenon.
• Defining Case Boundaries: Clearly define the boundaries of the case to ensure consistency and avoid ambiguity. Consider what is included and excluded from the case study, and justify these decisions.
• Practical Considerations: Assess the feasibility of accessing the selected cases. Consider factors such as availability, willingness to participate, and the practicality of data collection methods.
• Informed Consent: Obtain informed consent from participants, ensuring that they understand the purpose of the study and the ways in which their information will be used. Protect the confidentiality and anonymity of participants as needed.
• Pilot Testing the Sampling Strategy: Before conducting the full study, consider pilot testing the sampling strategy to identify potential challenges and refine the approach. This can help ensure the effectiveness of the sampling method.
• Transparent Reporting: Clearly document the sampling process in the research methodology section. Provide a rationale for the chosen sampling strategy and discuss any adjustments made during the study.

Sampling in case study research is a critical step that influences the depth and richness of the study’s findings. By carefully selecting cases based on specific criteria and considering the unique characteristics of the phenomenon under investigation, researchers can enhance the relevance and validity of their case study.

Case Study Research Methods With Examples

• Interviews:
• Interviews involve engaging with participants to gather detailed information, opinions, and insights. In a case study, interviews are often semi-structured, allowing flexibility in questioning.
• Example: A case study on workplace culture might involve conducting interviews with employees at different levels to understand their perceptions, experiences, and attitudes.
• Observations:
• Observations entail direct examination and recording of behavior, activities, or events in their natural setting. This method is valuable for understanding behaviors in context.
• Example: A case study investigating customer interactions at a retail store may involve observing and documenting customer behavior, staff interactions, and overall dynamics.
• Document Analysis:
• Document analysis involves reviewing and interpreting written or recorded materials, such as reports, memos, emails, and other relevant documents.
• Example: In a case study on organizational change, researchers may analyze internal documents, such as communication memos or strategic plans, to trace the evolution of the change process.
• Surveys and Questionnaires:
• Surveys and questionnaires collect structured data from a sample of participants. While less common in case studies, they can be used to supplement other methods.
• Example: A case study on the impact of a health intervention might include a survey to gather quantitative data on participants’ health outcomes.
• Focus Groups:
• Focus groups involve a facilitated discussion among a group of participants to explore their perceptions, attitudes, and experiences.
• Example: In a case study on community development, a focus group might be conducted with residents to discuss their views on recent initiatives and their impact.
• Archival Research:
• Archival research involves examining existing records, historical documents, or artifacts to gain insights into a particular phenomenon.
• Example: A case study on the history of a landmark building may involve archival research, exploring construction records, historical photos, and maintenance logs.
• Longitudinal Studies:
• Longitudinal studies involve the collection of data over an extended period to observe changes and developments.
• Example: A case study tracking the career progression of employees in a company may involve longitudinal interviews and document analysis over several years.
• Cross-Case Analysis:
• Cross-case analysis compares and contrasts multiple cases to identify patterns, similarities, and differences.
• Example: A comparative case study of different educational institutions may involve analyzing common challenges and successful strategies across various cases.
• Ethnography:
• Ethnography involves immersive, in-depth exploration within a cultural or social setting to understand the behaviors and perspectives of participants.
• Example: A case study using ethnographic methods might involve spending an extended period within a community to understand its social dynamics and cultural practices.
• Experimental Designs (Rare):
• While less common, experimental designs involve manipulating variables to observe their effects. In case studies, this might be applied in specific contexts.
• Example: A case study exploring the impact of a new teaching method might involve implementing the method in one classroom while comparing it to a traditional method in another.

These case study research methods offer a versatile toolkit for researchers to investigate and gain insights into complex phenomena across various disciplines. The choice of methods depends on the research questions, the nature of the case, and the desired depth of understanding.

Best Practices for a Case Study in 2024

Creating a high-quality case study involves adhering to best practices that ensure rigor, relevance, and credibility. Here are some key best practices for conducting and presenting a case study:

• Clearly articulate the purpose and objectives of the case study. Define the research questions or problems you aim to address, ensuring a focused and purposeful approach.
• Choose a case that aligns with the research objectives and provides the depth and richness needed for the study. Consider the uniqueness of the case and its relevance to the research questions.
• Develop a robust research design that aligns with the nature of the case study (single-case or multiple-case) and integrates appropriate research methods. Ensure the chosen design is suitable for exploring the complexities of the phenomenon.
• Use a variety of data sources to enhance the validity and reliability of the study. Combine methods such as interviews, observations, document analysis, and surveys to provide a comprehensive understanding of the case.
• Clearly document and describe the procedures for data collection to enhance transparency. Include details on participant selection, sampling strategy, and data collection methods to facilitate replication and evaluation.
• Implement measures to ensure the validity and reliability of the data. Triangulate information from different sources to cross-verify findings and strengthen the credibility of the study.
• Clearly define the boundaries of the case to avoid scope creep and maintain focus. Specify what is included and excluded from the study, providing a clear framework for analysis.
• Include perspectives from various stakeholders within the case to capture a holistic view. This might involve interviewing individuals at different organizational levels, customers, or community members, depending on the context.
• Adhere to ethical principles in research, including obtaining informed consent from participants, ensuring confidentiality, and addressing any potential conflicts of interest.
• Conduct a rigorous analysis of the data, using appropriate analytical techniques. Interpret the findings in the context of the research questions, theoretical framework, and relevant literature.
• Offer detailed and rich descriptions of the case, including the context, key events, and participant perspectives. This helps readers understand the intricacies of the case and supports the generalization of findings.
• Communicate findings in a clear and accessible manner. Avoid jargon and technical language that may hinder understanding. Use visuals, such as charts or graphs, to enhance clarity.
• Seek feedback from colleagues or experts in the field through peer review. This helps ensure the rigor and credibility of the case study and provides valuable insights for improvement.
• Connect the case study findings to existing theories or concepts, contributing to the theoretical understanding of the phenomenon. Discuss practical implications and potential applications in relevant contexts.
• Recognize that case study research is often an iterative process. Be open to revisiting and refining research questions, methods, or analysis as the study progresses. Practice reflexivity by acknowledging and addressing potential biases or preconceptions.

By incorporating these best practices, researchers can enhance the quality and impact of their case studies, making valuable contributions to the academic and practical understanding of complex phenomena.

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Investigating the effectiveness of endogenous and exogenous drivers of the sustainability (re)orientation of family smes in slovenia: qualitative content analysis approach.

1. Introduction

2. literature review, 2.1. legal framework on sustainable corporate governance (with a focus on smes), 2.1.1. corporate sustainability reporting directive, 2.1.2. corporate sustainability due diligence directive, 2.1.3. scope of the csddd for smes, 2.2. drivers of the family businesses’ (re)orientation towards sustainability, 2.3. endogenous drivers, 2.3.1. the protection of sew, 2.3.2. ownership and management composition, 2.3.3. values, beliefs and attitudes of family owner-managers, 2.3.4. transgenerational continuity and long-term orientation, 2.3.5. knowledge of sustainability, 2.4. exogenous drivers, 2.4.1. stakeholders pressure, 2.4.2. the impact of institutional environment and local communities, 3. empirical research, 3.1. institutional context of slovenia, 3.2. research method, 3.3. sampling and data collection, 3.4. data analysis, 4.1. results of the final coding of the family businesses’ sustainability (re)orientation, 4.2. references to responsibility, preserving (natural) environment and sustainability/sustainable development in the analysed statements, 4.3. family businesses with a higher level of sustainability awareness and orientation, 5. discussion, 5.1. sustainability awareness and readiness of investigated family smes to comply with the new eu legal framework, 5.2. the effectiveness of endogenous and exogenous drivers of family businesses’ sustainability (re)orientation, 6. conclusions, author contributions, institutional review board statement, informed consent statement, data availability statement, conflicts of interest.

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Share and Cite

Duh, M.; Primec, A. Investigating the Effectiveness of Endogenous and Exogenous Drivers of the Sustainability (Re)Orientation of Family SMEs in Slovenia: Qualitative Content Analysis Approach. Sustainability 2024 , 16 , 7285. https://doi.org/10.3390/su16177285

Duh M, Primec A. Investigating the Effectiveness of Endogenous and Exogenous Drivers of the Sustainability (Re)Orientation of Family SMEs in Slovenia: Qualitative Content Analysis Approach. Sustainability . 2024; 16(17):7285. https://doi.org/10.3390/su16177285

Duh, Mojca, and Andreja Primec. 2024. "Investigating the Effectiveness of Endogenous and Exogenous Drivers of the Sustainability (Re)Orientation of Family SMEs in Slovenia: Qualitative Content Analysis Approach" Sustainability 16, no. 17: 7285. https://doi.org/10.3390/su16177285

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• Open access
• Published: 28 August 2024

How does online postal self-sampling (OPSS) shape access to testing for sexually transmitted infections (STIs)? A qualitative study of service users

• Tommer Spence 1 ,
• Alison Howarth 2 ,
• David Reid 2 ,
• Jessica Sheringham 1 ,
• Vanessa Apea 3 ,
• David Crundwell 4 ,
• Sara Day 5 ,
• Claire Dewsnap 6 ,
• Louise Jackson 7 ,
• Catherine H. Mercer 2 ,
• Hamish Mohammed 8 ,
• Jonathan D. C. Ross 9 ,
• Ann Sullivan 5 ,
• Andy Williams 3 ,
• Andrew Winter 10 ,
• Geoff Wong 11 ,
• Fiona Burns 2   na1 &
• Jo Gibbs 2   na1  

BMC Public Health volume  24 , Article number:  2339 ( 2024 ) Cite this article

Metrics details

Sexually transmitted infections (STIs) are a serious public health issue in many countries. Online postal self-sampling (OPSS) is increasingly used to test for STIs, a trend accelerated by the COVID-19 pandemic. There remains limited understanding of how service users experience OPSS and what leads them to access it over clinic-based services, or vice versa. This research seeks to address these gaps, by undertaking a large qualitative study which sits within the ASSIST study, a mixed-methods, realist evaluation of OPSS.

