analyzing a case study

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• 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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Organizing Your Social Sciences Research Assignments

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• Group Project Survival Skills
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• Multiple Book Review Essay
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• Writing a Case Analysis Paper
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• Acknowledgments

A case study research paper examines a person, place, event, condition, phenomenon, or other type of subject of analysis in order to extrapolate  key themes and results that help predict future trends, illuminate previously hidden issues that can be applied to practice, and/or provide a means for understanding an important research problem with greater clarity. A case study research paper usually examines a single subject of analysis, but case study papers can also be designed as a comparative investigation that shows relationships between two or more subjects. The methods used to study a case can rest within a quantitative, qualitative, or mixed-method investigative paradigm.

Case Studies. Writing@CSU. Colorado State University; Mills, Albert J. , Gabrielle Durepos, and Eiden Wiebe, editors. Encyclopedia of Case Study Research . Thousand Oaks, CA: SAGE Publications, 2010 ; “What is a Case Study?” In Swanborn, Peter G. Case Study Research: What, Why and How? London: SAGE, 2010.

How to Approach Writing a Case Study Research Paper

General information about how to choose a topic to investigate can be found under the " Choosing a Research Problem " tab in the Organizing Your Social Sciences Research Paper writing guide. Review this page because it may help you identify a subject of analysis that can be investigated using a case study design.

However, identifying a case to investigate involves more than choosing the research problem . A case study encompasses a problem contextualized around the application of in-depth analysis, interpretation, and discussion, often resulting in specific recommendations for action or for improving existing conditions. As Seawright and Gerring note, practical considerations such as time and access to information can influence case selection, but these issues should not be the sole factors used in describing the methodological justification for identifying a particular case to study. Given this, selecting a case includes considering the following:

• The case represents an unusual or atypical example of a research problem that requires more in-depth analysis? Cases often represent a topic that rests on the fringes of prior investigations because the case may provide new ways of understanding the research problem. For example, if the research problem is to identify strategies to improve policies that support girl's access to secondary education in predominantly Muslim nations, you could consider using Azerbaijan as a case study rather than selecting a more obvious nation in the Middle East. Doing so may reveal important new insights into recommending how governments in other predominantly Muslim nations can formulate policies that support improved access to education for girls.
• The case provides important insight or illuminate a previously hidden problem? In-depth analysis of a case can be based on the hypothesis that the case study will reveal trends or issues that have not been exposed in prior research or will reveal new and important implications for practice. For example, anecdotal evidence may suggest drug use among homeless veterans is related to their patterns of travel throughout the day. Assuming prior studies have not looked at individual travel choices as a way to study access to illicit drug use, a case study that observes a homeless veteran could reveal how issues of personal mobility choices facilitate regular access to illicit drugs. Note that it is important to conduct a thorough literature review to ensure that your assumption about the need to reveal new insights or previously hidden problems is valid and evidence-based.
• The case challenges and offers a counter-point to prevailing assumptions? Over time, research on any given topic can fall into a trap of developing assumptions based on outdated studies that are still applied to new or changing conditions or the idea that something should simply be accepted as "common sense," even though the issue has not been thoroughly tested in current practice. A case study analysis may offer an opportunity to gather evidence that challenges prevailing assumptions about a research problem and provide a new set of recommendations applied to practice that have not been tested previously. For example, perhaps there has been a long practice among scholars to apply a particular theory in explaining the relationship between two subjects of analysis. Your case could challenge this assumption by applying an innovative theoretical framework [perhaps borrowed from another discipline] to explore whether this approach offers new ways of understanding the research problem. Taking a contrarian stance is one of the most important ways that new knowledge and understanding develops from existing literature.
• The case provides an opportunity to pursue action leading to the resolution of a problem? Another way to think about choosing a case to study is to consider how the results from investigating a particular case may result in findings that reveal ways in which to resolve an existing or emerging problem. For example, studying the case of an unforeseen incident, such as a fatal accident at a railroad crossing, can reveal hidden issues that could be applied to preventative measures that contribute to reducing the chance of accidents in the future. In this example, a case study investigating the accident could lead to a better understanding of where to strategically locate additional signals at other railroad crossings so as to better warn drivers of an approaching train, particularly when visibility is hindered by heavy rain, fog, or at night.
• The case offers a new direction in future research? A case study can be used as a tool for an exploratory investigation that highlights the need for further research about the problem. A case can be used when there are few studies that help predict an outcome or that establish a clear understanding about how best to proceed in addressing a problem. For example, after conducting a thorough literature review [very important!], you discover that little research exists showing the ways in which women contribute to promoting water conservation in rural communities of east central Africa. A case study of how women contribute to saving water in a rural village of Uganda can lay the foundation for understanding the need for more thorough research that documents how women in their roles as cooks and family caregivers think about water as a valuable resource within their community. This example of a case study could also point to the need for scholars to build new theoretical frameworks around the topic [e.g., applying feminist theories of work and family to the issue of water conservation].

Eisenhardt, Kathleen M. “Building Theories from Case Study Research.” Academy of Management Review 14 (October 1989): 532-550; Emmel, Nick. Sampling and Choosing Cases in Qualitative Research: A Realist Approach . Thousand Oaks, CA: SAGE Publications, 2013; Gerring, John. “What Is a Case Study and What Is It Good for?” American Political Science Review 98 (May 2004): 341-354; Mills, Albert J. , Gabrielle Durepos, and Eiden Wiebe, editors. Encyclopedia of Case Study Research . Thousand Oaks, CA: SAGE Publications, 2010; Seawright, Jason and John Gerring. "Case Selection Techniques in Case Study Research." Political Research Quarterly 61 (June 2008): 294-308.

Structure and Writing Style

The purpose of a paper in the social sciences designed around a case study is to thoroughly investigate a subject of analysis in order to reveal a new understanding about the research problem and, in so doing, contributing new knowledge to what is already known from previous studies. In applied social sciences disciplines [e.g., education, social work, public administration, etc.], case studies may also be used to reveal best practices, highlight key programs, or investigate interesting aspects of professional work.

In general, the structure of a case study research paper is not all that different from a standard college-level research paper. However, there are subtle differences you should be aware of. Here are the key elements to organizing and writing a case study research paper.

I.  Introduction

As with any research paper, your introduction should serve as a roadmap for your readers to ascertain the scope and purpose of your study . The introduction to a case study research paper, however, should not only describe the research problem and its significance, but you should also succinctly describe why the case is being used and how it relates to addressing the problem. The two elements should be linked. With this in mind, a good introduction answers these four questions:

• What is being studied? Describe the research problem and describe the subject of analysis [the case] you have chosen to address the problem. Explain how they are linked and what elements of the case will help to expand knowledge and understanding about the problem.
• Why is this topic important to investigate? Describe the significance of the research problem and state why a case study design and the subject of analysis that the paper is designed around is appropriate in addressing the problem.
• What did we know about this topic before I did this study? Provide background that helps lead the reader into the more in-depth literature review to follow. If applicable, summarize prior case study research applied to the research problem and why it fails to adequately address the problem. Describe why your case will be useful. If no prior case studies have been used to address the research problem, explain why you have selected this subject of analysis.
• How will this study advance new knowledge or new ways of understanding? Explain why your case study will be suitable in helping to expand knowledge and understanding about the research problem.

Each of these questions should be addressed in no more than a few paragraphs. Exceptions to this can be when you are addressing a complex research problem or subject of analysis that requires more in-depth background information.

II.  Literature Review

The literature review for a case study research paper is generally structured the same as it is for any college-level research paper. The difference, however, is that the literature review is focused on providing background information and  enabling historical interpretation of the subject of analysis in relation to the research problem the case is intended to address . This includes synthesizing studies that help to:

• Place relevant works in the context of their contribution to understanding the case study being investigated . This would involve summarizing studies that have used a similar subject of analysis to investigate the research problem. If there is literature using the same or a very similar case to study, you need to explain why duplicating past research is important [e.g., conditions have changed; prior studies were conducted long ago, etc.].
• Describe the relationship each work has to the others under consideration that informs the reader why this case is applicable . Your literature review should include a description of any works that support using the case to investigate the research problem and the underlying research questions.
• Identify new ways to interpret prior research using the case study . If applicable, review any research that has examined the research problem using a different research design. Explain how your use of a case study design may reveal new knowledge or a new perspective or that can redirect research in an important new direction.
• Resolve conflicts amongst seemingly contradictory previous studies . This refers to synthesizing any literature that points to unresolved issues of concern about the research problem and describing how the subject of analysis that forms the case study can help resolve these existing contradictions.
• Point the way in fulfilling a need for additional research . Your review should examine any literature that lays a foundation for understanding why your case study design and the subject of analysis around which you have designed your study may reveal a new way of approaching the research problem or offer a perspective that points to the need for additional research.
• Expose any gaps that exist in the literature that the case study could help to fill . Summarize any literature that not only shows how your subject of analysis contributes to understanding the research problem, but how your case contributes to a new way of understanding the problem that prior research has failed to do.
• Locate your own research within the context of existing literature [very important!] . Collectively, your literature review should always place your case study within the larger domain of prior research about the problem. The overarching purpose of reviewing pertinent literature in a case study paper is to demonstrate that you have thoroughly identified and synthesized prior studies in relation to explaining the relevance of the case in addressing the research problem.

III.  Method

In this section, you explain why you selected a particular case [i.e., subject of analysis] and the strategy you used to identify and ultimately decide that your case was appropriate in addressing the research problem. The way you describe the methods used varies depending on the type of subject of analysis that constitutes your case study.

If your subject of analysis is an incident or event . In the social and behavioral sciences, the event or incident that represents the case to be studied is usually bounded by time and place, with a clear beginning and end and with an identifiable location or position relative to its surroundings. The subject of analysis can be a rare or critical event or it can focus on a typical or regular event. The purpose of studying a rare event is to illuminate new ways of thinking about the broader research problem or to test a hypothesis. Critical incident case studies must describe the method by which you identified the event and explain the process by which you determined the validity of this case to inform broader perspectives about the research problem or to reveal new findings. However, the event does not have to be a rare or uniquely significant to support new thinking about the research problem or to challenge an existing hypothesis. For example, Walo, Bull, and Breen conducted a case study to identify and evaluate the direct and indirect economic benefits and costs of a local sports event in the City of Lismore, New South Wales, Australia. The purpose of their study was to provide new insights from measuring the impact of a typical local sports event that prior studies could not measure well because they focused on large "mega-events." Whether the event is rare or not, the methods section should include an explanation of the following characteristics of the event: a) when did it take place; b) what were the underlying circumstances leading to the event; and, c) what were the consequences of the event in relation to the research problem.

If your subject of analysis is a person. Explain why you selected this particular individual to be studied and describe what experiences they have had that provide an opportunity to advance new understandings about the research problem. Mention any background about this person which might help the reader understand the significance of their experiences that make them worthy of study. This includes describing the relationships this person has had with other people, institutions, and/or events that support using them as the subject for a case study research paper. It is particularly important to differentiate the person as the subject of analysis from others and to succinctly explain how the person relates to examining the research problem [e.g., why is one politician in a particular local election used to show an increase in voter turnout from any other candidate running in the election]. Note that these issues apply to a specific group of people used as a case study unit of analysis [e.g., a classroom of students].

If your subject of analysis is a place. In general, a case study that investigates a place suggests a subject of analysis that is unique or special in some way and that this uniqueness can be used to build new understanding or knowledge about the research problem. A case study of a place must not only describe its various attributes relevant to the research problem [e.g., physical, social, historical, cultural, economic, political], but you must state the method by which you determined that this place will illuminate new understandings about the research problem. It is also important to articulate why a particular place as the case for study is being used if similar places also exist [i.e., if you are studying patterns of homeless encampments of veterans in open spaces, explain why you are studying Echo Park in Los Angeles rather than Griffith Park?]. If applicable, describe what type of human activity involving this place makes it a good choice to study [e.g., prior research suggests Echo Park has more homeless veterans].

If your subject of analysis is a phenomenon. A phenomenon refers to a fact, occurrence, or circumstance that can be studied or observed but with the cause or explanation to be in question. In this sense, a phenomenon that forms your subject of analysis can encompass anything that can be observed or presumed to exist but is not fully understood. In the social and behavioral sciences, the case usually focuses on human interaction within a complex physical, social, economic, cultural, or political system. For example, the phenomenon could be the observation that many vehicles used by ISIS fighters are small trucks with English language advertisements on them. The research problem could be that ISIS fighters are difficult to combat because they are highly mobile. The research questions could be how and by what means are these vehicles used by ISIS being supplied to the militants and how might supply lines to these vehicles be cut off? How might knowing the suppliers of these trucks reveal larger networks of collaborators and financial support? A case study of a phenomenon most often encompasses an in-depth analysis of a cause and effect that is grounded in an interactive relationship between people and their environment in some way.

NOTE:   The choice of the case or set of cases to study cannot appear random. Evidence that supports the method by which you identified and chose your subject of analysis should clearly support investigation of the research problem and linked to key findings from your literature review. Be sure to cite any studies that helped you determine that the case you chose was appropriate for examining the problem.

IV.  Discussion

The main elements of your discussion section are generally the same as any research paper, but centered around interpreting and drawing conclusions about the key findings from your analysis of the case study. Note that a general social sciences research paper may contain a separate section to report findings. However, in a paper designed around a case study, it is common to combine a description of the results with the discussion about their implications. The objectives of your discussion section should include the following:

Reiterate the Research Problem/State the Major Findings Briefly reiterate the research problem you are investigating and explain why the subject of analysis around which you designed the case study were used. You should then describe the findings revealed from your study of the case using direct, declarative, and succinct proclamation of the study results. Highlight any findings that were unexpected or especially profound.

Explain the Meaning of the Findings and Why They are Important Systematically explain the meaning of your case study findings and why you believe they are important. Begin this part of the section by repeating what you consider to be your most important or surprising finding first, then systematically review each finding. Be sure to thoroughly extrapolate what your analysis of the case can tell the reader about situations or conditions beyond the actual case that was studied while, at the same time, being careful not to misconstrue or conflate a finding that undermines the external validity of your conclusions.

Relate the Findings to Similar Studies No study in the social sciences is so novel or possesses such a restricted focus that it has absolutely no relation to previously published research. The discussion section should relate your case study results to those found in other studies, particularly if questions raised from prior studies served as the motivation for choosing your subject of analysis. This is important because comparing and contrasting the findings of other studies helps support the overall importance of your results and it highlights how and in what ways your case study design and the subject of analysis differs from prior research about the topic.

Consider Alternative Explanations of the Findings Remember that the purpose of social science research is to discover and not to prove. When writing the discussion section, you should carefully consider all possible explanations revealed by the case study results, rather than just those that fit your hypothesis or prior assumptions and biases. Be alert to what the in-depth analysis of the case may reveal about the research problem, including offering a contrarian perspective to what scholars have stated in prior research if that is how the findings can be interpreted from your case.