Participants were recruited via clinic-based and online sexual health services in three case study areas in England. Purposive sampling was used to over-represent populations disproportionately affected by poor sexual health: young people; people of colour; men who have sex with men; and trans and non-binary people. Semi-structured interviews were analysed using Levesque’s conceptual framework of access to healthcare.

We interviewed 100 service users. Participants typically became aware of OPSS from sexual health services, the internet or word of mouth. Acceptability of OPSS was facilitated by the perceived privacy it offered over clinic-based services, which some participants found embarrassing to access. OPSS also enabled participants to overcome barriers to reaching clinic-based services, such as a lack of appointment availability, although difficulty obtaining OPSS kits in some areas undermined this. As all services in our case study areas were free to use, affordability did not significantly shape access, although OPSS enabled some participants to avoid costs associated with travelling to clinic-based services. Participants were usually able to engage with OPSS, finding it easy to use and reliable, although blood self-sampling was challenging for most. Participants valued the support offered by clinic-based services beyond STI testing, including the opportunity to access contraception or ask staff questions, and felt this was more appropriate when they had specific concerns about their sexual health, such as STI symptoms.

Conclusions

Our findings constitute one of the largest qualitative studies to have explored OPSS and offer valuable insights to providers. OPSS shapes access to STI testing in a number of ways, including facilitating access in many circumstances, but users also want to retain access to clinic-based services, particularly for when they believe they need support beyond STI testing.

Peer Review reports

Sexually transmitted infections (STIs) are a serious public health issue in many countries [ 1 ]. In England, diagnoses of chlamydia – the most common STI – are now stable, but syphilis and gonorrhoea diagnoses reached record levels in 2023 [ 2 ]. STIs in England are distributed inequitably across the population, with men who have sex with men (MSM), black ethnic minorities and young people aged 15–24 being disproportionately affected [ 2 ].

STI testing is crucial to enabling treatment and limiting onward infection [ 3 ]. Over the past decade, online postal self-sampling (OPSS) has emerged as an alternative to testing in sexual health clinics and other clinic-based settings. OPSS allows users to order a kit online, collect their own samples, post them to a laboratory for testing and receive results remotely [ 4 ]. Accelerated by the COVID-19 pandemic, when access to clinic-based services was restricted, usage of OPSS for chlamydia testing by young women aged 15–24 in England increased from 16% in 2018 to 43% in 2023 [ 2 , 5 ]. This transition has occurred in the context of a wider effort to digitise healthcare, which has included a national recommendation that sexual health services in England provide OPSS [ 6 ]. OPSS services have also been introduced, and demonstrated strong uptake, in other high-income countries [ 7 , 8 , 9 ].

Despite this increase in usage, there remains limited understanding of what leads service users to access OPSS over clinic-based services, or vice versa. Uptake of OPSS has been found to be significantly higher among some population groups – such as heterosexual women, white people, MSM and those living in less deprived areas – than others [ 4 ]. Populations with lower uptake include black ethnic minorities and teenagers, both of whom experience high incidence of STIs. If populations which have lower uptake of OPSS also face barriers to accessing clinic-based services, then this could be leading to widening of health inequalities and increasing unmet need. Poor return rates for OPSS kits are also a cause for concern, with 52% of kits ordered from some services not being returned [ 10 ]. This is socially patterned, with heterosexual men and those living in deprived areas the least likely to use kits they have received [ 11 ]. There is wider evidence of certain populations being excluded by the shift towards digital healthcare, including some people with disabilities and those with fewer socioeconomic resources [ 12 , 13 ].

Access to healthcare is viewed by Levesque et al. [ 14 ] as “the possibility to identify healthcare needs , to seek healthcare services , to reach the healthcare resources , to obtain or use health care services , and to actually be offered services appropriate to the needs for care” . As set out in Fig.  1 , they theorise that the ability of service users to progress through these stages of access is influenced by five dimensions of healthcare services: approachability; acceptability; availability; affordability; and appropriateness. Each of these dimensions corresponds with a parallel dimension of service user ability: ability to perceive; ability to seek; ability to reach; ability to pay; and ability to engage. This widely-used framework – which informed the design of our research – centres the perceptions and experiences of service users and allows facilitators and barriers to be explored, with a focus on socioeconomic determinants [ 15 ].

Conceptual framework of access to healthcare by Levesque et al. [ 14 ]

Existing research on access to STI testing within the context of OPSS is limited, with much of the literature exploring OPSS focusing exclusively on uptake [ 4 ]. Although several surveys have found high levels of acceptability of OPSS, these typically explore only the views of users who have successfully completed an OPSS pathway and are therefore affected by responder bias [ 7 , 16 , 17 , 18 , 19 ]. They are also limited in how far they explore nuances in experiences. Qualitative research, which is well positioned to explore those nuances, has found that OPSS is acceptable to many people, in large part due to its perceived convenience and anonymity, but that many also have concerns around test accuracy, a lack of support when receiving results and inferior care compared to clinic-based testing [ 20 ]. Very few studies, however, have explored the experiences of users and those that have typically have small samples, or focus on a specific population or component of the OPSS pathway [ 20 , 21 , 22 ]. It is therefore challenging to know the applicability of these findings to other contexts and to understand divergent views.

This study seeks to address this gap by qualitatively exploring experiences of OPSS, alongside other sexual health services, and how this influences service users’ decisions on how they access STI testing. Unlike previous research, it explores OPSS in three case study areas, with large samples in each, allowing comparison of perceptions and experiences in different contexts. It also explores users’ previous experiences of sexual health services in considerable depth, giving insight into their routes to different services, and their experiences of the entire OPSS pathway. This includes access to care in clinic-based services, when participants were directed to these following the completion of STI testing.

This research formed part of the ASSIST study, a mixed-methods, realist evaluation of the implementation and impact of OPSS [ 23 ]. One of the study’s objectives was to understand the impact of OPSS on access to care and the service user experience.

ASSIST evaluated OPSS in three case study areas, labelled CSA1, CSA2 and CSA3 for anonymity. Although distinct in many ways, all three areas are urban and were selected in part because of their highly diverse populations, in terms of socioeconomic status, ethnicity, age and LGBTQ + identity. Each has a unique delivery model for sexual health services, including OPSS, which was launched at different times in each area. CSA1 operates OPSS, alongside a number of clinics, as part of an integrated sexual health service, which in England describes services set up to address most sexual health needs, including contraception, HIV pre-exposure prophylaxis (PrEP) and STI testing and treatment [ 6 ]. CSA2 operates OPSS as a standalone service, outsourced to a private sector partner. It is commissioned separately from, but works in partnership with, clinic-based integrated sexual health services across the city; two of these clinic-based services were selected as sites for this research, due to their high representation of populations of interest to this study. CSA3 delivers STI testing as part of a non-integrated sexual health service, with most contraceptive services in the area delivered separately and OPSS outsourced to a private sector partner. An overview of service provision in each area is provided in Table  1 . OPSS and other STI testing is available free at the point of use to residents in all three areas.

Sampling and recruitment

We aimed to recruit 30–45 participants per case study area and used a purposive sampling strategy to ensure participant demographics over-represented populations which disproportionately experience poor sexual health. Our quotas for each case study area were: 3–5 MSM; 7–10 people from ethnic minority backgrounds; 14–20 people under the age of 25; and 3–5 trans or non-binary people. We sought to include equal numbers of men and women, irrespective of whether they identified as trans. We also purposively sampled people who had used either one or both of OPSS and clinic-based services, as well as those who had received an STI diagnosis from OPSS, in order to gain insight into this aspect of the user journey. All participants were required to be 16 years or over, to speak English and to have accessed online or clinic-based sexual health services within the past 12 months, in the three case study areas.

Participants were recruited via OPSS or in sexual health clinics between December 2021 and February 2023. OPSS users saw a link on the landing page of the service website or at the end of the OPSS kit request form, which invited them to express interest in the research. Clinic users saw recruitment posters or were approached by clinic staff. Potential participants were screened according to their age; gender; ethnicity; sexual orientation; and previous use of sexual health services. Potential participants who fulfilled quota requirements were contacted by TS or DR, who explained the study and arranged a time for interview if they were interested in participating. Participants completed an online consent form ahead of the interview and consent was confirmed again verbally at the start.

Data collection

Data were collected via semi-structured interviews which explored participants’ use of the internet and online health services, their previous experiences of sexual health services (including, but not limited to, STI testing), their perceptions or experiences of the entire OPSS pathway (including ordering a kit, receiving and using it, returning it, receiving results and accessing treatment) and their perspectives on the appropriateness of different STI testing services in various contexts. The interview topic guide is provided as Supplementary Material 1. Participants had the choice of conducting their interview by phone, MS Teams or in person. They all received a £30 shopping voucher for participating. Interviews were conducted by TS, DR and AH, all of whom are professional researchers.

Data analysis

Interviews were audio recorded and transcribed verbatim. The transcripts were reviewed for accuracy and to gain familiarity, before being pseudonymised, uploaded to NVivo software and coded using an inductive-deductive approach. This began with TS developing codes from the initial programme theory (IPT), developed by the research team as part of the wider realist evaluation, which hypothesised how service users would access and experience OPSS based on prior literature and clinician perspectives [ 23 ]. The IPT was developed from an initial logic model postulated by the research team before the study began (Supplementary Material 2), which set out to explain the introduction and impact of OPSS. It assumed that service users would perceive OPSS as: easy to find and access; convenient; easy to use and fitting in with 21st century life; providing privacy and minimising embarrassment or judgement by others; as ‘good’ a service as clinic-based services; and providing test results they could believe [ 23 ]. Additional codes were added inductively by TS from an initial sample of transcripts. Coding of the remaining transcripts was then undertaken by TS, DR and AH, who double-coded a selection of transcripts initially to check for consistency and codebook clarity. As analysis progressed, codes were continuously modified and added inductively. There were periodic meetings between TS, DR and AH to discuss new codes and their organisation into categories; meetings were also held with other members of the research team to discuss the analysis. The final code categories were organised into the dimensions of the Levesque et al. [ 14 ] conceptual framework of access, as it equipped us to understand the relationship between service users’ experiences of sexual health services and the determinants of using OPSS.

Participants

We interviewed 100 participants. All participants chose to be interviewed by phone, aside from one who interviewed in person. Full demographic information is set out in Table  2 .

Our findings are organised according to the Levesque et al. [ 14 ]. conceptual framework of access. The framework’s corresponding service and service user dimensions are presented together, giving five overarching determinants of access. For each, we have articulated a question that illustrates how we have applied the framework to OPSS.

Approachability and ability to perceive: Could service users identify clinic-based and online sexual health services and what prompted them to recognise a need to access them?

All participants were aware of clinic-based services, often viewing them as the default option for STI testing before becoming aware of OPSS. However, participants were also overwhelmingly aware of OPSS, in large part due to the efforts of services to promote it. They often discovered it while searching for STI testing services online, with OPSS often featuring prominently on search engine results, in social media adverts or on the websites of sexual health services:

“I went onto the [sexual health service] website trying to get an appointment and they told me I could order a home kit instead. So , I just went with that option […] I think that’s where the first time I saw it [was].” (Participant 17 , Black cis heterosexual woman , aged 25–34) .

Staff in services raised awareness of OPSS, for example by directing participants to use it instead of attending a clinic, particularly when access to clinics was restricted during COVID-19 lockdowns:

“I called the clinic up and thought I need to make an appointment , but the lady said oh , you can register for a self test online , and it will be out this week.” (Participant 62 , White cis lesbian woman , aged 20–24) .

Participants also reported being recommended OPSS as a test of cure, following treatment for an STI:

“I went in to get tested , it did come back positive , so they said to test again to make sure it has gone before you see other sexual partners […] which you can do through an online testing kit , so that’s what I did.” (Participant 45 , White cis gay man , aged under 20) .

Alongside proactive efforts by services to increase awareness of OPSS, many participants reported learning about it via word of mouth, often from friends or new sexual partners:

“I was talking to a best friend about it really because he’d done it before and he recommended how easier it was and stuff like that.” (Participant 53 , White cis heterosexual man , aged 20–24) .

The corresponding demand-side dimension of Levesque’s et al. [ 12 ] framework addresses service users’ ability to perceive services, which is shaped by factors such as health literacy and beliefs. Participants expressed a range of reasons that motivated them to access STI testing, many of which indicated a high level of sexual health literacy. New sexual partners were a trigger for many participants to get tested, usually because they had had a condomless sexual encounter – and were concerned about having contracted an STI – or because they wanted to transition to having regular sex without condoms. Some participants had tested due to a sexual partner notifying them that they had been diagnosed with an STI. Many also attempted to test regularly if they were sexually active, regardless of the status of their relationships:

“I’ve had multiple friends in relationships that their partner has cheated on them and they’ve had chlamydia without knowing for a really long time. So , I’m a little bit of a hypochondriac where I’m like- I want kids eventually. […] So , if I get tested every three months , if I’ve had chlamydia for three months , it’s less likely to have a long term effect.” (Participant 28 , White cis heterosexual woman , aged 20–24) .

Participants were also aware that genitourinary symptoms were a reason to access testing and many had done so for this reason, either in their most recent testing experience or in an earlier one. However, they often believed that symptoms would mean it was more appropriate to get tested in sexual health clinics:

“I think if I knew I had symptoms I would go to the clinic […] but I think if I just , if I’d just had a new partner , or just had unprotected sex or whatever , I’d probably get the self-testing kit. Particularly as you can still get the blood test for the HIV in the self-testing kit as well , so I feel like unless I was experiencing at the minute , symptoms , or there was […] another thing that was going on , I probably would get the self-test kit.” (Participant 48 , White cis heterosexual woman , aged 25–34) .

There were also participants who had less awareness of when or where to get tested, however, which was sometimes shaped by their cultural background. One participant, for example, only considered testing after her GP recommended that she do so:

“I’m not really from the UK , I live in [country] and I’ve moved here recently and STI is not really a test people do unless you have to , like it’s not very common to do STI tests so I didn’t think about it.” (Participant 33 , Asian cis heterosexual woman , aged 25–34) .

Acceptability and ability to seek: Did service users feel able to access clinic-based or online services within wider cultural and social norms?

OPSS appealed to many due to the privacy they felt it offered over clinic-based services, and there were specific elements of the OPSS pathway which participants focused on as underpinning the privacy of the service, such as the discreet packaging kits were delivered in:

“I thought it was very well packaged. So it comes in a brown box , it’s quite discreet. So I think if anyone was worried about , if they are living with friends or whatever their circumstances , as to oh someone is going to see that I am getting STD tested , it’s quite a discreet box.” (Participant 4 , Asian cis gay man , aged 25–34) .

Similarly, the opportunity to self-sample rather than have samples collected by a clinician appealed to many participants:

“I’m quite a squeamish kind of person and I don’t like to be prodded and poked as everybody doesn’t. So , for me I was like oh yes , that sounds really good because you do it in privacy , do it myself and just send it off.” (Participant 73 , Asian cis heterosexual woman , aged 25–34) .

The option in some case study areas to collect OPSS kits, rather than having them posted, enhanced the perceived privacy of the service to some participants whose living situations meant that they felt they could not have a kit posted to their home:

“My dad’s a bit nosy at times. So a box probably comes through the letterbox he’d probably most likely open it to see what it is. And then if he does do that , that will be difficult for me explaining to him what it is.” (Participant 76 , Asian cis bisexual man , aged 35–44) .

The perceived privacy of OPSS contrasted strongly with many participants’ perceptions of sexual health clinics, which they often felt required uncomfortable waits among other service users, or awkward interactions with staff. Concerns about stigma were raised by a number of participants, even some who had had positive, non-stigmatising interactions with staff in clinics:

“I have got to say , the staff that I’ve come across at the NHS for sexual health specifically , have been absolutely wonderful. But I think with STI testing there is still societally such a stigma against it that I think when you are going for testing it’s invariable to have some of these […] anxieties.” (Participant 5 , White cis heterosexual woman , aged under 20) .

These concerns were also held about other clinic-based services, such as general practitioners (GPs). Although a number of participants had accessed STI testing opportunistically via their GP – and they did not feel the same concern about being seen in a GP practice, as no one in the waiting room would know their reason for being there – some still felt uncomfortable discussing sexual health with their GP:

“There are times when I’ve been to the GP for stuff like that , you almost get the talk of like what you should be doing and what you shouldn’t be doing and that sort of thing. And whereas like they don’t do that at the sexual health clinics , which I think is , is what you’d want , like […] you are there for a reason , you don’t want to be like told off at the same time.” (Participant 48 , White cis heterosexual woman , aged 25–34) .

There were also concerns from some younger users that a GP they shared with their family may be less confidential, for example if test results were routinely sent to a parent’s mobile phone. There were participants, however, who felt a GP was the most familiar and confidential option, at least in circumstances when they felt they need to be examined by a clinician:

“I go to the doctor’s for my contraception and […] smear tests and all of those things. So for some people if the clinic is somewhere where they already go to do all those other things , they might not have so much of a problem with going to the clinic whereas I don’t. I go to my doctor’s for those things. If I had symptoms , I would go to my doctor.” (Participant 52 , White cis heterosexual woman , aged 45–54) .

The communication of results was a component of STI testing which some participants felt compromised the acceptability of the service, particularly in the case study area which used SMS for this. Although participants were typically satisfied with results delivery, some had concerns that an SMS containing test results could be seen by others – a scenario which one participant had experienced:

“I was sitting at dinner with friends and my phone was face up on the table. Everyone at the table had known that I was waiting on results so it wasn’t a big deal but had I been with others who weren’t , then they would have seen the results of my sexual health screening.” (Participant 10 , Mixed ethnicity cis man , aged 20–24) .

This concern was not expressed in relation to the two OPSS services which required users to log into an online portal in order to see their results.

The corresponding service user dimension of Levesque’s et al. [ 14 ] framework focuses on the ability to seek healthcare, within the context of societal norms and rights. As all of our participants had successfully accessed STI testing, this was not a strong feature of our data and there were contrasting views between participants about the role their identities played in access. There were many who felt their identities had no impact on which services they might use:

“I’ve never felt like me being the skin colour I am or whatever is going to affect me wanting to go to a sex clinic or anything really. No , I’ve never felt that way.” (Participant 9 , Black cis heterosexual man , aged 35–44) .

There were a number of MSM, however, who felt that they were more easily able to access all STI testing services with less risk of stigmatisation due to cultural norms within their community and efforts by services to ensure they were inclusive:

“Being Indian not really , I don’t think that has impacted anything. I think the one thing about being gay is that I think you are just more aware of the importance of sexual health and regular testing. I think it’s drilled into you quite early in your sexual experience , when you come out.” (Participant 4 , Asian cis gay man , aged 25–34) .