Acknowledge the Study's Limitations You can state the study's limitations in the conclusion section of your paper but describing the limitations of your subject of analysis in the discussion section provides an opportunity to identify the limitations and explain why they are not significant. This part of the discussion section should also note any unanswered questions or issues your case study could not address. More detailed information about how to document any limitations to your research can be found here .

Suggest Areas for Further Research Although your case study may offer important insights about the research problem, there are likely additional questions related to the problem that remain unanswered or findings that unexpectedly revealed themselves as a result of your in-depth analysis of the case. Be sure that the recommendations for further research are linked to the research problem and that you explain why your recommendations are valid in other contexts and based on the original assumptions of your study.

V.  Conclusion

As with any research paper, you should summarize your conclusion in clear, simple language; emphasize how the findings from your case study differs from or supports prior research and why. Do not simply reiterate the discussion section. Provide a synthesis of key findings presented in the paper to show how these converge to address the research problem. If you haven't already done so in the discussion section, be sure to document the limitations of your case study and any need for further research.

The function of your paper's conclusion is to: 1) reiterate the main argument supported by the findings from your case study; 2) state clearly the context, background, and necessity of pursuing the research problem using a case study design in relation to an issue, controversy, or a gap found from reviewing the literature; and, 3) provide a place to persuasively and succinctly restate the significance of your research problem, given that the reader has now been presented with in-depth information about the topic.

Consider the following points to help ensure your conclusion is appropriate:

• If the argument or purpose of your paper is complex, you may need to summarize these points for your reader.
• If prior to your conclusion, you have not yet explained the significance of your findings or if you are proceeding inductively, use the conclusion of your paper to describe your main points and explain their significance.
• Move from a detailed to a general level of consideration of the case study's findings that returns the topic to the context provided by the introduction or within a new context that emerges from your case study findings.

Note that, depending on the discipline you are writing in or the preferences of your professor, the concluding paragraph may contain your final reflections on the evidence presented as it applies to practice or on the essay's central research problem. However, the nature of being introspective about the subject of analysis you have investigated will depend on whether you are explicitly asked to express your observations in this way.

Problems to Avoid

Overgeneralization One of the goals of a case study is to lay a foundation for understanding broader trends and issues applied to similar circumstances. However, be careful when drawing conclusions from your case study. They must be evidence-based and grounded in the results of the study; otherwise, it is merely speculation. Looking at a prior example, it would be incorrect to state that a factor in improving girls access to education in Azerbaijan and the policy implications this may have for improving access in other Muslim nations is due to girls access to social media if there is no documentary evidence from your case study to indicate this. There may be anecdotal evidence that retention rates were better for girls who were engaged with social media, but this observation would only point to the need for further research and would not be a definitive finding if this was not a part of your original research agenda.

Failure to Document Limitations No case is going to reveal all that needs to be understood about a research problem. Therefore, just as you have to clearly state the limitations of a general research study , you must describe the specific limitations inherent in the subject of analysis. For example, the case of studying how women conceptualize the need for water conservation in a village in Uganda could have limited application in other cultural contexts or in areas where fresh water from rivers or lakes is plentiful and, therefore, conservation is understood more in terms of managing access rather than preserving access to a scarce resource.

Failure to Extrapolate All Possible Implications Just as you don't want to over-generalize from your case study findings, you also have to be thorough in the consideration of all possible outcomes or recommendations derived from your findings. If you do not, your reader may question the validity of your analysis, particularly if you failed to document an obvious outcome from your case study research. For example, in the case of studying the accident at the railroad crossing to evaluate where and what types of warning signals should be located, you failed to take into consideration speed limit signage as well as warning signals. When designing your case study, be sure you have thoroughly addressed all aspects of the problem and do not leave gaps in your analysis that leave the reader questioning the results.

Case Studies. Writing@CSU. Colorado State University; Gerring, John. Case Study Research: Principles and Practices . New York: Cambridge University Press, 2007; Merriam, Sharan B. Qualitative Research and Case Study Applications in Education . Rev. ed. San Francisco, CA: Jossey-Bass, 1998; Miller, Lisa L. “The Use of Case Studies in Law and Social Science Research.” Annual Review of Law and Social Science 14 (2018): TBD; Mills, Albert J., Gabrielle Durepos, and Eiden Wiebe, editors. Encyclopedia of Case Study Research . Thousand Oaks, CA: SAGE Publications, 2010; Putney, LeAnn Grogan. "Case Study." In Encyclopedia of Research Design , Neil J. Salkind, editor. (Thousand Oaks, CA: SAGE Publications, 2010), pp. 116-120; Simons, Helen. Case Study Research in Practice . London: SAGE Publications, 2009;  Kratochwill,  Thomas R. and Joel R. Levin, editors. Single-Case Research Design and Analysis: New Development for Psychology and Education .  Hilldsale, NJ: Lawrence Erlbaum Associates, 1992; Swanborn, Peter G. Case Study Research: What, Why and How? London : SAGE, 2010; Yin, Robert K. Case Study Research: Design and Methods . 6th edition. Los Angeles, CA, SAGE Publications, 2014; Walo, Maree, Adrian Bull, and Helen Breen. “Achieving Economic Benefits at Local Events: A Case Study of a Local Sports Event.” Festival Management and Event Tourism 4 (1996): 95-106.

Writing Tip

At Least Five Misconceptions about Case Study Research

Social science case studies are often perceived as limited in their ability to create new knowledge because they are not randomly selected and findings cannot be generalized to larger populations. Flyvbjerg examines five misunderstandings about case study research and systematically "corrects" each one. To quote, these are:

Misunderstanding 1 :  General, theoretical [context-independent] knowledge is more valuable than concrete, practical [context-dependent] knowledge. Misunderstanding 2 :  One cannot generalize on the basis of an individual case; therefore, the case study cannot contribute to scientific development. Misunderstanding 3 :  The case study is most useful for generating hypotheses; that is, in the first stage of a total research process, whereas other methods are more suitable for hypotheses testing and theory building. Misunderstanding 4 :  The case study contains a bias toward verification, that is, a tendency to confirm the researcher’s preconceived notions. Misunderstanding 5 :  It is often difficult to summarize and develop general propositions and theories on the basis of specific case studies [p. 221].

While writing your paper, think introspectively about how you addressed these misconceptions because to do so can help you strengthen the validity and reliability of your research by clarifying issues of case selection, the testing and challenging of existing assumptions, the interpretation of key findings, and the summation of case outcomes. Think of a case study research paper as a complete, in-depth narrative about the specific properties and key characteristics of your subject of analysis applied to the research problem.

Flyvbjerg, Bent. “Five Misunderstandings About Case-Study Research.” Qualitative Inquiry 12 (April 2006): 219-245.

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How to Analyse a Case Study

Last Updated: March 22, 2024 Fact Checked

This article was co-authored by Sarah Evans . Sarah Evans is a Public Relations & Social Media Expert based in Las Vegas, Nevada. With over 14 years of industry experience, Sarah is the Founder & CEO of Sevans PR, a Public Relations Strategy agency. Sarah’s team offers strategic communications services to help clients across industries including tech, finance, medical, real estate, law, and startups. The agency is renowned for its development of the "reputation+" methodology, a data-driven and AI-powered approach designed to elevate brand credibility, trust, awareness, and authority in a competitive marketplace. Sarah’s thought leadership has led to regular appearances on The Doctors TV show, CBS Las Vegas Now, and as an Adobe influencer. She is a respected contributor at Entrepreneur magazine, Hackernoon, Grit Daily, and KLAS Las Vegas. Sarah has been featured in PR Daily and PR Newswire and is a member of the Forbes Agency Council. She received her B.A. in Communications and Public Relations from Millikin University. This article has been fact-checked, ensuring the accuracy of any cited facts and confirming the authority of its sources. This article has been viewed 410,444 times.

Case studies are used in many professional education programs, primarily in business school, to present real-world situations to students and to assess their ability to parse out the important aspects of a given dilemma. In general, a case study should include, in order: background on the business environment, description of the given business, identification of a key problem or issue, steps taken to address the issue, your assessment of that response, and suggestions for better business strategy. The steps below will guide you through the process of analyzing a business case study in this way.

• Describe the nature of the organization under consideration and its competitors. Provide general information about the market and customer base. Indicate any significant changes in the business environment or any new endeavors upon which the business is embarking.

• Analyze its management structure, employee base, and financial history. Describe annual revenues and profit. Provide figures on employment. Include details about private ownership, public ownership, and investment holdings. Provide a brief overview of the business's leaders and command chain.

• In all likelihood, there will be several different factors at play. Decide which is the main concern of the case study by examining what most of the data talks about, the main problems facing the business, and the conclusions at the end of the study. Examples might include expansion into a new market, response to a competitor's marketing campaign, or a changing customer base. [4] X Research source

• Draw on the information you gathered and trace a chronological progression of steps taken (or not taken). Cite data included in the case study, such as increased marketing spending, purchasing of new property, changed revenue streams, etc.

• Indicate whether or not each aspect of the response met its goal and whether the response overall was well-crafted. Use numerical benchmarks, like a desired customer share, to show whether goals were met; analyze broader issues, like employee management policies, to talk about the response as a whole. [5] X Research source

• Suggest alternative or improved measures that could have been taken by the business, using specific examples and backing up your suggestions with data and calculations.

Community Q&A

• Always read a case study several times. At first, you should read just for the basic details. On each subsequent reading, look for details about a specific topic: competitors, business strategy, management structure, financial loss. Highlight phrases and sections relating to these topics and take notes. Thanks Helpful 0 Not Helpful 0
• In the preliminary stages of analyzing a case study, no detail is insignificant. The biggest numbers can often be misleading, and the point of an analysis is often to dig deeper and find otherwise unnoticed variables that drive a situation. Thanks Helpful 0 Not Helpful 0
• If you are analyzing a case study for a consulting company interview, be sure to direct your comments towards the matters handled by the company. For example, if the company deals with marketing strategy, focus on the business's successes and failures in marketing; if you are interviewing for a financial consulting job, analyze how well the business keeps their books and their investment strategy. Thanks Helpful 0 Not Helpful 0

• Do not use impassioned or emphatic language in your analysis. Business case studies are a tool for gauging your business acumen, not your personal beliefs. When assigning blame or identifying flaws in strategy, use a detached, disinterested tone. Thanks Helpful 15 Not Helpful 4

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Thanks for reading our article! If you’d like to learn more about business writing, check out our in-depth interview with Sarah Evans .

• ↑ https://plato.acadiau.ca/courses/Busi/IntroBus/CASEMETHOD.html
• ↑ https://www.gvsu.edu/cms4/asset/CC3BFEEB-C364-E1A1-A5390F221AC0FD2D/business_case_analysis_gg_final.pdf
• ↑ https://bizfluent.com/12741914/how-to-analyze-a-business-case-study
• ↑ http://www.business-fundas.com/2009/how-to-analyze-business-case-studies/
• ↑ https://writingcenter.uagc.edu/writing-case-study-analysis
• http://college.cengage.com/business/resources/casestudies/students/analyzing.htm

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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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• Case Study | Definition, Examples & Methods

Case Study | Definition, Examples & Methods

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

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

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

Table of contents

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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What the Case Study Method Really Teaches

• Nitin Nohria

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

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

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

• Nitin Nohria is the George F. Baker Jr. Professor at Harvard Business School and the former dean of HBS.

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15.7 Evaluation: Presentation and Analysis of Case Study

Learning outcomes.

By the end of this section, you will be able to:

• Revise writing to follow the genre conventions of case studies.
• Evaluate the effectiveness and quality of a case study report.

Case studies follow a structure of background and context , methods , findings , and analysis . Body paragraphs should have main points and concrete details. In addition, case studies are written in formal language with precise wording and with a specific purpose and audience (generally other professionals in the field) in mind. Case studies also adhere to the conventions of the discipline’s formatting guide ( APA Documentation and Format in this study). Compare your case study with the following rubric as a final check.

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How to Write a Case Study Analysis

Step-By-Step Instructions

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When writing a business case study analysis , you must first have a good understanding of the case study . Before you begin the steps below, read the business case carefully, taking notes all the while. It may be necessary to read the case several times to get all of the details and fully grasp the issues facing the group, company, or industry.

As you are reading, do your best to identify key issues, key players, and the most pertinent facts. After you are comfortable with the information, use the following step-by-step instructions (geared toward a single-company analysis) to write your report. To write about an industry, just adapt the steps listed here to discuss the segment as a whole.

Step 1: Investigate the Company’s History and Growth

A company’s past can greatly affect the present and future state of the organization. To begin, investigate the company’s founding, critical incidents, structure, and growth. Create a timeline of events, issues, and achievements. This timeline will come in handy for the next step. 

Step 2: Identify Strengths and Weaknesses

Using the information you gathered in step one, continue by examining and making a list of the value creation functions of the company. For example, the company may be weak in product development but strong in marketing. Make a list of problems that have occurred and note the effects they have had on the company. You should also list areas where the company has excelled. Note the effects of these incidents as well.

You're essentially conducting a partial SWOT analysis to get a better understanding of the company's strengths and weaknesses. A SWOT analysis involves documenting things like internal strengths (S) and weaknesses (W) and external opportunities (O) and threats (T). 

Step 3: Examine the External Environment

The third step involves identifying opportunities and threats within the company’s external environment. This is where the second part of the SWOT analysis (the O and the T) comes into play. Special items to note include competition within the industry, bargaining powers, and the threat of substitute products. Some examples of opportunities include expansion into new markets or new technology. Some examples of threats include increasing competition and higher interest rates.

Step 4: Analyze Your Findings

Using the information in steps 2 and 3, create an evaluation for this portion of your case study analysis. Compare the strengths and weaknesses within the company to the external threats and opportunities. Determine if the company is in a strong competitive position, and decide if it can continue at its current pace successfully.

Step 5: Identify Corporate-Level Strategy

To identify a company’s corporate-level strategy, identify and evaluate the company’s mission , goals, and actions toward those goals. Analyze the company’s line of business and its subsidiaries and acquisitions. You also want to debate the pros and cons of the company strategy to determine whether or not a change might benefit the company in the short or long term.​

Step 6: Identify Business-Level Strategy

Thus far, your case study analysis has identified the company’s corporate-level strategy. To perform a complete analysis, you will need to identify the company’s business-level strategy. (Note: If it is a single business, without multiple companies under one umbrella, and not an industry-wide review, the corporate strategy and the business-level strategy are the same.) For this part, you should identify and analyze each company’s competitive strategy, marketing strategy, costs, and general focus.

Step 7: Analyze Implementations

This portion requires that you identify and analyze the structure and control systems that the company is using to implement its business strategies. Evaluate organizational change, levels of hierarchy, employee rewards, conflicts, and other issues that are important to the company you are analyzing.

Step 8: Make Recommendations

The final part of your case study analysis should include your recommendations for the company. Every recommendation you make should be based on and supported by the context of your analysis. Never share hunches or make a baseless recommendation.

You also want to make sure that your suggested solutions are actually realistic. If the solutions cannot be implemented due to some sort of restraint, they are not realistic enough to make the final cut.

Finally, consider some of the alternative solutions that you considered and rejected. Write down the reasons why these solutions were rejected. 

Step 9: Review

Look over your analysis when you have finished writing. Critique your work to make sure every step has been covered. Look for grammatical errors , poor sentence structure, or other things that can be improved. It should be clear, accurate, and professional.

Business Case Study Analysis Tips

Keep these strategic tips in mind:

• Know the case study ​backward and forward before you begin your case study analysis.
• Give yourself enough time to write the case study analysis. You don't want to rush through it.
• Be honest in your evaluations. Don't let personal issues and opinions cloud your judgment.
• Be analytical, not descriptive.
• Proofread your work, and even let a test reader give it a once-over for dropped words or typos that you no longer can see.
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How to Write a Case Study | Examples & Methods

What is a case study?

A case study is a research approach that provides an in-depth examination of a particular phenomenon, event, organization, or individual. It involves analyzing and interpreting data to provide a comprehensive understanding of the subject under investigation. 

Case studies can be used in various disciplines, including business, social sciences, medicine ( clinical case report ), engineering, and education. The aim of a case study is to provide an in-depth exploration of a specific subject, often with the goal of generating new insights into the phenomena being studied.

When to write a case study

Case studies are often written to present the findings of an empirical investigation or to illustrate a particular point or theory. They are useful when researchers want to gain an in-depth understanding of a specific phenomenon or when they are interested in exploring new areas of inquiry. 

Case studies are also useful when the subject of the research is rare or when the research question is complex and requires an in-depth examination. A case study can be a good fit for a thesis or dissertation as well.

Case study examples

Below are some examples of case studies with their research questions:

These examples demonstrate the diversity of research questions and case studies that can be explored. From studying small businesses in Ghana to the ethical issues in supply chains, case studies can be used to explore a wide range of phenomena.

Outlying cases vs. representative cases

An outlying case stud y refers to a case that is unusual or deviates significantly from the norm. An example of an outlying case study could be a small, family-run bed and breakfast that was able to survive and even thrive during the COVID-19 pandemic, while other larger hotels struggled to stay afloat.

On the other hand, a representative case study refers to a case that is typical of the phenomenon being studied. An example of a representative case study could be a hotel chain that operates in multiple locations that faced significant challenges during the COVID-19 pandemic, such as reduced demand for hotel rooms, increased safety and health protocols, and supply chain disruptions. The hotel chain case could be representative of the broader hospitality industry during the pandemic, and thus provides an insight into the typical challenges that businesses in the industry faced.

Steps for Writing a Case Study

As with any academic paper, writing a case study requires careful preparation and research before a single word of the document is ever written. Follow these basic steps to ensure that you don’t miss any crucial details when composing your case study.

Step 1: Select a case to analyze

After you have developed your statement of the problem and research question , the first step in writing a case study is to select a case that is representative of the phenomenon being investigated or that provides an outlier. For example, if a researcher wants to explore the impact of COVID-19 on the hospitality industry, they could select a representative case, such as a hotel chain that operates in multiple locations, or an outlying case, such as a small bed and breakfast that was able to pivot their business model to survive during the pandemic. Selecting the appropriate case is critical in ensuring the research question is adequately explored.

Step 2: Create a theoretical framework

Theoretical frameworks are used to guide the analysis and interpretation of data in a case study. The framework should provide a clear explanation of the key concepts, variables, and relationships that are relevant to the research question. The theoretical framework can be drawn from existing literature, or the researcher can develop their own framework based on the data collected. The theoretical framework should be developed early in the research process to guide the data collection and analysis.

To give your case analysis a strong theoretical grounding, be sure to include a literature review of references and sources relating to your topic and develop a clear theoretical framework. Your case study does not simply stand on its own but interacts with other studies related to your topic. Your case study can do one of the following: 

• Demonstrate a theory by showing how it explains the case being investigated
• Broaden a theory by identifying additional concepts and ideas that can be incorporated to strengthen it
• Confront a theory via an outlier case that does not conform to established conclusions or assumptions

Step 3: Collect data for your case study

Data collection can involve a variety of research methods , including interviews, surveys, observations, and document analyses, and it can include both primary and secondary sources . It is essential to ensure that the data collected is relevant to the research question and that it is collected in a systematic and ethical manner. Data collection methods should be chosen based on the research question and the availability of data. It is essential to plan data collection carefully to ensure that the data collected is of high quality

Step 4: Describe the case and analyze the details

The final step is to describe the case in detail and analyze the data collected. This involves identifying patterns and themes that emerge from the data and drawing conclusions that are relevant to the research question. It is essential to ensure that the analysis is supported by the data and that any limitations or alternative explanations are acknowledged.

The manner in which you report your findings depends on the type of research you are doing. Some case studies are structured like a standard academic paper, with separate sections or chapters for the methods section , results section , and discussion section , while others are structured more like a standalone literature review.

Regardless of the topic you choose to pursue, writing a case study requires a systematic and rigorous approach to data collection and analysis. By following the steps outlined above and using examples from existing literature, researchers can create a comprehensive and insightful case study that contributes to the understanding of a particular phenomenon.

Preparing Your Case Study for Publication

After completing the draft of your case study, be sure to revise and edit your work for any mistakes, including grammatical errors , punctuation errors , spelling mistakes, and awkward sentence structure . Ensure that your case study is well-structured and that your arguments are well-supported with language that follows the conventions of academic writing .  To ensure your work is polished for style and free of errors, get English editing services from Wordvice, including our paper editing services and manuscript editing services . Let our academic subject experts enhance the style and flow of your academic work so you can submit your case study with confidence.

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What Is a Case Study?

Weighing the pros and cons of this method of research

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

Cara Lustik is a fact-checker and copywriter.

Verywell / Colleen Tighe

• Pros and Cons

What Types of Case Studies Are Out There?

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

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

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

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

At a Glance

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

What Are the Benefits and Limitations of Case Studies?

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

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

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

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

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

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

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

Case Study Examples

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

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

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

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

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

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

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

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

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

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

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

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

Section 1: A Case History

This section will have the following structure and content:

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

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

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

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

Section 2: Treatment Plan

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

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

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

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

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

Need More Tips?

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

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

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

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

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

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

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

Do Your Students Know How to Analyze a Case—Really?

Explore more.

• Case Teaching
• Student Engagement

J ust as actors, athletes, and musicians spend thousands of hours practicing their craft, business students benefit from practicing their critical-thinking and decision-making skills. Students, however, often have limited exposure to real-world problem-solving scenarios; they need more opportunities to practice tackling tough business problems and deciding on—and executing—the best solutions.

To ensure students have ample opportunity to develop these critical-thinking and decision-making skills, we believe business faculty should shift from teaching mostly principles and ideas to mostly applications and practices. And in doing so, they should emphasize the case method, which simulates real-world management challenges and opportunities for students.

To help educators facilitate this shift and help students get the most out of case-based learning, we have developed a framework for analyzing cases. We call it PACADI (Problem, Alternatives, Criteria, Analysis, Decision, Implementation); it can improve learning outcomes by helping students better solve and analyze business problems, make decisions, and develop and implement strategy. Here, we’ll explain why we developed this framework, how it works, and what makes it an effective learning tool.

The Case for Cases: Helping Students Think Critically

Business students must develop critical-thinking and analytical skills, which are essential to their ability to make good decisions in functional areas such as marketing, finance, operations, and information technology, as well as to understand the relationships among these functions. For example, the decisions a marketing manager must make include strategic planning (segments, products, and channels); execution (digital messaging, media, branding, budgets, and pricing); and operations (integrated communications and technologies), as well as how to implement decisions across functional areas.

Faculty can use many types of cases to help students develop these skills. These include the prototypical “paper cases”; live cases , which feature guest lecturers such as entrepreneurs or corporate leaders and on-site visits; and multimedia cases , which immerse students into real situations. Most cases feature an explicit or implicit decision that a protagonist—whether it is an individual, a group, or an organization—must make.

For students new to learning by the case method—and even for those with case experience—some common issues can emerge; these issues can sometimes be a barrier for educators looking to ensure the best possible outcomes in their case classrooms. Unsure of how to dig into case analysis on their own, students may turn to the internet or rely on former students for “answers” to assigned cases. Or, when assigned to provide answers to assignment questions in teams, students might take a divide-and-conquer approach but not take the time to regroup and provide answers that are consistent with one other.

To help address these issues, which we commonly experienced in our classes, we wanted to provide our students with a more structured approach for how they analyze cases—and to really think about making decisions from the protagonists’ point of view. We developed the PACADI framework to address this need.

PACADI: A Six-Step Decision-Making Approach

The PACADI framework is a six-step decision-making approach that can be used in lieu of traditional end-of-case questions. It offers a structured, integrated, and iterative process that requires students to analyze case information, apply business concepts to derive valuable insights, and develop recommendations based on these insights.

Prior to beginning a PACADI assessment, which we’ll outline here, students should first prepare a two-paragraph summary—a situation analysis—that highlights the key case facts. Then, we task students with providing a five-page PACADI case analysis (excluding appendices) based on the following six steps.

Step 1: Problem definition. What is the major challenge, problem, opportunity, or decision that has to be made? If there is more than one problem, choose the most important one. Often when solving the key problem, other issues will surface and be addressed. The problem statement may be framed as a question; for example, How can brand X improve market share among millennials in Canada? Usually the problem statement has to be re-written several times during the analysis of a case as students peel back the layers of symptoms or causation.

Step 2: Alternatives. Identify in detail the strategic alternatives to address the problem; three to five options generally work best. Alternatives should be mutually exclusive, realistic, creative, and feasible given the constraints of the situation. Doing nothing or delaying the decision to a later date are not considered acceptable alternatives.

Step 3: Criteria. What are the key decision criteria that will guide decision-making? In a marketing course, for example, these may include relevant marketing criteria such as segmentation, positioning, advertising and sales, distribution, and pricing. Financial criteria useful in evaluating the alternatives should be included—for example, income statement variables, customer lifetime value, payback, etc. Students must discuss their rationale for selecting the decision criteria and the weights and importance for each factor.

Step 4: Analysis. Provide an in-depth analysis of each alternative based on the criteria chosen in step three. Decision tables using criteria as columns and alternatives as rows can be helpful. The pros and cons of the various choices as well as the short- and long-term implications of each may be evaluated. Best, worst, and most likely scenarios can also be insightful.

Step 5: Decision. Students propose their solution to the problem. This decision is justified based on an in-depth analysis. Explain why the recommendation made is the best fit for the criteria.

Step 6: Implementation plan. Sound business decisions may fail due to poor execution. To enhance the likeliness of a successful project outcome, students describe the key steps (activities) to implement the recommendation, timetable, projected costs, expected competitive reaction, success metrics, and risks in the plan.

“Students note that using the PACADI framework yields ‘aha moments’—they learned something surprising in the case that led them to think differently about the problem and their proposed solution.”

PACADI’s Benefits: Meaningfully and Thoughtfully Applying Business Concepts

The PACADI framework covers all of the major elements of business decision-making, including implementation, which is often overlooked. By stepping through the whole framework, students apply relevant business concepts and solve management problems via a systematic, comprehensive approach; they’re far less likely to surface piecemeal responses.

As students explore each part of the framework, they may realize that they need to make changes to a previous step. For instance, when working on implementation, students may realize that the alternative they selected cannot be executed or will not be profitable, and thus need to rethink their decision. Or, they may discover that the criteria need to be revised since the list of decision factors they identified is incomplete (for example, the factors may explain key marketing concerns but fail to address relevant financial considerations) or is unrealistic (for example, they suggest a 25 percent increase in revenues without proposing an increased promotional budget).

In addition, the PACADI framework can be used alongside quantitative assignments, in-class exercises, and business and management simulations. The structured, multi-step decision framework encourages careful and sequential analysis to solve business problems. Incorporating PACADI as an overarching decision-making method across different projects will ultimately help students achieve desired learning outcomes. As a practical “beyond-the-classroom” tool, the PACADI framework is not a contrived course assignment; it reflects the decision-making approach that managers, executives, and entrepreneurs exercise daily. Case analysis introduces students to the real-world process of making business decisions quickly and correctly, often with limited information. This framework supplies an organized and disciplined process that students can readily defend in writing and in class discussions.

PACADI in Action: An Example

Here’s an example of how students used the PACADI framework for a recent case analysis on CVS, a large North American drugstore chain.

The CVS Prescription for Customer Value*

PACADI Stage

Summary Response

How should CVS Health evolve from the “drugstore of your neighborhood” to the “drugstore of your future”?

Alternatives

A1. Kaizen (continuous improvement)

A2. Product development

A3. Market development

A4. Personalization (micro-targeting)

Criteria (include weights)

C1. Customer value: service, quality, image, and price (40%)

C2. Customer obsession (20%)

C3. Growth through related businesses (20%)

C4. Customer retention and customer lifetime value (20%)

Each alternative was analyzed by each criterion using a Customer Value Assessment Tool

Alternative 4 (A4): Personalization was selected. This is operationalized via: segmentation—move toward segment-of-1 marketing; geodemographics and lifestyle emphasis; predictive data analysis; relationship marketing; people, principles, and supply chain management; and exceptional customer service.

Implementation

Partner with leading medical school

Curbside pick-up

Pet pharmacy

E-newsletter for customers and employees

Employee incentive program

CVS beauty days

Expand to Latin America and Caribbean

Healthier/happier corner

Holiday toy drives/community outreach

*Source: A. Weinstein, Y. Rodriguez, K. Sims, R. Vergara, “The CVS Prescription for Superior Customer Value—A Case Study,” Back to the Future: Revisiting the Foundations of Marketing from Society for Marketing Advances, West Palm Beach, FL (November 2, 2018).

Results of Using the PACADI Framework

When faculty members at our respective institutions at Nova Southeastern University (NSU) and the University of North Carolina Wilmington have used the PACADI framework, our classes have been more structured and engaging. Students vigorously debate each element of their decision and note that this framework yields an “aha moment”—they learned something surprising in the case that led them to think differently about the problem and their proposed solution.

These lively discussions enhance individual and collective learning. As one external metric of this improvement, we have observed a 2.5 percent increase in student case grade performance at NSU since this framework was introduced.

Tips to Get Started

The PACADI approach works well in in-person, online, and hybrid courses. This is particularly important as more universities have moved to remote learning options. Because students have varied educational and cultural backgrounds, work experience, and familiarity with case analysis, we recommend that faculty members have students work on their first case using this new framework in small teams (two or three students). Additional analyses should then be solo efforts.