Trans and non-binary participants also often felt that sexual health services – whether OPSS or clinics – were more inclusive than more generic services offering STI testing, such as pharmacies:

“Doing it through a pharmacy did mean that even though I was , my partner was a woman at the time , I was still being pushed contraceptives , which was not a pleasant experience […] I do think that if I was someone who was more sensitive to those issues it might have caused me distress. So, but like I have mentioned , I did really appreciate that [sexual health service] seems to be quite mindful about the gendered language that they are using.” (Participant 90 , White bisexual non-binary , aged 25–34) .

Although many appreciated that sexual health clinics were more trans-inclusive than other health services, trans and non-binary participants tended to prefer to test using OPSS, in part because it removed the risk of being misgendered or the burden of having to explain their gender identity.

Younger participants often felt they faced barriers accessing STI testing, although this led to different preferences in terms of service usage. There were some who were concerned about OPSS usage being identified, due to it arriving to their family home in the post, while others were more reluctant to use clinic-based services:

“At that age , because it’s your first time approaching the topic of contraception […] it was a bit daunting. You go on your own , because you are a little bit shy , so it’s a bit daunting , going in person.” (Participant 85 , Black cis woman , aged 25–34) .

Availability and ability to reach: How did the design , location and opening hours of sexual health services influence whether participants were able to access them?

This was another clear and strong influence for our participants. Almost all perceived OPSS as relatively convenient, particularly in terms of time saved and reduction in travel compared to attending clinic-based testing services, such as sexual health clinics:

“I am usually very , very limited for time , so […] I’ve missed maybe once or twice some appointments. So just the convenience of having a test kit come to your house , and you being able to test yourself , that’s […] very , very convenient. And then having to send it back , that’s pretty convenient.” (Participant 21 , Black cis heterosexual man , aged 25–34) .

Convenience also shaped how some participants chose to use OPSS, for example by posting their kit back for testing rather than dropping it off at a designated location:

“[Posting is] the easiest way I think. I think anything else would require me to get in the car and drive somewhere or interact with someone or , you know , to a post office and have to queue up or whatever. Whereas that’s just straight there , dropped off , straight back.” (Participant 51 , White cis heterosexual man , aged 25–34) .

The perceived convenience of OPSS stands in stark contrast to most participants’ perceptions of sexual health clinics. There was a widely-held view, often based on personal experience, that getting an appointment at a sexual health clinic was extremely challenging or time-consuming:

“I’ve not tried for a while but trying to get an appointment with [the sexual health clinic] was a little bit like trying to buy Glastonbury tickets. You have to be online at the exact right moment and you have to get lucky on top of that.” (Participant 26 , White bisexual non-binary , aged 35–44) .

Similarly, many participants spoke about the long waits which they expected or had experienced in clinics, even in circumstances where they had managed to get an appointment:

“The wait was a lot longer than I thought it was going to be […] I had to wait for like three hours which was really kind of , inconvenient. And annoying.” (Participant 49 , White non-binary , aged 20–24) .

The time and costs associated with travelling to attend clinics were another inconvenience for some participants:

“I was working and I’d have to take time out of work. I’d have to travel to the hospital. I’d have to have paid for parking. I’d have had to get there […] If I’d gone to a clinic , it would have easily took me maybe three , four hours to travel there and back , wait there.” (Participant 57 , Mixed ethnicity cis gay man , aged 25–34) .

There were participants who had experiences in clinics they felt were quick, however, for example in clinics which implemented effective processes to minimise waiting times:

“After the first visit I seen [sic] one particular nurse and then he gave me a number , it might have even been a direct number to book into upstairs and the real good thing about that was there was no waiting times at all. So , if your appointment was at four you would get seen at four , so that I really , really liked.” (Participant 11 , White cis gay man , aged 35–44) .

There were also issues around the availability of OPSS in some circumstances, which presented a barrier to access. For example, one case study area saw delivery and processing times increase considerably during the COVID-19 pandemic:

“I think the first time I got it , it did take a little while to get to my house. So , I was a bit annoyed , I wish I’d got it sooner in the post than I did […] I could have been seen to quicker if I’d just made an appointment.” (Participant 17 , Black cis heterosexual woman , aged 25–34) . “I’ve ordered the kit online and I think it took three months for the kit to arrive and it’s been three or four weeks since I’ve done the test and I’ve still not had the results.” (Participant 78 , White cis heterosexual woman , aged 25–34) .

Another case study area introduced a cap on daily OPSS orders during our data collection, which made it challenging for some participants to access this option:

“The only issue I have is this time it said all the packs had been ordered but it came up like that for five times a day for three days on a roll , so I think they’d maxed out.” (Participant 54 , White bisexual non-binary , aged 25–34) .

Similarly, some OPSS services restricted how often users could order a kit. This was frustrating for some participants, who felt they were doing the right thing for their sexual – and for public – health but being impeded by the service provider:

“The only bad thing about it is the fact that they don’t let you have more than a certain amount. Like the quota. And it makes you feel bad about yourself. It’s like , why won’t you just let me have a test? […] Because you’re trying to be responsible and get checked out.” (Participant 58 , White cis heterosexual woman , aged 25–34) .

Affordability and ability to pay: What was the cost of accessing sexual health services and can users afford this?

As all of the services included in this research were free to access, these dimensions were not strongly present in our data. However, many participants explicitly praised the fact that STI testing was available for free to them, particularly OPSS. This view was expressed particularly strongly by a number of people who were migrants to the UK when comparing sexual health services here to their countries of origin:

“I was a bit shocked that they were free and they would pay for delivery then pay for the delivery back and also do all this stuff and it’s all like written out and it’s just a lot of effort. I was pleasantly surprised because we definitely don’t have those in [my country of origin].” (Participant 92 , White cis heterosexual man , aged under 20) .

There were also a number of participants who had used, or considered using, private OPSS services and valued that this was available to them for free:

I did click on the [high street pharmacy] one first and I did look at all the different tests and the test for everything was like £120 […] If those tests had been cheaper and they’ve been like £15 , I might have only got to that point and just gone , oh , well , for £15 I don’t have to go to a clinic. I don’t have to take time off work. I’ll just pay for that and just do it because that would feel like not that much money. (Participant 52 , White cis heterosexual woman , aged 25–54)

As noted earlier, some participants chose to access OPSS due in part to costs associated with attending clinic-based services, such as parking.

Although it did not necessarily shape their own access, some participants expressed a perception of limited NHS resources. This led a number to accept service standards which were below their desired levels:

“Okay so I’d say that the walk-in clinics […] it’s a good and a bad. Like you’d wait for hours sometimes […] which obviously is not ideal. But at the end of the day I see it as , it’s a free service. And if there was more medical like staff to do it then yes , that would be the ideal world but we all know that we’re short staffed.” (Participant 14 , White cis heterosexual woman , aged 20–24) .

Some participants also expressed this view when discussing the wait for OPSS kits to be delivered in the case study area which experienced service disruption during the COVID-19 pandemic, although others were more critical of the delays.

There were also participants who chose OPSS over attending a clinic to preserve NHS resources for others they felt had greater need than them:

“It frees up appointments for people that need them , because I know they only do a certain amount a day, which I completely respect , because you can only do so much in one day , and there’s people that will need in-person appointments a lot more than just me.” (Participant 80 , White cis heterosexual woman , aged under 20) .

Appropriateness and ability to engage: Did services meet users’ health needs and did users have the capacity to do what services require of them?

Participants typically felt that OPSS was appropriate to meet their needs, with many sharing that they felt it was able to provide results quickly and accurately:

“I usually get those back within a week , week and a half , so it’s quicker to find out the results online which is [why] I use them […] I tested positive before so I know they’re obviously picking stuff up.” (Participant 55 , White cis gay man , 25–34) .

However, there was also a strong consensus among most participants that they should be seen in clinic-based in circumstances where they deemed themselves to be at higher likelihood of having an STI, such as when they were presenting with symptoms. This appealed to some participants as they felt it would enable them to be examined by a medical professional, to discuss their concerns with a clinician, receive quicker results and treatment, particularly in the case study area which experience delays in processing OPSS kits following the COVID-19 pandemic. Another appeal was the opportunity clinics offered to be tested for a wider range of STIs:

“Postal testing is very limited […] if you go somewhere like [sexual health clinic] […] they search for a range of things. So trichomoniasis you can get tested for , BV because they have the laboratory , they test for thrush if it may be thrush.” (Participant 7 , Black cis heterosexual woman , 25–34) .

There were a number of participants who valued these qualities of clinic-based testing, irrespective of whether they were concerned they had an STI, although for many the convenience of OPSS superseded these positive aspects. There were also participants who felt that clinics enabled better access to further care, such as contraception, PrEP or vaccines for conditions like hepatitis B:

“They talked about PrEP and were like , ‘Do you want to get on that? Go online and we can set up an appointment for you next week.’ So I’m actually going in next week to have my first PrEP appointment which is great. They were telling me about all the tests that they were doing and how I would get results back via text and that was great. I think the thing that surprised me the most was that I was able to get the vaccinations done right there and then.” (Participant 10 , Mixed ethnicity cis man , aged 20–24) .

Participants who had received a positive result via OPSS, however, often stated that they saw little difference in the pathway they subsequently followed. There were also some who had accessed additional care as a result of using OPSS:

“I got the testing kit […] and it was great that it actually showed that I’m not hep B immune , which actually prompted me to get my vaccination this year.” (Participant 2 , White cis gay man , aged 35–44) .

There were also a small number of participants who shared that they had deliberately given false responses to order an OPSS kit, in order to avoid attending a clinic, even when they thought that it might be more appropriate for their health needs:

“If you do have symptoms which ordinarily would require you to go to a [clinic] but […] there are no slots of , you know , convenient , in terms of time , you are more likely to say ‘Right well okay then , I will answer the questions in such a way that it does enable me to get this kit.’” (Participant 9 , Mixed ethnicity cis gay man , aged 55–64) .