To use PACADI effectively in your classroom, we suggest the following:

Advise your students that your course will stress critical thinking and decision-making skills, not just course concepts and theory.

Use a varied mix of case studies. As marketing professors, we often address consumer and business markets; goods, services, and digital commerce; domestic and global business; and small and large companies in a single MBA course.

As a starting point, provide a short explanation (about 20 to 30 minutes) of the PACADI framework with a focus on the conceptual elements. You can deliver this face to face or through videoconferencing.

Give students an opportunity to practice the case analysis methodology via an ungraded sample case study. Designate groups of five to seven students to discuss the case and the six steps in breakout sessions (in class or via Zoom).

Ensure case analyses are weighted heavily as a grading component. We suggest 30–50 percent of the overall course grade.

Once cases are graded, debrief with the class on what they did right and areas needing improvement (30- to 40-minute in-person or Zoom session).

Encourage faculty teams that teach common courses to build appropriate instructional materials, grading rubrics, videos, sample cases, and teaching notes.

When selecting case studies, we have found that the best ones for PACADI analyses are about 15 pages long and revolve around a focal management decision. This length provides adequate depth yet is not protracted. Some of our tested and favorite marketing cases include Brand W , Hubspot , Kraft Foods Canada , TRSB(A) , and Whiskey & Cheddar .

Art Weinstein , Ph.D., is a professor of marketing at Nova Southeastern University, Fort Lauderdale, Florida. He has published more than 80 scholarly articles and papers and eight books on customer-focused marketing strategy. His latest book is Superior Customer Value—Finding and Keeping Customers in the Now Economy . Dr. Weinstein has consulted for many leading technology and service companies.

Herbert V. Brotspies , D.B.A., is an adjunct professor of marketing at Nova Southeastern University. He has over 30 years’ experience as a vice president in marketing, strategic planning, and acquisitions for Fortune 50 consumer products companies working in the United States and internationally. His research interests include return on marketing investment, consumer behavior, business-to-business strategy, and strategic planning.

John T. Gironda , Ph.D., is an assistant professor of marketing at the University of North Carolina Wilmington. His research has been published in Industrial Marketing Management, Psychology & Marketing , and Journal of Marketing Management . He has also presented at major marketing conferences including the American Marketing Association, Academy of Marketing Science, and Society for Marketing Advances.

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Your Step-By-Step Guide To Writing a Case Study

Creating a case study is both an art and a science. It requires making an in-depth exploration of your chosen subject in order to extract meaningful insights and understand the dynamics that more general surveys or statistical research might not uncover. At the same time, your case study also needs to be a compelling read to ensure those insights get attention from other people!

Unsurprisingly, the prospect of crafting an effective case study can be daunting. It calls for strategic planning, careful organization, and clear communication, all of which can be challenging even for experienced researchers. That's why we've created this step-by-step guide, which breaks the process down into manageable steps, demystifying the journey from defining your research question to sharing your findings. Whether you're a seasoned researcher or a first-timer, this guide aims to equip you with the necessary tools and tips to create a case study that's not just informative, but also engaging and impactful.

Are you ready to unlock the potential of case studies? Let's dive in!

What is a case study?

First, it's important to understand what a case study is – and what it isn't.

A case study is a thorough exploration of a specific subject or event over a certain time frame. Case studies are utilized in numerous fields, including sociology, psychology, education, anthropology, business, and the health sciences, and employ various research techniques to shed light on complex issues.

A case study does not provide absolute proof or conclusions that can be universally applied. Because it concentrates on one particular case or just a few cases, the findings might not apply to different contexts or subjects. Case studies also aren't ideal for determining cause-and-effect relationships as they do not use controlled conditions to separate and measure the impacts of different factors. Lastly, it must be said that a case study isn't just a random assortment of facts or observations; it necessitates a clear research question, a methodical approach to data collection and analysis, and a thoughtful interpretation of the results.

Getting started

Now that we've established the definition and purpose of a case study, let's explore the process by which one is created. You can produce a case study by following these nine steps:

1. Define the purpose of your case study

Before you start writing a case study, you need to define its purpose clearly. Ask yourself: What is the research question or problem you aim to solve? What insights are you looking to uncover? Your goals will guide your research design and influence your choice of case. This initial stage of introspection and clarification is crucial as it acts as a roadmap for your study.

2. Select the case to study

Once you've defined your research objective, the next step is to choose a suitable case that can help answer your research question. This might be a unique, critical, or representative instance. Unique cases offer the opportunity to observe and analyze a situation that is unusual or not well-understood. In contrast, a representative or typical case is often chosen because it represents other cases or a broader phenomenon.

In any case, be sure to justify your choice. Explain why the case is of interest and how it can contribute to the knowledge or understanding of the issue at hand. For instance, if you're studying the effects of corporate restructuring on employee morale, you might choose to focus on a company that recently underwent a significant restructure.

3. Conduct a thorough literature review

Performing a literature review involves a careful examination of relevant scholarly articles, books, and other sources related to your research question or problem. In the process, you identify gaps in the current knowledge and determine how your case study can address them. By critically examining existing research, you will not only gain a comprehensive understanding of your chosen topic but also be able to refine your research question or hypothesis, if necessary.

4. Choose a methodological approach

The methodological approach used in your case study will depend on your research objectives and the nature of the case. Methodologies that can be employed in case studies include qualitative, quantitative, and mixed methods .

Qualitative methods are often used when the goal is to explore, understand, or interpret certain phenomena. These involve approaches like interviews, focus groups, or ethnography. Quantitative methods, on the other hand, are used when the goal is to test hypotheses or examine relationships between variables. Quantitative approaches often include experiments. Also, surveys may be either qualitative or quantitative depending on the question design.

You may choose to use a combination of qualitative and quantitative methods (mixed methods) if it suits your research objectives.

5. Collect and organize your data

Data collection should be systematic and organized to maintain the integrity and reliability of your research. You need to plan how you will record and store your data to ensure that it's accessible and usable.

If you're conducting interviews or observations, consider using recording devices (with participant consent) to capture the data accurately. In addition, you may want to transcribe the recorded material for easier analysis. If you're using documents or archival records, develop a system for coding and categorizing the data.

6. Analyze the data

Analysis involves interpreting your data to draw out meaningful insights; it is in this stage that your findings start to take shape. Depending on the nature of your data and your research question, you might use any of a variety of analysis methods. For qualitative data, you might employ thematic analysis to identify key themes or grounded theory to generate a new theoretical framework. For quantitative data, you might use statistical analysis to identify patterns or correlations.

Always be open to unexpected findings. Your initial hypotheses might not be supported, or you might uncover new insights that you hadn't initially considered. Remember that all data, whether they fit neatly into your analysis or not, provide valuable insights and contribute to the holistic understanding of your case.

7. Write the case study report

After analyzing the data, it's finally time to compose your case study. In terms of structure, a typical case study might consist of an introduction, background information, the collected data (results), analysis of that data, and the conclusion. Here's a brief breakdown of each section:

• Introduction: The introduction should be brief but engaging, providing a clear statement of the research question or problem, explaining why the case was chosen, and outlining what the case study will cover.
• Background: The background provides the context for your case. Describe the case, its history, and any relevant information that will help readers understand the situation.
• Results: This section should provide a comprehensive account of what you found, without interpretation or opinion. Present your findings in a clear, organized manner. Use visuals such as charts or graphs if they aid comprehension.
• Analysis: This section should provide your interpretations and arguments. Discuss the patterns, themes, or relationships you've identified in your data. Explain what these findings mean in relation to your research question.
• Conclusion: Finally, summarize the key insights from your case study along with their implications. Discuss the limitations of your study and propose avenues for future research.

8. Review and revise

The process of writing a case study doesn't actually end when the report is written; you also need to review your writing for coherence, clarity, and correctness. Don't underestimate the importance of this step! Make sure the information flows logically and that your arguments are well-supported. Check for any grammar or spelling errors. Having a peer or mentor review your work can be incredibly helpful as they provide a fresh perspective and can catch mistakes you might have missed.

9. Get approval if required

If your case study involves human subjects, you may need to obtain approval from an ethical review board. You'll also need to obtain informed consent from your subjects and ensure you respect their privacy and confidentiality throughout the research process. Always follow your institution's ethical guidelines and any other relevant legislation .

Practical tips for writing a compelling case study

Getting through all those steps can feel like a formidable challenge, but here are some practical tips to make the process more manageable:

Be systematic and organized

Given the importance of detail in case studies, it's vital to be systematic and organized from the get-go. This means keeping meticulous records of your data, your sources, and any changes to your research design. A good practice is to maintain a research journal or log where you can record your process, thoughts, and reflections.

In addition, use technology to your advantage. Digital tools like citation managers can help you keep track of your sources and make formatting references a breeze, while spreadsheet or database software can assist in managing and organizing your data. Developing a consistent system for labeling and storing information at the outset will save you time and effort later when you need to retrieve data for analysis.

Stay focused

One common pitfall in research and writing is loss of focus: getting sidetracked by interesting but ultimately irrelevant digressions, which can be very easy, especially when you're dealing with a rich and complex case. Always remember your research question and objectives, and let these guide your study at every step. It's perfectly acceptable – and in fact advisable – to delineate what your study will not cover. Setting clear boundaries can help you stay focused and manage the scope of your study effectively.

Use visual aids

Visual aids such as charts, diagrams, or photographs can greatly enhance your case study. They provide readers with a break from the monotony of text and can communicate complex data or relationships more easily. For instance, if you're presenting a lot of numerical data, consider using a chart or graph. If you're describing a process or sequence of events, portraying it in a flowchart or timeline might be useful. Remember, the goal is to aid comprehension, so make sure your visual aids are clear, well-labeled, and integrated into the text.

Include direct quotes

If your case study involves interviews, including direct quotes can add depth and a sense of the personal to your findings. They provide readers with a firsthand perspective and make your case study more engaging.

When using quotes, be sure to integrate them smoothly into your text. Provide enough context so readers understand the quote's relevance. Also, remember to adhere to ethical guidelines– always respect confidentiality and anonymity agreements.

Maintain ethical standards

Ethics is a fundamental consideration in all research, including case studies. Ensure you have proper consent from participants, respect their privacy, and accurately present your findings without manipulation.

Misrepresenting data or failing to respect participants' rights can lead to serious ethical violations. Always follow your institution's ethical guidelines and any other relevant legislation. If in doubt, seek advice from a supervisor or your institution's ethics committee.

Acknowledge limitations

Every research study has limitations, which could relate to the research design, data collection methods, or other aspects of the study. Being transparent about the limitations of your study can enhance its credibility; moreover, not only does identifying limitations demonstrate your critical thinking and honesty, but it also helps readers accurately interpret your findings.

Finally, acknowledging the limitations of your work helps to set the stage for further research. By identifying aspects that your study couldn't address, you provide other researchers with avenues for building on your findings.

Learn from examples

Before you start writing your case study, it can be helpful to review some published case studies in your field. Different fields may have different conventions, and familiarizing yourself with case studies in your own field can help guide your writing. Look at the structure, tone, and style. Pay attention to how the authors present and analyze data, and how they link their findings back to the research question. You can also learn a lot from the strengths and weaknesses of previously published works. However, remember to develop your own unique voice and perspective – don't just mimic what others have done.

Design for triangulation

Triangulation involves using multiple data sources or methods to gain a more comprehensive and balanced understanding of your research topic. By coming at your research question from multiple directions, such as by examining different datasets or using different methods, you can increase the validity of your results and gain more nuanced insights.

For example, if you're studying the impact of a new teaching method in a school, you might observe classes, interview teachers, and also survey students. Each method will provide a slightly different perspective, and together, they allow you to develop a more complete picture of the teaching method's impact.

Practice reflexivity

Reflexivity involves reflecting on how your assumptions, values, or experiences might influence your research process and interpretations. As a researcher, it's essential to be aware of your potential biases and how they might shape your study.

Consider keeping a reflexivity journal where you can note your thoughts, feelings, and reflections throughout the research process. This practice can help you stay aware of your biases and ensure your research is as objective and balanced as possible.

Write for your audience

Always make sure that your writing is on target for your intended audience. If you're writing for an academic audience, for example, you'll likely use a more formal tone and include more detailed methodological information. If you're writing for practitioners or a general audience, you might use a more accessible language and focus more on practical implications.

Remember to define any technical terms or jargon, and provide sufficient context so your readers can understand your research. The goal is to communicate your findings effectively, regardless of who your readers are.

Seek feedback

Feedback is valuable for improving your case study. Consider sharing drafts with your peers, mentors, or supervisors and asking for their input. Fresh eyes can provide different perspectives, catch errors, or suggest ways to strengthen your arguments.

Remember, feedback is not personal; it's about improving your work. Be open to critique and willing to revise your work based on the feedback you receive.

Writing a case study is a meticulous process that requires clear purpose, careful planning, systematic data collection, and thoughtful analysis. Although it can be time-consuming, the rich, detailed insights a well-executed case study can provide make this study design an invaluable tool in research.

By following this guide and adopting its practical tips, you will be well on your way to crafting a compelling case study that contributes meaningful insights to your chosen field. Good luck with your research journey!

Header image by Kateryna Hliznitsova .

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What is a case study?

A case study is a type of research method. In case studies, the unit of analysis is a case . The case typically provides a detailed account of a situation that usually focuses on a conflict or complexity that one might encounter in the workplace.

• Case studies help explain the process by which a unit (a person, department, business, organization, industry, country, etc.) deals with the issue or problem confronting it, and offers possible solutions that can be applied to other units facing similar situations.
• The information presented in case studies is usually qualitative in nature - gathered through methods such as interview, observation, and document collection.
• There are different types of case study, including  intrinsic, instrumental, naturalistic,  and  pragmatic.

This research guide will assist you in finding individual case studies, as well as providing information on designing case studies. If you need assistance locating information, please Ask a Librarian .

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• Last Updated: Nov 2, 2023 2:39 PM
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How to write a case study — examples, templates, and tools

It’s a marketer’s job to communicate the effectiveness of a product or service to potential and current customers to convince them to buy and keep business moving. One of the best methods for doing this is to share success stories that are relatable to prospects and customers based on their pain points, experiences, and overall needs.

That’s where case studies come in. Case studies are an essential part of a content marketing plan. These in-depth stories of customer experiences are some of the most effective at demonstrating the value of a product or service. Yet many marketers don’t use them, whether because of their regimented formats or the process of customer involvement and approval.

A case study is a powerful tool for showcasing your hard work and the success your customer achieved. But writing a great case study can be difficult if you’ve never done it before or if it’s been a while. This guide will show you how to write an effective case study and provide real-world examples and templates that will keep readers engaged and support your business.

In this article, you’ll learn:

What is a case study?

How to write a case study, case study templates, case study examples, case study tools.

A case study is the detailed story of a customer’s experience with a product or service that demonstrates their success and often includes measurable outcomes. Case studies are used in a range of fields and for various reasons, from business to academic research. They’re especially impactful in marketing as brands work to convince and convert consumers with relatable, real-world stories of actual customer experiences.

The best case studies tell the story of a customer’s success, including the steps they took, the results they achieved, and the support they received from a brand along the way. To write a great case study, you need to:

• Celebrate the customer and make them — not a product or service — the star of the story.
• Craft the story with specific audiences or target segments in mind so that the story of one customer will be viewed as relatable and actionable for another customer.
• Write copy that is easy to read and engaging so that readers will gain the insights and messages intended.
• Follow a standardized format that includes all of the essentials a potential customer would find interesting and useful.
• Support all of the claims for success made in the story with data in the forms of hard numbers and customer statements.

Case studies are a type of review but more in depth, aiming to show — rather than just tell — the positive experiences that customers have with a brand. Notably, 89% of consumers read reviews before deciding to buy, and 79% view case study content as part of their purchasing process. When it comes to B2B sales, 52% of buyers rank case studies as an important part of their evaluation process.

Telling a brand story through the experience of a tried-and-true customer matters. The story is relatable to potential new customers as they imagine themselves in the shoes of the company or individual featured in the case study. Showcasing previous customers can help new ones see themselves engaging with your brand in the ways that are most meaningful to them.

Besides sharing the perspective of another customer, case studies stand out from other content marketing forms because they are based on evidence. Whether pulling from client testimonials or data-driven results, case studies tend to have more impact on new business because the story contains information that is both objective (data) and subjective (customer experience) — and the brand doesn’t sound too self-promotional.

Case studies are unique in that there’s a fairly standardized format for telling a customer’s story. But that doesn’t mean there isn’t room for creativity. It’s all about making sure that teams are clear on the goals for the case study — along with strategies for supporting content and channels — and understanding how the story fits within the framework of the company’s overall marketing goals.

Here are the basic steps to writing a good case study.

1. Identify your goal

Start by defining exactly who your case study will be designed to help. Case studies are about specific instances where a company works with a customer to achieve a goal. Identify which customers are likely to have these goals, as well as other needs the story should cover to appeal to them.

The answer is often found in one of the buyer personas that have been constructed as part of your larger marketing strategy. This can include anything from new leads generated by the marketing team to long-term customers that are being pressed for cross-sell opportunities. In all of these cases, demonstrating value through a relatable customer success story can be part of the solution to conversion.

2. Choose your client or subject

Who you highlight matters. Case studies tie brands together that might otherwise not cross paths. A writer will want to ensure that the highlighted customer aligns with their own company’s brand identity and offerings. Look for a customer with positive name recognition who has had great success with a product or service and is willing to be an advocate.

The client should also match up with the identified target audience. Whichever company or individual is selected should be a reflection of other potential customers who can see themselves in similar circumstances, having the same problems and possible solutions.

Some of the most compelling case studies feature customers who:

• Switch from one product or service to another while naming competitors that missed the mark.
• Experience measurable results that are relatable to others in a specific industry.
• Represent well-known brands and recognizable names that are likely to compel action.
• Advocate for a product or service as a champion and are well-versed in its advantages.

Whoever or whatever customer is selected, marketers must ensure they have the permission of the company involved before getting started. Some brands have strict review and approval procedures for any official marketing or promotional materials that include their name. Acquiring those approvals in advance will prevent any miscommunication or wasted effort if there is an issue with their legal or compliance teams.

3. Conduct research and compile data

Substantiating the claims made in a case study — either by the marketing team or customers themselves — adds validity to the story. To do this, include data and feedback from the client that defines what success looks like. This can be anything from demonstrating return on investment (ROI) to a specific metric the customer was striving to improve. Case studies should prove how an outcome was achieved and show tangible results that indicate to the customer that your solution is the right one.

This step could also include customer interviews. Make sure that the people being interviewed are key stakeholders in the purchase decision or deployment and use of the product or service that is being highlighted. Content writers should work off a set list of questions prepared in advance. It can be helpful to share these with the interviewees beforehand so they have time to consider and craft their responses. One of the best interview tactics to keep in mind is to ask questions where yes and no are not natural answers. This way, your subject will provide more open-ended responses that produce more meaningful content.

4. Choose the right format

There are a number of different ways to format a case study. Depending on what you hope to achieve, one style will be better than another. However, there are some common elements to include, such as:

• An engaging headline
• A subject and customer introduction
• The unique challenge or challenges the customer faced
• The solution the customer used to solve the problem
• The results achieved
• Data and statistics to back up claims of success
• A strong call to action (CTA) to engage with the vendor

It’s also important to note that while case studies are traditionally written as stories, they don’t have to be in a written format. Some companies choose to get more creative with their case studies and produce multimedia content, depending on their audience and objectives. Case study formats can include traditional print stories, interactive web or social content, data-heavy infographics, professionally shot videos, podcasts, and more.

5. Write your case study

We’ll go into more detail later about how exactly to write a case study, including templates and examples. Generally speaking, though, there are a few things to keep in mind when writing your case study.

• Be clear and concise. Readers want to get to the point of the story quickly and easily, and they’ll be looking to see themselves reflected in the story right from the start.
• Provide a big picture. Always make sure to explain who the client is, their goals, and how they achieved success in a short introduction to engage the reader.
• Construct a clear narrative. Stick to the story from the perspective of the customer and what they needed to solve instead of just listing product features or benefits.
• Leverage graphics. Incorporating infographics, charts, and sidebars can be a more engaging and eye-catching way to share key statistics and data in readable ways.
• Offer the right amount of detail. Most case studies are one or two pages with clear sections that a reader can skim to find the information most important to them.
• Include data to support claims. Show real results — both facts and figures and customer quotes — to demonstrate credibility and prove the solution works.

6. Promote your story

Marketers have a number of options for distribution of a freshly minted case study. Many brands choose to publish case studies on their website and post them on social media. This can help support SEO and organic content strategies while also boosting company credibility and trust as visitors see that other businesses have used the product or service.

Marketers are always looking for quality content they can use for lead generation. Consider offering a case study as gated content behind a form on a landing page or as an offer in an email message. One great way to do this is to summarize the content and tease the full story available for download after the user takes an action.

Sales teams can also leverage case studies, so be sure they are aware that the assets exist once they’re published. Especially when it comes to larger B2B sales, companies often ask for examples of similar customer challenges that have been solved.

Now that you’ve learned a bit about case studies and what they should include, you may be wondering how to start creating great customer story content. Here are a couple of templates you can use to structure your case study.

Template 1 — Challenge-solution-result format

• Start with an engaging title. This should be fewer than 70 characters long for SEO best practices. One of the best ways to approach the title is to include the customer’s name and a hint at the challenge they overcame in the end.
• Create an introduction. Lead with an explanation as to who the customer is, the need they had, and the opportunity they found with a specific product or solution. Writers can also suggest the success the customer experienced with the solution they chose.
• Present the challenge. This should be several paragraphs long and explain the problem the customer faced and the issues they were trying to solve. Details should tie into the company’s products and services naturally. This section needs to be the most relatable to the reader so they can picture themselves in a similar situation.
• Share the solution. Explain which product or service offered was the ideal fit for the customer and why. Feel free to delve into their experience setting up, purchasing, and onboarding the solution.
• Explain the results. Demonstrate the impact of the solution they chose by backing up their positive experience with data. Fill in with customer quotes and tangible, measurable results that show the effect of their choice.
• Ask for action. Include a CTA at the end of the case study that invites readers to reach out for more information, try a demo, or learn more — to nurture them further in the marketing pipeline. What you ask of the reader should tie directly into the goals that were established for the case study in the first place.

Template 2 — Data-driven format

• Start with an engaging title. Be sure to include a statistic or data point in the first 70 characters. Again, it’s best to include the customer’s name as part of the title.
• Create an overview. Share the customer’s background and a short version of the challenge they faced. Present the reason a particular product or service was chosen, and feel free to include quotes from the customer about their selection process.
• Present data point 1. Isolate the first metric that the customer used to define success and explain how the product or solution helped to achieve this goal. Provide data points and quotes to substantiate the claim that success was achieved.
• Present data point 2. Isolate the second metric that the customer used to define success and explain what the product or solution did to achieve this goal. Provide data points and quotes to substantiate the claim that success was achieved.
• Present data point 3. Isolate the final metric that the customer used to define success and explain what the product or solution did to achieve this goal. Provide data points and quotes to substantiate the claim that success was achieved.
• Summarize the results. Reiterate the fact that the customer was able to achieve success thanks to a specific product or service. Include quotes and statements that reflect customer satisfaction and suggest they plan to continue using the solution.
• Ask for action. Include a CTA at the end of the case study that asks readers to reach out for more information, try a demo, or learn more — to further nurture them in the marketing pipeline. Again, remember that this is where marketers can look to convert their content into action with the customer.

While templates are helpful, seeing a case study in action can also be a great way to learn. Here are some examples of how Adobe customers have experienced success.

Juniper Networks

One example is the Adobe and Juniper Networks case study , which puts the reader in the customer’s shoes. The beginning of the story quickly orients the reader so that they know exactly who the article is about and what they were trying to achieve. Solutions are outlined in a way that shows Adobe Experience Manager is the best choice and a natural fit for the customer. Along the way, quotes from the client are incorporated to help add validity to the statements. The results in the case study are conveyed with clear evidence of scale and volume using tangible data.

The story of Lenovo’s journey with Adobe is one that spans years of planning, implementation, and rollout. The Lenovo case study does a great job of consolidating all of this into a relatable journey that other enterprise organizations can see themselves taking, despite the project size. This case study also features descriptive headers and compelling visual elements that engage the reader and strengthen the content.

Tata Consulting

When it comes to using data to show customer results, this case study does an excellent job of conveying details and numbers in an easy-to-digest manner. Bullet points at the start break up the content while also helping the reader understand exactly what the case study will be about. Tata Consulting used Adobe to deliver elevated, engaging content experiences for a large telecommunications client of its own — an objective that’s relatable for a lot of companies.

Case studies are a vital tool for any marketing team as they enable you to demonstrate the value of your company’s products and services to others. They help marketers do their job and add credibility to a brand trying to promote its solutions by using the experiences and stories of real customers.

When you’re ready to get started with a case study:

• Think about a few goals you’d like to accomplish with your content.
• Make a list of successful clients that would be strong candidates for a case study.
• Reach out to the client to get their approval and conduct an interview.
• Gather the data to present an engaging and effective customer story.

Adobe can help

There are several Adobe products that can help you craft compelling case studies. Adobe Experience Platform helps you collect data and deliver great customer experiences across every channel. Once you’ve created your case studies, Experience Platform will help you deliver the right information to the right customer at the right time for maximum impact.

To learn more, watch the Adobe Experience Platform story .

Keep in mind that the best case studies are backed by data. That’s where Adobe Real-Time Customer Data Platform and Adobe Analytics come into play. With Real-Time CDP, you can gather the data you need to build a great case study and target specific customers to deliver the content to the right audience at the perfect moment.

Watch the Real-Time CDP overview video to learn more.

Finally, Adobe Analytics turns real-time data into real-time insights. It helps your business collect and synthesize data from multiple platforms to make more informed decisions and create the best case study possible.

Request a demo to learn more about Adobe Analytics.

https://business.adobe.com/blog/perspectives/b2b-ecommerce-10-case-studies-inspire-you

https://business.adobe.com/blog/basics/business-case

https://business.adobe.com/blog/basics/what-is-real-time-analytics

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Case Study Research: Design and Methods

• https://www.betterevaluation.org/sites/default/files/24737_Chapter_5.pdf File type PDF File size 382.65 KB

This book from Robert K. Yin provides detailed guidance on case study research.  Outlining a clear definition of the case study method, the book also looks at design and analysis techniques that can be used in case study research. The book includes tutorials at the end of each chapter and a discussion of values and ethics and logic models.

This book is available to purchase from Sage Publications

Chapter five of this book is available to download from Sage Publications: Chapter 5 - Analyzing Case Study Evidence

• Chapter 1. Getting Started: How to Know Whether and When to Use the Case Study as a Research Method
• Chapter 2. Designing Case Studies: Identifying Your Case(s) and Establishing the Logic of Your Case Study
• Chapter 3. Preparing to Collect Case Study Evidence: What You Need to Do before Starting to Collect Case Study Data
• Chapter 4. Collecting Case Study Evidence: The Principles You Should Follow in Working with Six Sources of Evidence
• Chapter 5. Analyzing Case Study Evidence: How to Start Your Analysis, Your Analytic Choices, and How They Work
• Chapter 6. Reporting Case Studies: How and What to Compose
• Appendix A: A Note on the Uses of Case Study Research in Psychology
• Appendix B: A Note on the Uses of Case Study Research in Evaluations
• Appendix C: Index of Individual Case Studies (cited in BOXES or from Expanded Case Study Materials)

Yin, R. K. (2014).  Case study research: design and methods  (Fifth ed.).Sage Publications

Related links

• http://www.sagepub.com/books/Book237921/toc#tabview=toc

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Case study definition

Case study, a term which some of you may know from the "Case Study of Vanitas" anime and manga, is a thorough examination of a particular subject, such as a person, group, location, occasion, establishment, phenomena, etc. They are most frequently utilized in research of business, medicine, education and social behaviour. There are a different types of case studies that researchers might use:

• Collective case studies

• Descriptive case studies

• Explanatory case studies

• Exploratory case studies

• Instrumental case studies

• Intrinsic case studies

Case studies are usually much more sophisticated and professional than regular essays and courseworks, as they require a lot of verified data, are research-oriented and not necessarily designed to be read by the general public.

How to write a case study?

It very much depends on the topic of your case study, as a medical case study and a coffee business case study have completely different sources, outlines, target demographics, etc. But just for this example, let's outline a coffee roaster case study. Firstly, it's likely going to be a problem-solving case study, like most in the business and economics field are. Here are some tips for these types of case studies:

• Your case scenario should be precisely defined in terms of your unique assessment criteria.

• Determine the primary issues by analyzing the scenario. Think about how they connect to the main ideas and theories in your piece.

• Find and investigate any theories or methods that might be relevant to your case.

• Keep your audience in mind. Exactly who are your stakeholder(s)? If writing a case study on coffee roasters, it's probably gonna be suppliers, landlords, investors, customers, etc.

• Indicate the best solution(s) and how they should be implemented. Make sure your suggestions are grounded in pertinent theories and useful resources, as well as being realistic, practical, and attainable.

• Carefully proofread your case study. Keep in mind these four principles when editing: clarity, honesty, reality and relevance.

Are there any online services that could write a case study for me?

Luckily, there are!

We completely understand and have been ourselves in a position, where we couldn't wrap our head around how to write an effective and useful case study, but don't fear - our service is here.