The corresponding demand-side dimension of the framework addresses whether users have the ability to engage with a service. Most participants found OPSS easy to use, particularly in terms of ordering kits and – thanks to clear instructions – collecting urine, vaginal, oropharyngeal and rectal samples:

“So for me [self-swabbing has] always been fine , really easy. Like no problems , like the instructions are there , it tells you what to do.” (Participant 58 , White cis heterosexual woman , aged 25–34) .

Participants were typically confident with their self-swabs and urine samples, although some said they would be more confident if they had been obtained by a clinician.

There was a widespread view, however, that blood self-sampling was prohibitively difficult and unpleasant. Lots of participants had difficulty obtaining enough blood, despite following the instructions in the kit closely. This meant some received invalid HIV and syphilis test results, leading them to attend a clinic for repeat testing:

“It was very hard to get the blood out of. So I just ended up binning it because it was a nightmare […] It was painful […] I would have needed to literally slice my finger open and have the blood dripping in it for it to fill up.” (Participant 19 , White cis gay man , aged 35–44) .

There were a small number of participants who refused to use OPSS again following difficulties self-sampling blood, although others stated that it got easier with repeat usage and some had no difficulty at all. There were also a number of participants who accessed OPSS with a friend or partner, in some cases to get support with blood self-sampling:

“One person I’ve helped do them quite a lot. We would find that her blood taking is really difficult. It takes ages. Whereas , for me it was really quick , my blood just came out straightaway. But for her it takes so long.” (Participant 35 , Asian cis heterosexual woman , aged under 20) .

Other participants spoke about previously attending sexual health clinics with friends, to overcome barriers such as embarrassment and anxiety, with one saying that OPSS enabled them to get tested when a companion was not available to attend a clinic:

Interviewer: Okay. But previously , you’d always gone into the clinic. I guess , why did you choose to look for online services then? Participant: Just because- I didn’t really go into the clinic all that often because I didn’t get tested previously. But […] I have anxiety , so I don’t really like going places on my own , and that. And obviously , I couldn’t always have someone with me. (Participant 60 , Mixed ethnicity cis heterosexual woman , aged 20–24)

We found that service users’ experiences of OPSS and other sexual health services shaped their future access to STI testing in a number of ways, as identified by the Levesque et al. [ 14 ] conceptual framework of access. Service users usually had a longstanding awareness of clinic-based services, while their awareness of OPSS typically came from being directed towards it by sexual health services, discovering it online or receiving an informal recommendation from a friend or partner. The acceptability of, and ability to seek, OPSS was facilitated by the perceived privacy it offers over clinic-based services, with many participants reporting that they felt embarrassed or uncomfortable when attending a sexual health clinic. However, MSM and trans participants often felt that specialist sexual health services – including OPSS – were inclusive towards them. The availability and ability to reach OPSS was predominantly influenced by its perceived convenience, as it enabled participants to avoid travel to clinics and waiting for an appointment, although difficulty obtaining OPSS kits in some areas undermined this. Affordability and ability to pay did not demonstrably shape access, as OPSS and clinic-based services were all free at the point of use, although some associated costs were a barrier to clinic-based testing, such as parking. In respect to appropriateness and ability to engage, participants generally found OPSS easy to use, aside from blood self-sampling, and were confident in its reliability, but felt that the holistic support offered by clinic-based services would be more appropriate in situations where they were particularly concerned about having an STI or another sexual or reproductive health issue.

Our findings are consistent with previous qualitative studies on OPSS, which have also identified convenience and privacy as strong facilitators to access [ 16 , 18 , 24 , 25 , 26 , 27 , 28 , 29 , 30 ]. As most previous studies had explored OPSS as a hypothetical scenario and did not include the perspectives of people who had experienced using OPSS, our findings add significant weight to the evidence indicating that these qualities facilitate access in practice. However, we also found that the ways in which OPSS is delivered can affect the impact of convenience and privacy as facilitators. Services which heavily restricted the availability of OPSS, for example, or which had long processing times for kits, were more likely to have users who felt clinic-based testing was a more convenient option.

Existing research has also identified concerns among some prospective users about self-sampling, such as worries about discomfort or samples being inaccurate. However, these were partially refuted by our data, highlighting the value of exploring the views of people who have used services [ 28 , 31 ]. We found that participants overwhelmingly consider OPSS easy to use, including the vaginal, oropharyngeal and rectal swabs, and have confidence that these samples are sufficiently accurate. However, most participants struggled considerably with blood self-sampling, which offers insight to studies which have identified poor return rates for the blood component of OPSS kits [ 32 ]. Studies of prospective users have also found mixed views on the acceptability of blood self-sampling [ 27 , 28 , 30 ]. This research also identified facilitators to blood self-sampling, such as repeat usage, having access to multiple lancets and taking a sample with the support of another person. Our findings on participant satisfaction with self-swabbing and/or urine sampling highlight a limitation of our study: our sample’s relatively high health literacy. Research by Middleton et al. [ 21 ]. found that people with a mild intellectual disability saw the prospect of self-swabbing as overwhelming and challenging, something which we did not identify frequently in our data. However, to date there have been no studies exploring the experiences of people with mild intellectual disabilities who have accessed, or attempted to access, OPSS.

Our findings offer insight into how people enter and leave the OPSS pathway, a topic which has not previously been explored. As with previous research, exploring access to clinic-based sexual health services, we found that new sexual partners and symptoms were common prompts for participants to access testing [ 33 ]. However, we also found that sexual health services and social networks both played a significant role in enabling many of our participants to access OPSS, with some even doing so with friends or partners. This contrasts with some previous research which found that people often attempt to keep their use of sexual health services secret, even from friends, although some studies have also found social networks to be a route into accessing other sexual health services, such as PrEP [ 34 , 35 ].

Access to further or more comprehensive care was part of the reason many participants valued the care on offer at clinics, at least in cases of high need, and there is some existing evidence supporting this perception. Bosó Pérez et al. [ 36 ]. found that people using remote sexual health services during the COVID-19 pandemic were less satisfied during more sensitive and emotional consultations, even though many recognised its value in other circumstances. Day et al. [ 37 ]. also reported challenges in identifying OPSS users who had experienced sexual assault, and providing them with adequate support. However, another study by the same research team found that OPSS operating procedures are effective at identifying and actioning safeguarding concerns with teenage users [ 38 ]. It is noteworthy that many of our participants who had tested positive for chlamydia or gonorrhoea using OPSS did not feel their treatment and care beyond this point was compromised or differed from what they would have experienced if they had tested at a sexual health clinic.

The communication of results is a key component of any STI testing pathway and there have been inconsistent findings from previous studies about service user preferences for how results are delivered. Research exploring the views of prospective users of OPSS had identified a range of preferred media for results communication, including SMS, email and phone, although with concerns among some about confidentiality and the lack of support from a healthcare professional [ 16 , 24 , 26 , 30 ]. Studies which have explored users’ experiences of OPSS results have found high satisfaction with both online portals and SMS [ 22 , 39 ]. Our findings corroborate this, with users of both methods typically expressing satisfaction. Although some users did have privacy concerns about SMS, it was not clear that this played a significant role in access.

Strengths and limitations

This study is, to our knowledge, the largest qualitative exploration of OPSS, as well as the first to include users of different OPSS services. This allowed us to capture a wide range of perceptions and experiences, while also comparing and contrasting between different methods of delivering OPSS, in different contexts. The use of the Levesque et al. [ 14 ] conceptual framework of access enabled us to explore a wide range of facilitators and barriers to accessing both OPSS and clinic-based STI testing, including a number – such as participants’ awareness of, and ability to seek, OPSS alongside other testing options – which have received limited attention in prior research. The study sample was also highly diverse, as a result of our efforts to include populations of interest, such as young people, people of colour, MSM and trans people.

The study was limited by the fact that we found it difficult to recruit participants who had no experience of OPSS, despite this population being a key demographic in our sampling strategy. This was partially a consequence of the COVID-19 pandemic and its after-effects, which were ongoing during our data collection and had restricted access to clinic-based services. Staff in clinics also had limited capacity to support recruitment of service users who may not have accessed OPSS. We also found it challenging to recruit service users with low digital literacy, and did not analyse the impact of participants’ socioeconomic status, meaning we could not draw conclusions on these as barriers to access. As previously discussed, our sample typically had reasonably high sexual health literacy, as having tested for STIs was one of our inclusion criteria, and all participants were inherently comfortable discussing sexual health, having volunteered for the research. This made it challenging to explore these factors as barriers.

Access to STI testing in the context of OPSS was shaped by a range of factors, including privacy, convenience, self-perceived risk, ability to self-sample and the opportunities users have to learn about OPSS. Commissioners and service providers seeking to improve access to STI testing should consider how the way services are delivered can reinforce facilitators to access, for example by minimising OPSS processing times and enabling kits to be collected as an alternative to home delivery, while also maintaining access to clinic-based testing for those who face barriers accessing OPSS. There would be value in further, targeted research exploring very marginalised populations whose perspectives have been insufficiently explored in the literature to date, such as those who are digitally excluded or who have never accessed OPSS, alongside populations which demonstrate persistently lower uptake of OPSS, including black ethnic groups, heterosexual men and people living in deprived areas.

Data availability

The data that support the findings of this study are not publicly available, as participants did not consent to this. Questions about the data can be directed to JG, Co-Chief Investigator, on [email protected].

Abbreviations

General practitioner

Initial programme theory

Men who have sex with men

Online postal self-sampling

Sexually transmitted infection(s)

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Acknowledgements

We thank the participants for sharing their time and experiences with us. We also thank the staff in our research sites who supported participant recruitment. We dedicate this paper to the memories of Prof Elizabeth Murray and Dr Naomi Fisher, who were co-applicants on ASSIST and made invaluable contributions to the study design.

This study is funded by the NIHR Health and Social Care Delivery Research Programme (NIHR129157). The views expressed are those of the authors and not necessarily those of the NIHR or the Department of Health and Social Care.

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Fiona Burns and Jo Gibbs are joint senior authors.

Authors and Affiliations

Institute of Epidemiology and Health Care, University College London, London, UK

Tommer Spence & Jessica Sheringham

Institute for Global Health, University College London, London, UK

Alison Howarth, David Reid, Catherine H. Mercer, Fiona Burns & Jo Gibbs

Barts Health NHS Trust, London, UK

Vanessa Apea & Andy Williams

Lay representative, London, UK

David Crundwell

Chelsea and Westminster Hospital NHS Foundation Trust, London, UK

Sara Day & Ann Sullivan

Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK

Claire Dewsnap

Institute of Applied Health Research, University of Birmingham, Birmingham, UK

Louise Jackson

STIs and HIV Division, Blood Safety, Health Security Agency, Hepatitis, London, UK

Hamish Mohammed

University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK

Jonathan D. C. Ross

NHS Greater Glasgow and Clyde, Glasgow, UK

Andrew Winter

Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK

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The study was conceived by FB and JG and designed by FB, JG, JS, LJ, GW and AH. Data were collected by TS, DR and AH. Data were analysed by TS, DR and AH, with input from JG, FB and JS. The manuscript was drafted by TS and revised by JG, FB, JS, AH and DR. VA, DC, SD, CD, LJ, CHM, HM, JDCR, AS, AW, AW and GW contributed to the interpretation of findings and critically reviewed the manuscript. All authors have read and approved the final version.

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Correspondence to Tommer Spence .

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VA is a Medical Director of Preventx; FB has received speaker fees and an institutional grant from Gilead Sciences Ltd. The authors declare no other competing interests.

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Spence, T., Howarth, A., Reid, D. et al. How does online postal self-sampling (OPSS) shape access to testing for sexually transmitted infections (STIs)? A qualitative study of service users. BMC Public Health 24 , 2339 (2024). https://doi.org/10.1186/s12889-024-19741-x

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Methodologic and Data-Analysis Triangulation in Case Studies: A Scoping Review

Margarithe charlotte schlunegger.

1 Department of Health Professions, Applied Research & Development in Nursing, Bern University of Applied Sciences, Bern, Switzerland

2 Faculty of Health, School of Nursing Science, Witten/Herdecke University, Witten, Germany

Maya Zumstein-Shaha

Rebecca palm.

3 Department of Health Care Research, Carl von Ossietzky University Oldenburg, Oldenburg, Germany

Associated Data

Supplemental material, sj-docx-1-wjn-10.1177_01939459241263011 for Methodologic and Data-Analysis Triangulation in Case Studies: A Scoping Review by Margarithe Charlotte Schlunegger, Maya Zumstein-Shaha and Rebecca Palm in Western Journal of Nursing Research

We sought to explore the processes of methodologic and data-analysis triangulation in case studies using the example of research on nurse practitioners in primary health care.

Design and methods:

We conducted a scoping review within Arksey and O’Malley’s methodological framework, considering studies that defined a case study design and used 2 or more data sources, published in English or German before August 2023.

Data sources:

The databases searched were MEDLINE and CINAHL, supplemented with hand searching of relevant nursing journals. We also examined the reference list of all the included studies.

In total, 63 reports were assessed for eligibility. Ultimately, we included 8 articles. Five studies described within-method triangulation, whereas 3 provided information on between/across-method triangulation. No study reported within-method triangulation of 2 or more quantitative data-collection procedures. The data-collection procedures were interviews, observation, documentation/documents, service records, and questionnaires/assessments. The data-analysis triangulation involved various qualitative and quantitative methods of analysis. Details about comparing or contrasting results from different qualitative and mixed-methods data were lacking.

Conclusions:

Various processes for methodologic and data-analysis triangulation are described in this scoping review but lack detail, thus hampering standardization in case study research, potentially affecting research traceability. Triangulation is complicated by terminological confusion. To advance case study research in nursing, authors should reflect critically on the processes of triangulation and employ existing tools, like a protocol or mixed-methods matrix, for transparent reporting. The only existing reporting guideline should be complemented with directions on methodologic and data-analysis triangulation.

Case study research is defined as “an empirical method that investigates a contemporary phenomenon (the ‘case’) in depth and within its real-world context, especially when the boundaries between phenomenon and context may not be clearly evident. A case study relies on multiple sources of evidence, with data needing to converge in a triangulating fashion.” 1 (p15) This design is described as a stand-alone research approach equivalent to grounded theory and can entail single and multiple cases. 1 , 2 However, case study research should not be confused with single clinical case reports. “Case reports are familiar ways of sharing events of intervening with single patients with previously unreported features.” 3 (p107) As a methodology, case study research encompasses substantially more complexity than a typical clinical case report. 1 , 3

A particular characteristic of case study research is the use of various data sources, such as quantitative data originating from questionnaires as well as qualitative data emerging from interviews, observations, or documents. Therefore, a case study always draws on multiple sources of evidence, and the data must converge in a triangulating manner. 1 When using multiple data sources, a case or cases can be examined more convincingly and accurately, compensating for the weaknesses of the respective data sources. 1 Another characteristic is the interaction of various perspectives. This involves comparing or contrasting perspectives of people with different points of view, eg, patients, staff, or leaders. 4 Through triangulation, case studies contribute to the completeness of the research on complex topics, such as role implementation in clinical practice. 1 , 5 Triangulation involves a combination of researchers from various disciplines, of theories, of methods, and/or of data sources. By creating connections between these sources (ie, investigator, theories, methods, data sources, and/or data analysis), a new understanding of the phenomenon under study can be obtained. 6 , 7

This scoping review focuses on methodologic and data-analysis triangulation because concrete procedures are missing, eg, in reporting guidelines. Methodologic triangulation has been called methods, mixed methods, or multimethods. 6 It can encompass within-method triangulation and between/across-method triangulation. 7 “Researchers using within-method triangulation use at least 2 data-collection procedures from the same design approach.” 6 (p254) Within-method triangulation is either qualitative or quantitative but not both. Therefore, within-method triangulation can also be considered data source triangulation. 8 In contrast, “researchers using between/across-method triangulation employ both qualitative and quantitative data-collection methods in the same study.” 6 (p254) Hence, methodologic approaches are combined as well as various data sources. For this scoping review, the term “methodologic triangulation” is maintained to denote between/across-method triangulation. “Data-analysis triangulation is the combination of 2 or more methods of analyzing data.” 6 (p254)

Although much has been published on case studies, there is little consensus on the quality of the various data sources, the most appropriate methods, or the procedures for conducting methodologic and data-analysis triangulation. 5 According to the EQUATOR (Enhancing the QUAlity and Transparency Of health Research) clearinghouse for reporting guidelines, one standard exists for organizational case studies. 9 Organizational case studies provide insights into organizational change in health care services. 9 Rodgers et al 9 pointed out that, although high-quality studies are being funded and published, they are sometimes poorly articulated and methodologically inadequate. In the reporting checklist by Rodgers et al, 9 a description of the data collection is included, but reporting directions on methodologic and data-analysis triangulation are missing. Therefore, the purpose of this study was to examine the process of methodologic and data-analysis triangulation in case studies. Accordingly, we conducted a scoping review to elicit descriptions of and directions for triangulation methods and analysis, drawing on case studies of nurse practitioners (NPs) in primary health care as an example. Case studies are recommended to evaluate the implementation of new roles in (primary) health care, such as that of NPs. 1 , 5 Case studies on new role implementation can generate a unique and in-depth understanding of specific roles (individual), teams (smaller groups), family practices or similar institutions (organization), and social and political processes in health care systems. 1 , 10 The integration of NPs into health care systems is at different stages of progress around the world. 11 Therefore, studies are needed to evaluate this process.

The methodological framework by Arksey and O’Malley 12 guided this scoping review. We examined the current scientific literature on the use of methodologic and data-analysis triangulation in case studies on NPs in primary health care. The review process included the following stages: (1) establishing the research question; (2) identifying relevant studies; (3) selecting the studies for inclusion; (4) charting the data; (5) collating, summarizing, and reporting the results; and (6) consulting experts in the field. 12 Stage 6 was not performed due to a lack of financial resources. The reporting of the review followed the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Review) guideline by Tricco et al 13 (guidelines for reporting systematic reviews and meta-analyses [ Supplementary Table A ]). Scoping reviews are not eligible for registration in PROSPERO.

Stage 1: Establishing the Research Question

The aim of this scoping review was to examine the process of triangulating methods and analysis in case studies on NPs in primary health care to improve the reporting. We sought to answer the following question: How have methodologic and data-analysis triangulation been conducted in case studies on NPs in primary health care? To answer the research question, we examined the following elements of the selected studies: the research question, the study design, the case definition, the selected data sources, and the methodologic and data-analysis triangulation.

Stage 2: Identifying Relevant Studies

A systematic database search was performed in the MEDLINE (via PubMed) and CINAHL (via EBSCO) databases between July and September 2020 to identify relevant articles. The following terms were used as keyword search strategies: (“Advanced Practice Nursing” OR “nurse practitioners”) AND (“primary health care” OR “Primary Care Nursing”) AND (“case study” OR “case studies”). Searches were limited to English- and German-language articles. Hand searches were conducted in the journals Nursing Inquiry , BMJ Open , and BioMed Central ( BMC ). We also screened the reference lists of the studies included. The database search was updated in August 2023. The complete search strategy for all the databases is presented in Supplementary Table B .