We are a group that specializes in writing all kinds of case studies and other projects for academic customers and business clients who require assistance with its creation. We require our writers to have a degree in your topic and carefully interview them before they can join our team, as we try to ensure quality above all. We cover a great range of topics, offer perfect quality work, always deliver on time and aim to leave our customers completely satisfied with what they ordered.

The ordering process is fully online, and it goes as follows:

• Select the topic and the deadline of your case study.

• Provide us with any details, requirements, statements that should be emphasized or particular parts of the writing process you struggle with.

• Leave the email address, where your completed order will be sent to.

• Select your payment type, sit back and relax!

With lots of experience on the market, professionally degreed writers, online 24/7 customer support and incredibly low prices, you won't find a service offering a better deal than ours.

20+ Best Case Study PowerPoint Templates for In-Depth Analysis

In today’s dynamic professional environment, presenting in-depth case studies becomes critical for businesses and individuals alike. This compilation features over 20 of the best PowerPoint templates specifically designed for presenting comprehensive and engaging case studies. Whether you aim to detail the analysis and strategies behind a business decision, or delve into a person’s journey, these assets can streamline your process and elevate your presentation.

Each template is carefully curated, equipped with slides that cater to an array of elements necessary for a persuasive case study – presenting research, displaying data, sharing interviews, and more. With these templates at your disposal, you can easily translate raw information into an insightful and visually appealing narrative.

Available in both free and paid options, these PowerPoint templates encompass a diverse set of designs and formats. Be it a start-up pitch or an academic research presentation, this post brings forward a wide variety of quality tools for crafting impactful case studies.

One Subscription: Everything You Need for Your PowerPoint Presentation

Get everything you need to give the perfect presentation. From just $16, get unlimited access to thousands of PowerPoint presentation templates, graphics, fonts, and photos.

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Ciri PPT Template

Bolo PPT Template

Agency Portfolio PPT

Clean Business PPT

The X Note Template

Analysiz Powerpoint

Blue case study powerpoint template.

The Blue Case Study PowerPoint Template offers a sleek and modern design, perfect for various presentations. Designed meticulously, this 18-slide multipurpose template allows users to easily edit graphics and texts. It’s user-friendly, simply drag and drop pictures into placeholders. The template, ideal for seminars, webinars, business presentations, arrives with a documentation file and free support. Recommended free web fonts included. Note, preview images aren’t included within download files.

Black & Yellow Study PowerPoint Template

The Black & Yellow Study PowerPoint Template is a sleek, easy-to-use resource perfect for presenting information in an engaging way. With 35 customizable slides, charts and graphs for data representation, and drop-and-drag image placeholders, it balances professional design with practical features. Ideal for students, workers, or any professional who needs to visually communicate information, this template enhances any presentation. Note: preview photos are not included.

Vibrant Case Study PPT Template

Introducing the Vibrant Case Study PPT Template: a modern, versatile tool perfect for enhancing business presentations, project pitches and lookbook slides. Features include a 16:9 widescreen format, resizable and editable graphics, and a convenient drag & drop picture placeholder. The package comes with PowerPoint and XML files, as well as a helpful guidance file. Please note, images are not included.

Stylish Case Study PowerPoint Template

The Stylish Case Study PowerPoint Template by Decentrace is a clean, contemporary, and professional-grade deck design perfect for various business endeavours. Whether it’s a case study proposal, a sales report, or a startup pitch, this template, boasting of 25 total slides, resizable graphics, and free fonts, is an excellent tool. It comes with a handy help file and allows for easy image placement. However, images shown are just previews and not included in the file.

Case Study PowerPoint Template

The Case Study PowerPoint Template by RRGraph Design is an all-inclusive tool for enhancing your business presentations. With 30 unique slides, 90+ customizable XML files, and options for light and dark backgrounds, it transforms every stage of your business development into engaging visual stories. Handmade infographics give an authentic touch to your brand’s narrative. Please note, image stocks are not included.

Case Study Presentation Template

The Case Study Presentation Template is a professional PowerPoint template designed to enhance the quality of your next presentation. It comes with a helpful ‘Read Me’ text file and includes 30 easily customizable slides in seven different color themes. Despite the absence of images, its organization into named groups and ability to change size, recolor, and more make it a highly versatile asset.

Buminas Case Study PowerPoint Template

The Buminas Case Study PowerPoint Template is a clear, versatile tool that can be used for a wide range of business presentations including finance, marketing, management, and many more. Its features include 30 unique, easily editable slides, free web fonts, and widescreen ratio. Keep in mind, demo images are for preview purposes only and are not included in the files.

Fun Case Study Presentation Template

The Fun Case Study Presentation Template is a unique yet professional choice for those needing a clean, creative and straightforward template. It features more than 20 unique slides, theme color options, resizable graphics and drag and drop photo replacement. The full HD 16:9 ratio and the minimal design make your presentation visually appealing. Easy to customize in Microsoft PowerPoint to match your personal or company brand.

Purple Case Study PowerPoint Template

The Purple Case Study PowerPoint Template offers a professional style that is easy to fully customize according to your preferences. Offered in both a dark version and a light version, this template is editable in PowerPoint format files, allowing you to alter images, colours, and text. It also features unique font themes, a color scheme, image placeholders, and free font use. Please note, preview and image stocks are not included.

Case Study Finance PowerPoint Template

The Case Study Finance PowerPoint Template offers a sleek and professional look for various presentations. It’s great for financial reports, business meetings, project pitches, and other uses. With 30 unique slides, a light background, and all graphics being resizable and editable, this versatile tool makes it easy to customize your presentation. The package also includes XML files, an icon pack, and a help file. Note: Image stocks are not included.

Study Case PowerPoint Template

The Study Case PowerPoint Template is a flexible and creative asset perfect for both corporate and personal presentations. Boasting a clean, elegant design with 60 total slides – split evenly between light and dark versions – all in a widescreen 16:9 ratio. This user-friendly template, including master slide layouts and a free font, can enhance your presentations, potentially attracting more customers. Note: Images used in preview not included.

Case Study PowerPoint Presentation

The Case Study PowerPoint Presentation is a versatile and interactive creative template that is easily customizable. Crafted for a wide range of uses, from academic presentations to innovative team projects, you can personalize elements like text, images, and colors. Offering over 125 slides, 5 predefined color variations, animations, infographic icons, and an easy drag-and-drop picture replacement, it’s compatible with all versions of PowerPoint. Please note, original template images are not included.

Cestudy Case Study PowerPoint Template

The CeStudy Case Study PowerPoint Template is a resourceful tool designed to amplify your company’s presentations. It comes with 26 distinctive slides, features such as resizable and editable graphics, easy-to-edit colors, and a wide screen ratio. Supported by free, prompt customer service, this template also provides provisions for drag and drop images, enhancing the beauty and creativity of your content.

Acropolis Case Study PowerPoint Template

The Acropolis Case Study PowerPoint Template, provided by RRGraph Design, is an extensive asset for your presentations. With 45 unique slides, over 90 custom theme colors, and options for light or dark backgrounds, this template is fully customizable. It also includes handmade infographics to enhance your storytelling. Designed to accompany your business development stages, it’s a great tool for project presentations and brand recognition.

Casevoke Case Study PowerPoint Template

The Casevoke Case Study PowerPoint Template is a versatile presentation resource suitable for various purposes, including case studies, research, reports, and proposals. It offers 30 easily-editable master slides with 16:9 widescreen ratio, customizable graphics, a placeholder for pictures, and an included data chart. The usage of recommended free web fonts ensures an aesthetically appealing presentation. Please note, images in the demo are for preview purposes only.

Busca Business Case Study PowerPoint

The Busca Business Case Study PowerPoint is a universally adaptable presentation template, perfect for a spectrum of uses – from creative agencies and corporate business profiles to personal portfolios and start-ups. This asset, featuring 30 easily editable slides available in three color options, boasts a 16:9 wide screen ratio and a simple drag-and-drop mechanism. Please note, demo images are for preview only and not included in the file.

Bresky Case Study PowerPoint Template

The Bresky Case Study PowerPoint Template offers a sleek and unique design for a variety of presentation needs. With 25 slides that have been carefully created for aesthetic appeal and usability, it’s a versatile choice for any business, portfolio or branding project. Easy to use and customizable, it focuses on strong typography and incorporates unique mockup devices and portfolio slides, providing a professional and modern feel to any presentation.

Minimal Case Study PowerPoint Template

The Minimal Case Study PowerPoint Template is a versatile and user-friendly tool. Ideal for creative agencies, startups, corporations and more, it features 15 customizable slides and easy-to-edit elements. It has an intuitive drag-and-drop image feature, and the text, photos, shapes and colors are all easily adjustable. The template comes in a 16:9 ratio and uses free fonts. Note, images aren’t included.

Case Study and Education PowerPoint Template

The Case Study and Education PowerPoint Template offers a professional, ultra-modern design for educational and academic presentations. With 20 resizable and editable slides, this versatile template can be used for any topic, from school research projects to management seminars. With user-friendly features like drag-and-drop picture placeholders, free web fonts, and wide screen ratio, creating an engaging presentation becomes effortless.

Case Study Powerpoint Template is a sleek and professional presentation asset well-suited for those aiming for a clean, creative, and unique style. It features over 20 unique slides, a customizable color palette to match your brand, and is fully editable with easy-to-use drag and drop functions. With its high quality, resizable vector elements and free fonts, it’s an accessible tool to elevate your presentations.

Case Study Business PowerPoint Template

The Case Study Business PowerPoint Template is a sleek, minimalist style presentation tool ideal for various needs such as business proposals, lookbooks, and project pitches. With 30 unique slides, light and dark backgrounds, resizable graphics, and a drag & drop image feature, it offers versatility and ease of use. The package includes PowerPoint files, color schemes, a help file, and an icon pack, although images must be supplied separately.

The Case Study Presentation Template is a unique, clean, and professional PowerPoint tool perfect for creating captivating presentations. With over 20 unique, easy-to-edit slides, a full HD 16:9 ratio, and a master slide layout allowing easy photo replacement, this asset is a time-saver. The minimalistic and creative design makes for engaging presentations that align with your brand’s aesthetics.

Scilast Study Case Lab Template PowerPoint

The Scilast Study Case Lab Template PowerPoint is a versatile and artistically designed presentation tool. Perfect for both corporate and individual presentations, it boasts of a total of 60 slides, with an equal mix of light and dark themes to suit your style. It’s easily customizable with a widescreen ratio of 16:9 and includes master slide layouts. Please note, images used in previews are not included.

CONCEPTUAL ANALYSIS article

Role of institutions in public management: developing case studies for divergent policy systems provisionally accepted.

• 1 XIM University, India

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

Public policy management has an intractable nature, and the institutional complexity of governance further exacerbates its practice. Transnational learning cutting across countries and policy areas can contribute to this policy knowledge in dealing with multifarious issues in public management. Understanding the institutional mix in public management in various contexts enhances the existing comprehension of how the national pattern of public management works differently in different socio-economic, cultural, and political settings. The present research aims to study the institutional framework in the form of state structure (unitary or federal) and the nature of executive government (majoritarian or consensual) in delineating the influence of institutions on public management processes in divergent policy systems. The paper undertakes four in-depth country case studies and the public management reforms as a response to institutional pressure are examined using the 4M strategy (Pollitt and Bouckaert, 2017)-Maintain (holding on to existing administrative structures and processes), Modernize (keeping service delivery and regulation up to date), Marketize (efficiency and user-responsive public management), and Minimize (reducing state-led regulation). The case studies highlight the differences in the broad direction and energy of implementation that characterize a particular policy style. The results of the study indicate that even though the institutional dimensions are not present in strict polarization, the impact of the institutional mix is evident in the dominant strategies of public management reforms adopted at the national level.

Keywords: political executive, Institutionalism and institutions, Public management, State Structure, Comparative politics

Received: 14 Jul 2023; Accepted: 05 Apr 2024.

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

* Correspondence: Dr. Vaishali Singh, XIM University, Bhubaneswar, India

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• Published: 03 April 2024

Heavy metal association with chronic kidney disease of unknown cause in central India-results from a case-control study

• Mahendra Atlani 1   na1 ,
• Ashok Kumar 2   na1 ,
• Rajesh Ahirwar 3 ,
• M. N. Meenu 1 ,
• Sudhir K. Goel 2 ,
• Ravita Kumari 2 ,
• Athira Anirudhan 1 ,
• Saikrishna Vallamshetla 4 &
• G. Sai Tharun Reddy 4  

BMC Nephrology volume  25 , Article number:  120 ( 2024 ) Cite this article

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Chronic Kidney Disease of unknown cause (CKDu) a disease of exclusion, and remains unexplained in various parts of the world, including India. Previous studies have reported mixed findings about the role of heavy metals or agrochemicals in CKDu. These studies compared CKDu with healthy controls but lacked subjects with CKD as controls. The purpose of this study was to test the hypothesis whether heavy metals, i.e. Arsenic (As), Cadmium (Cd), Lead (Pb), and Chromium (Cr) are associated with CKDu, in central India.

The study was conducted in a case-control manner at a tertiary care hospital. CKDu cases ( n  = 60) were compared with CKD ( n  = 62) and healthy subjects ( n  = 54). Blood and urine levels of As, Cd, Pb, and Cr were measured by Inductively Coupled Plasma- Optical Emission Spectrometry. Pesticide use, painkillers, smoking, and alcohol addiction were also evaluated. The median blood and urine metal levels were compared among the groups by the Kruskal-Wallis rank sum test.

CKDu had significantly higher pesticide and surface water usage as a source of drinking water. Blood As levels (median, IQR) were significantly higher in CKDu 91.97 (1.3–132.7) µg/L compared to CKD 4.5 (0.0–58.8) µg/L and healthy subjects 39.01 (4.8–67.4) µg/L ( p  < 0.001) On multinominal regression age and sex adjusted blood As was independently associated with CKDu[ OR 1.013 (95%CI 1.003–1.024) P  < .05].Blood and urinary Cd, Pb, and Cr were higher in CKD compared to CKDu ( p  > .05). Urinary Cd, Pb and Cr were undetectable in healthy subjects and were significantly higher in CKDu and CKD compared to healthy subjects ( P  = < 0.001). There was a significant correlation of Cd, Pb and Cr in blood and urine with each other in CKDu and CKD subjects as compared to healthy subjects. Surface water use also associated with CKDu [OR 3.178 (95%CI 1.029–9.818) p  < .05).

The study showed an independent association of age and sex adjusted blood As with CKDu in this Indian cohort. Subjects with renal dysfunction (CKDu and CKD) were found to have significantly higher metal burden of Pb, Cd, As, and Cr as compared to healthy controls. CKDu subjects had significantly higher pesticide and surface water usage, which may be the source of differential As exposure in these subjects.