Stage 3: Selecting the Studies

Inclusion and exclusion criteria.

We used the inclusion and exclusion criteria reported in Table 1 . We included studies of NPs who had at least a master’s degree in nursing according to the definition of the International Council of Nurses. 14 This scoping review considered studies that were conducted in primary health care practices in rural, urban, and suburban regions. We excluded reviews and study protocols in which no data collection had occurred. Articles were included without limitations on the time period or country of origin.

Inclusion and Exclusion Criteria.

Screening process

After the search, we collated and uploaded all the identified records into EndNote v.X8 (Clarivate Analytics, Philadelphia, Pennsylvania) and removed any duplicates. Two independent reviewers (MCS and SA) screened the titles and abstracts for assessment in line with the inclusion criteria. They retrieved and assessed the full texts of the selected studies while applying the inclusion criteria. Any disagreements about the eligibility of studies were resolved by discussion or, if no consensus could be reached, by involving experienced researchers (MZ-S and RP).

Stages 4 and 5: Charting the Data and Collating, Summarizing, and Reporting the Results

The first reviewer (MCS) extracted data from the selected publications. For this purpose, an extraction tool developed by the authors was used. This tool comprised the following criteria: author(s), year of publication, country, research question, design, case definition, data sources, and methodologic and data-analysis triangulation. First, we extracted and summarized information about the case study design. Second, we narratively summarized the way in which the data and methodological triangulation were described. Finally, we summarized the information on within-case or cross-case analysis. This process was performed using Microsoft Excel. One reviewer (MCS) extracted data, whereas another reviewer (SA) cross-checked the data extraction, making suggestions for additions or edits. Any disagreements between the reviewers were resolved through discussion.

A total of 149 records were identified in 2 databases. We removed 20 duplicates and screened 129 reports by title and abstract. A total of 46 reports were assessed for eligibility. Through hand searches, we identified 117 additional records. Of these, we excluded 98 reports after title and abstract screening. A total of 17 reports were assessed for eligibility. From the 2 databases and the hand search, 63 reports were assessed for eligibility. Ultimately, we included 8 articles for data extraction. No further articles were included after the reference list screening of the included studies. A PRISMA flow diagram of the study selection and inclusion process is presented in Figure 1 . As shown in Tables 2 and ​ and3, 3 , the articles included in this scoping review were published between 2010 and 2022 in Canada (n = 3), the United States (n = 2), Australia (n = 2), and Scotland (n = 1).

PRISMA flow diagram.

Characteristics of Articles Included.

Overview of Within-Method, Between/Across-Method, and Data-Analysis Triangulation.

Research Question, Case Definition, and Case Study Design

The following sections describe the research question, case definition, and case study design. Case studies are most appropriate when asking “how” or “why” questions. 1 According to Yin, 1 how and why questions are explanatory and lead to the use of case studies, histories, and experiments as the preferred research methods. In 1 study from Canada, eg, the following research question was presented: “How and why did stakeholders participate in the system change process that led to the introduction of the first nurse practitioner-led Clinic in Ontario?” (p7) 19 Once the research question has been formulated, the case should be defined and, subsequently, the case study design chosen. 1 In typical case studies with mixed methods, the 2 types of data are gathered concurrently in a convergent design and the results merged to examine a case and/or compare multiple cases. 10

Research question

“How” or “why” questions were found in 4 studies. 16 , 17 , 19 , 22 Two studies additionally asked “what” questions. Three studies described an exploratory approach, and 1 study presented an explanatory approach. Of these 4 studies, 3 studies chose a qualitative approach 17 , 19 , 22 and 1 opted for mixed methods with a convergent design. 16

In the remaining studies, either the research questions were not clearly stated or no “how” or “why” questions were formulated. For example, “what” questions were found in 1 study. 21 No information was provided on exploratory, descriptive, and explanatory approaches. Schadewaldt et al 21 chose mixed methods with a convergent design.

Case definition and case study design

A total of 5 studies defined the case as an organizational unit. 17 , 18 - 20 , 22 Of the 8 articles, 4 reported multiple-case studies. 16 , 17 , 22 , 23 Another 2 publications involved single-case studies. 19 , 20 Moreover, 2 publications did not state the case study design explicitly.

Within-Method Triangulation

This section describes within-method triangulation, which involves employing at least 2 data-collection procedures within the same design approach. 6 , 7 This can also be called data source triangulation. 8 Next, we present the single data-collection procedures in detail. In 5 studies, information on within-method triangulation was found. 15 , 17 - 19 , 22 Studies describing a quantitative approach and the triangulation of 2 or more quantitative data-collection procedures could not be included in this scoping review.

Qualitative approach

Five studies used qualitative data-collection procedures. Two studies combined face-to-face interviews and documents. 15 , 19 One study mixed in-depth interviews with observations, 18 and 1 study combined face-to-face interviews and documentation. 22 One study contained face-to-face interviews, observations, and documentation. 17 The combination of different qualitative data-collection procedures was used to present the case context in an authentic and complex way, to elicit the perspectives of the participants, and to obtain a holistic description and explanation of the cases under study.

All 5 studies used qualitative interviews as the primary data-collection procedure. 15 , 17 - 19 , 22 Face-to-face, in-depth, and semi-structured interviews were conducted. The topics covered in the interviews included processes in the introduction of new care services and experiences of barriers and facilitators to collaborative work in general practices. Two studies did not specify the type of interviews conducted and did not report sample questions. 15 , 18

Observations

In 2 studies, qualitative observations were carried out. 17 , 18 During the observations, the physical design of the clinical patients’ rooms and office spaces was examined. 17 Hungerford et al 18 did not explain what information was collected during the observations. In both studies, the type of observation was not specified. Observations were generally recorded as field notes.

Public documents

In 3 studies, various qualitative public documents were studied. 15 , 19 , 22 These documents included role description, education curriculum, governance frameworks, websites, and newspapers with information about the implementation of the role and general practice. Only 1 study failed to specify the type of document and the collected data. 15

Electronic health records

In 1 study, qualitative documentation was investigated. 17 This included a review of dashboards (eg, provider productivity reports or provider quality dashboards in the electronic health record) and quality performance reports (eg, practice-wide or co-management team-wide performance reports).

Between/Across-Method Triangulation

This section describes the between/across methods, which involve employing both qualitative and quantitative data-collection procedures in the same study. 6 , 7 This procedure can also be denoted “methodologic triangulation.” 8 Subsequently, we present the individual data-collection procedures. In 3 studies, information on between/across triangulation was found. 16 , 20 , 21

Mixed methods

Three studies used qualitative and quantitative data-collection procedures. One study combined face-to-face interviews, documentation, and self-assessments. 16 One study employed semi-structured interviews, direct observation, documents, and service records, 20 and another study combined face-to-face interviews, non-participant observation, documents, and questionnaires. 23

All 3 studies used qualitative interviews as the primary data-collection procedure. 16 , 20 , 23 Face-to-face and semi-structured interviews were conducted. In the interviews, data were collected on the introduction of new care services and experiences of barriers to and facilitators of collaborative work in general practices.

Observation

In 2 studies, direct and non-participant qualitative observations were conducted. 20 , 23 During the observations, the interaction between health professionals or the organization and the clinical context was observed. Observations were generally recorded as field notes.

In 2 studies, various qualitative public documents were examined. 20 , 23 These documents included role description, newspapers, websites, and practice documents (eg, flyers). In the documents, information on the role implementation and role description of NPs was collected.

Individual journals

In 1 study, qualitative individual journals were studied. 16 These included reflective journals from NPs, who performed the role in primary health care.

Service records

Only 1 study involved quantitative service records. 20 These service records were obtained from the primary care practices and the respective health authorities. They were collected before and after the implementation of an NP role to identify changes in patients’ access to health care, the volume of patients served, and patients’ use of acute care services.

Questionnaires/Assessment

In 2 studies, quantitative questionnaires were used to gather information about the teams’ satisfaction with collaboration. 16 , 21 In 1 study, 3 validated scales were used. The scales measured experience, satisfaction, and belief in the benefits of collaboration. 21 Psychometric performance indicators of these scales were provided. However, the time points of data collection were not specified; similarly, whether the questionnaires were completed online or by hand was not mentioned. A competency self-assessment tool was used in another study. 16 The assessment comprised 70 items and included topics such as health promotion, protection, disease prevention and treatment, the NP-patient relationship, the teaching-coaching function, the professional role, managing and negotiating health care delivery systems, monitoring and ensuring the quality of health care practice, and cultural competence. Psychometric performance indicators were provided. The assessment was completed online with 2 measurement time points (pre self-assessment and post self-assessment).

Data-Analysis Triangulation

This section describes data-analysis triangulation, which involves the combination of 2 or more methods of analyzing data. 6 Subsequently, we present within-case analysis and cross-case analysis.

Mixed-methods analysis

Three studies combined qualitative and quantitative methods of analysis. 16 , 20 , 21 Two studies involved deductive and inductive qualitative analysis, and qualitative data were analyzed thematically. 20 , 21 One used deductive qualitative analysis. 16 The method of analysis was not specified in the studies. Quantitative data were analyzed using descriptive statistics in 3 studies. 16 , 20 , 23 The descriptive statistics comprised the calculation of the mean, median, and frequencies.

Qualitative methods of analysis

Two studies combined deductive and inductive qualitative analysis, 19 , 22 and 2 studies only used deductive qualitative analysis. 15 , 18 Qualitative data were analyzed thematically in 1 study, 22 and data were treated with content analysis in the other. 19 The method of analysis was not specified in the 2 studies.

Within-case analysis

In 7 studies, a within-case analysis was performed. 15 - 20 , 22 Six studies used qualitative data for the within-case analysis, and 1 study employed qualitative and quantitative data. Data were analyzed separately, consecutively, or in parallel. The themes generated from qualitative data were compared and then summarized. The individual cases were presented mostly as a narrative description. Quantitative data were integrated into the qualitative description with tables and graphs. Qualitative and quantitative data were also presented as a narrative description.

Cross-case analyses

Of the multiple-case studies, 5 carried out cross-case analyses. 15 - 17 , 20 , 22 Three studies described the cross-case analysis using qualitative data. Two studies reported a combination of qualitative and quantitative data for the cross-case analysis. In each multiple-case study, the individual cases were contrasted to identify the differences and similarities between the cases. One study did not specify whether a within-case or a cross-case analysis was conducted. 23

Confirmation or contradiction of data

This section describes confirmation or contradiction through qualitative and quantitative data. 1 , 4 Qualitative and quantitative data were reported separately, with little connection between them. As a result, the conclusions on neither the comparisons nor the contradictions could be clearly determined.

Confirmation or contradiction among qualitative data

In 3 studies, the consistency of the results of different types of qualitative data was highlighted. 16 , 19 , 21 In particular, documentation and interviews or interviews and observations were contrasted:

• Confirmation between interviews and documentation: The data from these sources corroborated the existence of a common vision for an NP-led clinic. 19
• Confirmation among interviews and observation: NPs experienced pressure to find and maintain their position within the existing system. Nurse practitioners and general practitioners performed complete episodes of care, each without collaborative interaction. 21
• Contradiction among interviews and documentation: For example, interviewees mentioned that differentiating the scope of practice between NPs and physicians is difficult as there are too many areas of overlap. However, a clear description of the scope of practice for the 2 roles was provided. 21

Confirmation through a combination of qualitative and quantitative data

Both types of data showed that NPs and general practitioners wanted to have more time in common to discuss patient cases and engage in personal exchanges. 21 In addition, the qualitative and quantitative data confirmed the individual progression of NPs from less competent to more competent. 16 One study pointed out that qualitative and quantitative data obtained similar results for the cases. 20 For example, integrating NPs improved patient access by increasing appointment availability.

Contradiction through a combination of qualitative and quantitative data

Although questionnaire results indicated that NPs and general practitioners experienced high levels of collaboration and satisfaction with the collaborative relationship, the qualitative results drew a more ambivalent picture of NPs’ and general practitioners’ experiences with collaboration. 21

Research Question and Design

The studies included in this scoping review evidenced various research questions. The recommended formats (ie, how or why questions) were not applied consistently. Therefore, no case study design should be applied because the research question is the major guide for determining the research design. 2 Furthermore, case definitions and designs were applied variably. The lack of standardization is reflected in differences in the reporting of these case studies. Generally, case study research is viewed as allowing much more freedom and flexibility. 5 , 24 However, this flexibility and the lack of uniform specifications lead to confusion.

Methodologic Triangulation

Methodologic triangulation, as described in the literature, can be somewhat confusing as it can refer to either data-collection methods or research designs. 6 , 8 For example, methodologic triangulation can allude to qualitative and quantitative methods, indicating a paradigmatic connection. Methodologic triangulation can also point to qualitative and quantitative data-collection methods, analysis, and interpretation without specific philosophical stances. 6 , 8 Regarding “data-collection methods with no philosophical stances,” we would recommend using the wording “data source triangulation” instead. Thus, the demarcation between the method and the data-collection procedures will be clearer.

Within-Method and Between/Across-Method Triangulation

Yin 1 advocated the use of multiple sources of evidence so that a case or cases can be investigated more comprehensively and accurately. Most studies included multiple data-collection procedures. Five studies employed a variety of qualitative data-collection procedures, and 3 studies used qualitative and quantitative data-collection procedures (mixed methods). In contrast, no study contained 2 or more quantitative data-collection procedures. In particular, quantitative data-collection procedures—such as validated, reliable questionnaires, scales, or assessments—were not used exhaustively. The prerequisites for using multiple data-collection procedures are availability, the knowledge and skill of the researcher, and sufficient financial funds. 1 To meet these prerequisites, research teams consisting of members with different levels of training and experience are necessary. Multidisciplinary research teams need to be aware of the strengths and weaknesses of different data sources and collection procedures. 1

Qualitative methods of analysis and results

When using multiple data sources and analysis methods, it is necessary to present the results in a coherent manner. Although the importance of multiple data sources and analysis has been emphasized, 1 , 5 the description of triangulation has tended to be brief. Thus, traceability of the research process is not always ensured. The sparse description of the data-analysis triangulation procedure may be due to the limited number of words in publications or the complexity involved in merging the different data sources.

Only a few concrete recommendations regarding the operationalization of the data-analysis triangulation with the qualitative data process were found. 25 A total of 3 approaches have been proposed 25 : (1) the intuitive approach, in which researchers intuitively connect information from different data sources; (2) the procedural approach, in which each comparative or contrasting step in triangulation is documented to ensure transparency and replicability; and (3) the intersubjective approach, which necessitates a group of researchers agreeing on the steps in the triangulation process. For each case study, one of these 3 approaches needs to be selected, carefully carried out, and documented. Thus, in-depth examination of the data can take place. Farmer et al 25 concluded that most researchers take the intuitive approach; therefore, triangulation is not clearly articulated. This trend is also evident in our scoping review.

Mixed-methods analysis and results

Few studies in this scoping review used a combination of qualitative and quantitative analysis. However, creating a comprehensive stand-alone picture of a case from both qualitative and quantitative methods is challenging. Findings derived from different data types may not automatically coalesce into a coherent whole. 4 O’Cathain et al 26 described 3 techniques for combining the results of qualitative and quantitative methods: (1) developing a triangulation protocol; (2) following a thread by selecting a theme from 1 component and following it across the other components; and (3) developing a mixed-methods matrix.

The most detailed description of the conducting of triangulation is the triangulation protocol. The triangulation protocol takes place at the interpretation stage of the research process. 26 This protocol was developed for multiple qualitative data but can also be applied to a combination of qualitative and quantitative data. 25 , 26 It is possible to determine agreement, partial agreement, “silence,” or dissonance between the results of qualitative and quantitative data. The protocol is intended to bring together the various themes from the qualitative and quantitative results and identify overarching meta-themes. 25 , 26

The “following a thread” technique is used in the analysis stage of the research process. To begin, each data source is analyzed to identify the most important themes that need further investigation. Subsequently, the research team selects 1 theme from 1 data source and follows it up in the other data source, thereby creating a thread. The individual steps of this technique are not specified. 26 , 27

A mixed-methods matrix is used at the end of the analysis. 26 All the data collected on a defined case are examined together in 1 large matrix, paying attention to cases rather than variables or themes. In a mixed-methods matrix (eg, a table), the rows represent the cases for which both qualitative and quantitative data exist. The columns show the findings for each case. This technique allows the research team to look for congruency, surprises, and paradoxes among the findings as well as patterns across multiple cases. In our review, we identified only one of these 3 approaches in the study by Roots and MacDonald. 20 These authors mentioned that a causal network analysis was performed using a matrix. However, no further details were given, and reference was made to a later publication. We could not find this publication.

Case Studies in Nursing Research and Recommendations

Because it focused on the implementation of NPs in primary health care, the setting of this scoping review was narrow. However, triangulation is essential for research in this area. This type of research was found to provide a good basis for understanding methodologic and data-analysis triangulation. Despite the lack of traceability in the description of the data and methodological triangulation, we believe that case studies are an appropriate design for exploring new nursing roles in existing health care systems. This is evidenced by the fact that case study research is widely used in many social science disciplines as well as in professional practice. 1 To strengthen this research method and increase the traceability in the research process, we recommend using the reporting guideline and reporting checklist by Rodgers et al. 9 This reporting checklist needs to be complemented with methodologic and data-analysis triangulation. A procedural approach needs to be followed in which each comparative step of the triangulation is documented. 25 A triangulation protocol or a mixed-methods matrix can be used for this purpose. 26 If there is a word limit in a publication, the triangulation protocol or mixed-methods matrix needs to be identified. A schematic representation of methodologic and data-analysis triangulation in case studies can be found in Figure 2 .

Schematic representation of methodologic and data-analysis triangulation in case studies (own work).

Limitations

This study suffered from several limitations that must be acknowledged. Given the nature of scoping reviews, we did not analyze the evidence reported in the studies. However, 2 reviewers independently reviewed all the full-text reports with respect to the inclusion criteria. The focus on the primary care setting with NPs (master’s degree) was very narrow, and only a few studies qualified. Thus, possible important methodological aspects that would have contributed to answering the questions were omitted. Studies describing the triangulation of 2 or more quantitative data-collection procedures could not be included in this scoping review due to the inclusion and exclusion criteria.

Conclusions

Given the various processes described for methodologic and data-analysis triangulation, we can conclude that triangulation in case studies is poorly standardized. Consequently, the traceability of the research process is not always given. Triangulation is complicated by the confusion of terminology. To advance case study research in nursing, we encourage authors to reflect critically on methodologic and data-analysis triangulation and use existing tools, such as the triangulation protocol or mixed-methods matrix and the reporting guideline checklist by Rodgers et al, 9 to ensure more transparent reporting.

Supplemental Material

Acknowledgments.

The authors thank Simona Aeschlimann for her support during the screening process.

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding: The author(s) received no financial support for the research, authorship, and/or publication of this article.

Supplemental Material: Supplemental material for this article is available online.