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Chronic kidney disease of unknown cause (CKDu) has been reported in various parts of the world (i.e., Nicaragua, El Salvador, Sri Lanka), including India, as an endemic disease. The disease is a diagnosis of exclusion, made when a patient fulfils the Kidney Disease Improving Global Outcomes (KDIGO) CKD criteria but without the evidence of a recognized cause such as diabetes, hypertension, or glomerulonephritis [ 1 ]. No uniform and definite cause has yet been identified, though various environmental factors have been associated with and suggested to play a role in the pathogenesis. For example, heat stress, strenuous exercise, agrochemicals, and heavy metals have been held responsible for Mesoamerican nephropathy [ 2 ]. Mixed evidence has been reported for association with agrochemicals, heavy metals, and genetic variability for CKDu in Sri Lanka [ 3 , 4 , 5 ]. In India, one small study reported an association of heavy metals with CKD [ 6 ]. A study done on groundwater samples from the Uddanam region of Andhra Pradesh (India), which has a high prevalence of CKDu reported water as acidic (pH < 6.5) and to contain higher silica and lead in wet and dry seasons, respectively. Phthalates were also detected in the groundwater [ 7 ]. Previous studies have attempted to find a correlation between heavy metals and CKDu by comparing cases and endemic and nonendemic controls [ 4 ]. No study has yet tried to find the association of heavy metals comparing CKDu with CKD. Furthermore, previous studies have used urinary metal levels as a biomarker of metal exposure. There is an inherent issue of reverse causality i.e., reduced excretion of metals in urine with a reduction in glomerular filtration rate (GFR) [ 8 ]. Measurement of metals in blood has also been reported to be a promising biomarker of metal exposure [ 9 , 10 ]. Some studies have employed urine to blood ratio for deciding whether urine or blood levels should be used for a particular metal. For metals with urine/blood ratio more than one blood metal levels, whereas for metals with urine/blood ratio less than one, urine metal levels were used in estimation analysis [ 11 ]. The purpose of this study was to test hypothesis whether heavy metals i.e. Arsenic (As), Cadmium (Cd), Lead (Pb) and Chromium (Cr) are associated with CKDu, in central India using blood and urine levels as biomarker of metal exposure.

Materials and methods

Study setting and population.

Study was conducted in a tertiary care hospital setting in the Department of Nephrology in India in a case-control design between December 2019 to June 2022. Participants were enrolled between December 2019 -December 2021. The data collection was done simultaneously. The sample analysis was carried out between January to June-2022. The study was performed according to the guidelines of the Declaration of Helsinki. The study objective was to compare CKDu cases with CKD and healthy controls with regard to biomarkers of exposure of heavy metals [blood and urine levels of cadmium (Cd), lead (Pb), arsenic (As) and chromium (Cr)]. The study included adults aged 18–70 years with CKDu and two groups of the control population, one with CKD and another group of healthy controls without evidence of CKD.

The CKDu and CKD cases were inducted among the patients visiting the nephrology outpatient department and based on pre-defined criteria. At the same time, healthy controls were inducted among the healthy relatives accompanying the patients visiting other departments of the institute for treatment. Written informed consent was obtained from all the participants.

The case definition of CKDu was based on criteria proposed by the Indian Society of Nephrology for the diagnosis of CKDu [ 12 ]. The inclusion criteria included- eGFR < 60 mL/min/1.73m2 (CKD-EPI) [ 13 ] and albumin-to-creatinine ratio (ACR) > 30 mg/g for more than 3 months with:

Urine protein creatinine ratio(PCR) less than 2g/g.

No history of glomerulonephritis, pyelonephritis, renal calculi, polycystic kidneys or obstruction on renal ultrasound.

Not on treatment for diabetes and HbA1c less than 6.5%.

Blood pressure less than 140/90 if CKD stage 1 and 2; and less than 160/100 if CKD stage 3,4, and 5 and on a single drug for blood pressure control.

Case definition of CKD was based on: eGFR < 60 mL/min/1.73m2 (CKD-EPI) and albumin-to-creatinine ratio > 30 mg/g for more than 3 months. Patients were included in the CKD group only if PCR > 2g/g. Hypertension with BP > 140/90 in stages 1–2 and > 160/100 in stages 3–5 or on two or more drugs for BP control.

CKD staging was based on the KDIGO-2008 classification [ 1 ]. The same stages were applied to categorize the renal functions of subjects with CKDu.

Inclusion criteria for healthy controls included: Absence of CKD as evidenced by eGFR more than 90 ml/min/1.73m2, ACR < 30mg/g and lack of anatomical renal disease, obstruction or stone on renal ultrasound, no history of diabetes, HbA1C less than 6.5 and BP less than 140/90.

Biases were kept a minimum by adhering to the case definition described above, and study exposures are mainly objectively assessed with very less dependency on recall i.e. for pesticide or painkiller use. The urine metal levels were adjusted for urine dilution by estimating metals per gram of creatinine in urine.

Sample size

Assuming a difference of moderate effect size (0.25), between three groups (CKDu cases, CKD Controls, Normal Controls) with a confidence level of 95% and power of 80%, the calculated sample size was 159. The final sample size estimated, including a 10% non-response rate, was 180 (60 per group).

Specimen collection and analysis

For the analysis of heavy metals, venous blood (2 ml) was collected in trace element free Trace Element K2-EDTA Vacutainer (Cat# BD 368381). Whole blood was stored at -40 °C until analysis. Ten millilitres (10 ml) of first-morning urine was collected in 50 ml polypropylene tubes. Urine was stored at -40 °C in aliquots until analysis. Serum and urine creatinine was measured using a modified kinetic Jaffe’s method using a Random Access Fully Automated Chemistry Analyzer (Beckman Coulter). Urinary protein and urine albumin were estimated using a colorimetric and immune-turbidimetric methods, respectively, using a Random Access Fully Automated Chemistry Analyzer (Beckman Coulter). HbA1c was analyzed by ion-exchange high pressure liquid chromatography method using a D10 Haemoglobin testing system (BioRad Laboratories). eGFR was calculated from serum creatinine and CKD -EPI equation (Ref). A kidney ultrasound was performed in standard B Mode grey scale in 3.5–5 MHz, the longitudinal length was measured along with the width and thickness of the kidney, renal stones, and any other anatomical abnormality.

Estimation of heavy metals in blood and urine

Levels of Cd, Pb, Cr and As were measured in whole blood and urine. Urinary spot sample results of metal analysis were adjusted for dilution by urine creatinine. Metal analysis was carried out at NIREH, Bhopal (India).

Levels of various heavy metals, viz. Cd, Pb, Cr, As in the collected blood and urine samples were analyzed through inductively coupled plasma optical emission spectroscopy (iCAP® 7400 Duo ICP-OES, ThermoFisher Scientific® Pvt. Ltd). Blood and urine samples were acid-digested in a microwave oven prior to metal detection on ICP-OES. For blood digestion, 1 mL of whole blood sample was mixed with 6 ml of a freshly prepared mixture of concentrated trace metal grade nitric acid (HNO3) and hydrogen peroxide (H2O2) in a ratio 2:1 (v/v) in high-purity polytetrafluoroethylene (PTFE-TFM) vessels. For urine digestion, 5 mL of urine sample was mixed with 6 ml of a freshly prepared mixture of HNO3 and H2O2 in a ratio of 2:1. After gentle mixing of these reactants with blood, the PTFE-TFM vessels were arranged in the rotor (24HVT80, Anton PAAR) and digestion was carried out in the Anton Paar, multi microwave PRO Reaction System at 200 C for 15 min. Digested samples were cooled to 40°C and diluted to 30 ml with distilled water. Blank was prepared for each cycle of digestion using distilled water, nitric acid, and hydrogen peroxide mixture. All the chemicals were trace-element free.

Before the analysis of metal ions in processed blood and urine samples, calibration standards for each element were prepared from multi-element stock solutions (1000 mg L − 1) in triple distilled water. Detection of Cd, Pb, and Cr was performed using a standard sample introduction setup, whereas for As, the hydride generation sample introduction system was utilized. Online hydride generation for As was achieved with an Enhanced Vapor System sample introduction kit using 0.5% m/v sodium tetrahydroborate (NaBH4) stabilized in 0.5% m/v NaOH and 50% v/v HCl solution. Emission data acquisition was performed using the Qtegra ISDS Software at interference-free wavelengths.

Statistical analysis

Statistical analyses were performed with R version 4.2 (R Foundation for Statistical Computing, Vienna, Austria) and IBM SPSS 26 version. The distribution of data in groups was evaluated with Shapiro-Wilk, kurtosis, skewness, and histograms. Skewed data for three groups was compared with the Kruskal-Wallis test. Subgroup analysis in three groups was performed with pairwise comparisons by Dunn test. Parameters with homogeneous distribution were compared with the chi-square test. Data are presented as %, for categorical variables or as median (Q1-Q3) for continuous variables.

Detection rates for blood and urinary metal levels were calculated. For urine metal levels, all statistical analyses were performed with creatinine-adjusted metal concentrations.

Urine to blood ratio was calculated for all metal levels. Spearman correlation coefficient was used to find the association between blood and urine metal levels of individual metals as well as for the association between different metals both in blood and urine. Correlation of blood and urine As with GFR was also performed.

We performed multinominal regression analysis for significantly different metal level in CKDu cases with respect to CKD and healthy controls. We included age and gender (confounding factors) in the model to see the y independence of association and effect estimate of the factor associated with CKDu. Regression model matrices and goodness-of-fit were also determined by the pseudo R 2 coefficient and Hosmer-Lemeshow goodness-of-fit test.

For all analyses, we have considered a p -value less than 0.05 as statistically significant.

A total of 568 patients who visited Nephrology OPD during the study period were screened for inclusion in the study. Out of these, 66 CKDu and 70 CKD cases were found eligible to enroll in the study. Eight patients withdrew consent in the CKD group, whereas four patients in the CKDu group had uncontrolled blood pressure with a single drug, and two withdrew consent. Finally, 60 CKDu and 62 CKD cases were included in the study for outcome analysis. We have approached 120 relatives of patients attending other OPDs and screened them for eligibility criteria of the healthy control group. Out of these, 60 were eligible, and 54 provided consent for participation in the study.

Demography and lab parameters

The CKD and CKDu subjects were similar in demographics for age and sex. However, healthy subjects were younger (Table  1 ). There was no significant difference between CKDu and CKD with reference to stage V (32 vs. 44, P-0.107).There were 05 diabetic kidney disease 04 CKD due to secondary glomerular disease patients (3-lupus nephritis, 1-FSGS), 12 hypertension-associated renal disease, 01 ADPKD, 36 Chronic glomerulonephritis patients, and 04 Chronic pyelonephritis patients in the CKD group. Use of smoking, Alcohol, and painkillers was similar across the three groups (Table  1 ). A significant difference was found between the three study groups with respect to the source of drinking water (ground or surface water). A significantly higher number of CKDu subjects used surface water as a source of drinking water (Table  1 and Table-S 1 and Fig-S 1 ) and a higher number of CKDu subjects reported pesticide usage. As shown in Table  1 , blood pressures were significantly higher in CKD subjects compared to CKDu and healthy subjects and reflect the inclusion criteria with appropriate patient inclusion in three groups. Both ACR and PCR were also significantly different between CKD and CKDu. The eGFR was calculated based on the CKD-EPI formula and was not significantly different between the CKD and CKDu subjects, however, CKD subjects had lower median eGFR compared to CKDu subjects. The healthy subjects had significantly higher eGFR compared to both groups. HbA1c, were similar across the three groups (Table  1 ).

Analytical results

The urinary and blood levels of As, Cd, Pb, and Cr (Table  2 ) were measured in ppb (micrograms per litre), and median with interquartile ranges were reported. Urinary metal levels were also measured in ppb (micrograms per liter) and then adjusted for urinary dilution by urine creatinine value and were finally expressed as micrograms/grams of urine creatinine (Table  2 ).

Detection limits

The lowest detectable concentrations of various heavy metals analyzed on ICP OES with a signal-to-noise ratio of 1 were as follows: As (193.759 nm) - 0.191 ppb; Cd (214.438 nm) - 0 ppb; Pb (220.353 nm) - 0.822 ppb; Cr (283.563 nm) - 3.156 ppb (Table  2 , Figs-S 2 -S 5 ).

Detection percentage

The number of subjects with blood and urine metal levels above the respective detection limits in each study group is reported in Table  2 .

Urine to blood ratio

A urine/blood ratio for each metal in all study groups was calculated for patients with metal levels above the detection limit. The distribution of urine/blood ratios for all metals is presented in Table  2 . Ratios were different between healthy and subjects with deranged kidney functions i.e. low GFR (CKD and CKDu). Median urine/blood Ratio for As was > 1 in healthy subjects and < 1 in CKD and CKDu, reflecting higher urinary levels compared to blood in healthy and reverse in CKD and CKDu subjects. For Pb, it was < 1 in healthy subjects and > 1 in subjects with CKD and CKDu, reflecting higher blood levels compared to urine in healthy and reverse in CKD and CKDu subjects. For Cd and Cr the ratio were < 1 across all three groups suggesting higher urine levels compared to blood levels.

Correlation

A spearman correlation (ρ) was also performed to see the association between each urine and blood metal and among the metals with each other as well. In CKDu, UAs were negatively associated with BAs (ρ-0.260, p -0.11) and in CKD positively (0.138, p -0.37). There was a positive association between urine and blood levels of As,Pb, and Cr and negative association of urine and blood Cd in CKD. In CKDu, a positive association was found in blood and urine Cd,Pb and Cr. In addition, there was a strong correlation of blood Cd, Pb, and Cr ( p  < 0.01) [ρ = 0.68 (BCd and BPb), 0.88 (BCd and BCr), 0.71 (BPb and BCr) in CKDu and [ρ = 0.55 (BCd and BPb), 0.82 (BCd and BCr), 0.65 (BPb and BCr) in CKD. The Urine Cd, Pb, and Cr also had strong correlations [ρ = 0.33 (UCd and UPb), and 0.48(UPb and UCr)] in CKD and [ρ = 0.19(UCd and UPb), 0.67 (UCd and UCr), and 0.69 (UPb and UCr)] in CKDu < 0.05 (Table-S 2 -S 4 and Fig-S 6 ). Association of Blood and urine As with GFR was also evaluated, and BAs were found to be negatively associated with GFR (ρ = -0.097, p  = 0.56), whereas UAs were positively associated (ρ = 0.14, p  = 0.25) with GFR (Table-S 5 ). Metal levels: Blood As: was significantly higher in CKDu ( n  = 37) subjects compared to CKD ( n  = 41) and healthy ( n  = 53) subjects (Table  2 ). On the other hand, the urinary As (UAs) was significantly low in CKD ( n  = 50) and CKDu ( n  = 48) subjects compared to healthy subjects ( n  = 38) and was non significantly higher in CKD subjects compared to CKDu subjects (Fig.  1 , Table  2 ).The blood and urine As values were below detection limits in 21.6%, 35.7%, and 18.8% and in 6%, 16.6%, and 0% of subjects in CKDu, CKD, and healthy groups, respectively.

Box plot for distribution of blood and urine arsenic according to diagnosis categories. Median; microgram/Lt (blood); microgram/gm(urine); UAs- Urine arsenic;CKDu-Chronic kidney disease of unknown cause; CKD-Chronic kidney disease

Blood Cd also was significantly higher in CKD and CKDu subjects compared to healthy subjects. Urinary Cd (UCd) levels were significantly higher in CKD and CKDu subjects compared to healthy subjects,. There was a weak association of ( p  = 0.06) UCd with CKD subjects compared to CKDu subjects.UCd was higher in CKD subjects compared to CKDu (Fig.  2 , Table  2 ). The blood and urine Cd values were below detection limits in 8.3%, 8.1%, and 0% and 37.2%, 19.3%, and 75.9% of subjects in CKDu, CKD, and healthy groups, respectively.

Box plot for distribution of blood and urine cadmium according to diagnosis categories. Median, microgram/Lt (blood); micrograms/gm (urine); UCd- Urine cadmium;CKDu-Chronic kidney disease of unknown cause; CKD-Chronic kidney disease

Pb levels in the blood of CKD and CKDu as well as in urine of CKD and CKDu subjects were significantly higher compared to healthy subjects. The Pb levels were higher in CKD subjects compared to CKDu subjects, but it was not statistically significant (Fig.  3 , Table  2 ). The blood and urine Pb values were below detection limits in 15%, 20%, and 25.9% and 23.3%, 19.4% and 70.4% of subjects in CKDu, CKD, and healthy groups, respectively.

Box plot for distribution of blood and urine lead according to diagnosis categories. microgram/Lt (blood); microgram/gm(urine); UPb- Urine lead;CKDu-Chronic kidney disease of unknown cause; CKD-Chronic kidney disease

As shown in Table  2 and Fig.  4 , urinary and blood Cr was significantly higher in CKD, and CKDu patients than healthy subjects. The blood and urine Cr values were below detection limits in 13%, 0%, and 0% and 13.3%, 14.5% and 85.2% of subjects in CKDu, CKD, and healthy groups, respectively.

Box plot for distribution of blood and urine chromium according to diagnosis categories. Median; microgram/Lt(blood); microgram/gm(urine); UCr-urine chromium, CKDu-Chronic kidney disease of unknown cause; CKD-Chronic kidney disease

Multinominal regression

Though age, gender, were not significantly different between CKDu and CKD, on univariate analysis, we included these In the multinominal regression analysis between CKDu and CKD in reference to healthy subjects in addition to factors found significantly different ( p  < 0.01 on univariate analysis) i.e. blood As and source of drinking water.After the final model, gender had no association with CKDu. Blood As, surface water as drinking water source and age were independently associated with CKDu. Age was associated independently with CKD also (Table  3 ).

To the best of our knowledge, this is the first study wherein an attempt has been made to analyze the association of heavy metals with CKDu in central India, using blood and urine levels as biomarkers of metal exposure. In addition, CKD and healthy subjects have been used as control groups.

The current study showed that blood and urine creatinine-adjusted urinary levels of heavy metals Cd, Pb and Cr were significantly higher in patients with CKD and CKDu as compared to healthy subjects. The urinary levels of the above metals were undetectable in healthy subjects. The study also showed a weak association of ( p  = < 0.06) higher urinary Cd in CKD subjects compared to CKDu subjects of this Indian cohort.

The study also showed that Blood As was significantly higher in CKDu subjects compared to CKD and healthy subjects. On multinominalregression, blood As was independently ( p  < 0.05) associated with CKDu after age adjustment.

In our study, median GFR was rather high in CKDu subjects [14.5 (7.0, 34.2)] compared to GFR in CKD subjects [9.0 (6.0, 17.0)ml/min/1.73m 2 )] and it was non significantly different between the two groups. On correlation analysis, there was a negative correlation between Blood As and GFR and a positive correlation of urine As with GFR. Based on this, the higher blood As in CKDu with higher GFR appears to be truly elevated.

Previously a study from Sri Lanka has also reported an association of CKDu with chronic As toxicity. In that study, 48% of CKDu patients and 17.4% of the control subjects fulfilled the criteria to be diagnosed with chronic arsenical toxicity(CAT), indicating the potential link between CAT and CKDu and suggesting agrochemicals could be the possible source [ 14 ]. Later, it was reported that glyphosate was the most widely used pesticide in Sri Lanka, which contains an average of 1.9 mg/kg arsenic. Findings suggest that agrochemicals, especially phosphate fertilizers, are a major source of inorganic arsenic in CKDu endemic areas [ 15 ]. However, another study from Sri Lanka did not find any difference in UAs levels in patients of CKDu in endemic areas and controls from endemic and nonendemic areas [ 4 ].

Some other studies have reported associations of As with CKD. A study from Taiwan found total UAs to be associated with a four-fold risk of CKD [ 6 ]. Another study reported an association of MMA V (mono methyl arsenate pentavalent) and DMA V (dimethyl arsenate pentavalent) in urine with prevalence of CKD [ 16 ]. However, in both studies, the type of CKD was not reported.

The higher blood As in CKDu compared to CKD may be associated with exposures in our study; a significantly higher number of subjects in CKDu group reported use of pesticides, surface water as a source of drinking water in CKDu subjects.On regression analysis also, surface water was independently associated with CKDu.

A study from north India reported increased levels of OCPs, namely α-HCH, aldrin, and β-endosulfan, in CKDu patients as compared to healthy control and CKD patients of known etiology [ 17 ] and it is also known that arsenic is an important component of pesticides [ 18 ]. The contamination of surface water with various pollutants i.e. pesticides, is common [ 19 ]. Arsenic is a known nephrotoxin, and one of the case reports where kidney histopathology was evaluated reported As causes tubulointerstitial disease (TID) [ 20 ]. The difference in methylation processes of As has also been found responsible for various diseases associated with As i.e. for example, high proportions of urinary MMAs (%U-MMAs) have been associated with a higher risk of cancers and skin lesions [ 21 ]. In contrast, high %U-DMAs has been associated with diabetes risk [ 22 ]. We have measured only iAs in our study. Whether methylation resulting in various metabolite species has different associations with CKDu or CKD should be explored further. We recently found a significant association of single nucleotide polymorphism in a gene coding for sodium-dependent dicarboxylate transporter (SLC13A3) with the susceptibility to CKDu [ 23 ].

In the current study, the UAs results suggest that As levels of 97 µg/gm of creatinine in healthy subjects were not associated with decreased GFR or proteinuria. Similar results were reported by a study from China where researchers found a lower confidence limit on the benchmark dose (LBMD) of 102 and 0.88 µg/gm creatinine for As and Cd, respectively, in order to prevent renal damage in the general population co-exposed to arsenic and cadmium [ 24 ]. The UAs in healthy subjects in our study were nearly similar to the LBMD reference and, not surprisingly, not to be associated with CKD or proteinuria.

Some studies have reported lead to be associated with CKDu. An Indian study reported high levels of lead and silicon concentrations in Indian groundwater in the endemic Uddanam area [ 7 ]. Jaysuman et al. also reported higher levels of Pb (26.5 µg/gm) in the urine of patients with Sri Lankan agricultural nephropathy compared to endemic and nonendemic control [ 25 ].

In the current study, although the median level of blood Pb was almost double in CKD patients compared to CKDu, the result was not statistically significant.

Our study showed that Cd was significantly associated with renal disease. Blood Cd and urine Cd (UCd) levels were significantly higher in patients with renal disease (CKD and CKDu) as compared to healthy subjects. The findings of UCd also showed a weak association (p-0.06) of Cd with CKD compared to CKDu among patients with renal diseases. There are some concerns that UCd may not be truly reflective of metal burden in patients with advanced CKD [ 26 ], because initially, in the course of Cd toxicity with early tubular damage, the normal reabsorption of cadmium-metallothionein decreases, and the UCd concentration increases. However, in the long run, cadmium-induced kidney damage gives rise to low Cd concentrations in both the kidney and urine, while the tubular damage remains [ 27 ]. The U/B ratio of < 1 for Cd in our study supports the above findings.

The mean eGFR in our CKD cohort was lower compared to CKDu; despite this, higher UCd values in patients with CKD compared to CKDu in our study indicate a potential association of Cd with CKD.

Studies have reported variable association of Cd with CKDu when compared to healthy subjects. Nanayakkara et al. [ 28 ] did not find an association of UCd with CKDu in stages 1–4 compared to healthy controls. Whereas another Sri Lankan [ 4 ] study found significantly high UCd in patients with CKDu against the endemic and nonendemic controls. We also observed significantly higher UCd in CKDu vs. healthy controls.

In the current study, urinary Cr (UCr) was not detected in healthy subjects, whereas it was significantly higher in patients with CKD and CKDu as compared to healthy subjects. UCr levels were higher in CKD compared to CKDu. Epidemiologically, Cr exposure has been reported to be associated with kidney damage in occupational populations [ 26 ]. Recently, a study from Taiwan reported that a significant and independent association between Cr exposure and decreased renal function in the general population, and co-exposure to Cr with Pb and Cd is potentially associated with an additional decline in the GFR in Taiwanese adults [ 27 ]. A study from Bangladesh reported outcomes similar to our study; however, the study included only CKD ( n  = 30) patients and compared them with healthy subjects ( n  = 20). In that study, compared to the controls, CKD patients exhibited significantly higher levels of Pb, Cd, and Cr levels in their urine samples. This signifies a potential association between heavy metal co-exposure and CKD [ 29 ]. In the current study a significant correlation between blood Cd, Pb, and Cr and urine Cd, Pb, and Cr were found in CKDu and CKD subjects compared to healthy subjects. The levels of UCd, UPb, and UCr in CKD and CKDu patients were significantly higher compared to healthy controls; The possibility of the combined effect of Cd, Pb, and Cr in the causation of renal diseases could be evaluated further in future studies. As CKDu is an endemic disease, the results of our study suggest an association of arsenic with CKDu in the Indian population, and so the generalizability of the result should be used with caution.

Strengths and limitations

This is the first study which has included two controls (CKD and healthy) and compared metal levels in patients with CKDu. In addition, the comparison of metals in both blood and urine is another advantage, as falling GFR levels and urine levels of several metals do not reflect true metal burden in patients. Inclusion of CKDu patients, as per the suggested definition by the Indian society of Nephrology, is another strength of our study.

The small sample size of our study may be a limitation of our study though it was calculated scientifically. The study involved Indian patients and controls only so the generalization of the results should be with caution. Healthy controls were of younger age is also a limitation of the study.

Also the study included patients from central India, comparatively a larger area and does not points out endemicity.

The study finds an association of environmental toxins with CKDu and CKD. The age and sex-adjusted As were observed to have an independent association with CKDu. A weak association of Cd with CKD was also observed in this Indian cohort. Subjects with renal dysfunction (CKDu and CKD) were observed to have a significantly higher metal burden of Pb, Cd, As, and Cr as compared to healthy controls. CKDu patients may have higher exposure to As via pesticides, surface water usage, or both.

Availability of data and materials

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Abbreviations

Chronic Kidney Disease of unknown cause

Chronic Kidney Disease

Kidney Disease Improving Global Outcomes

Glomerular filteration rate

Institutional Human Ethics committee

Concentrated trace metal grade nitric acid

Hydrogen peroxide

High-purity polytetrafluoroethylene

Inorganic As

Tubulo-interstitial disease

Pentavalent monomethylarsonic acid

Pentavalent dimethylarsinic acid

Methylarsenous acid

Sodium-dependent dicarboxylate transporter

Limit on the benchmark dose

Arsenobetaine

Urinary MMAs

Urinary DMAs

Blood lead levels

End-stage kidney disease

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The Study was funded by Indian council of Medical Research (ICMR),New Delhi, India. Sanction no.:5/4/7-14/2019-NCD-II.

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Mahendra Atlani and Ashok Kumar contributed equally to this work.

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Department of Nephrology, All India Institute of Medical Sciences (AIIMS), Room No-3022, Academic Block, 3rd Floor, Saket Nagar, Bhopal, Madhya Pradesh, 462020, India

Mahendra Atlani, M. N. Meenu & Athira Anirudhan

Department of Biochemistry, All India Institute of Medical Sciences (AIIMS), Saket Nagar, Bhopal, Madhya Pradesh, 462020, India

Ashok Kumar, Sudhir K. Goel & Ravita Kumari

Department of Environmental Biochemistry, ICMR-National Institute for Research in Environmental Health (NIREH), Bhopal, Madhya Pradesh, India

Rajesh Ahirwar

All India Institute of Medical Sciences (AIIMS), Bhopal, Madhya Pradesh, India

Saikrishna Vallamshetla & G. Sai Tharun Reddy

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MA and AK were equally involved in conceptualising the study, winning the grant, analyzing the results, monitoring the progress of study. MA prepared the manuscript. AK and SKG did the editing. RA supervised analysis of metal levels, sample collection done by MMN, RK. Metal analysis done by AA. Data entry and file preparation for results done by MMN, AA, SKV and STR.

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Atlani, M., Kumar, A., Ahirwar, R. et al. Heavy metal association with chronic kidney disease of unknown cause in central India-results from a case-control study. BMC Nephrol 25 , 120 (2024). https://doi.org/10.1186/s12882-024-03564-4

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Expression analysis of zinc-metabolizing enzymes in the saliva as a new method of evaluating zinc content in the body: two case reports and a review of the literature

• Ken-ichiro Sakata 1 ,
• Ayako Hashimoto 2 ,
• Taiho Kambe 3 ,
• Jun Sato 1 ,
• Noritaka Ohga 1 ,
• Yutaka Yamazaki 4 ,
• Masahide Koyachi 5 ,
• Itagaki Tatsuki 1 ,
• Mai Okada 1 ,
• Okura Taro 1 ,
• Hiroshi Hikasa 1 &
• Yoshimasa Kitagawa 1  

Journal of Medical Case Reports volume  18 , Article number:  198 ( 2024 ) Cite this article

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Metrics details

The activity level of alkaline phosphatase, a zinc-requiring enzyme in the serum, is used to indicate zinc nutritional status; however, it does not correlate with serum zinc levels or subjective symptoms of taste disorder in many cases. Hence, this study focused on the total activity of alkaline phosphatase, a zinc-requiring enzyme. The total alkaline phosphatasa activity level in the saliva was measured before and after zinc supplementation, and the results were compared with serum zinc levels.

Case presentation

This study included patients with hypozincemia, specifically a patient with zinc-deficient taste disorder (patient 1: a 69-year-old Japanese woman) and a patient with glossodynia with zinc deficiency (patient 2: an 82-year-old Japanese woman). Saliva samples were collected, and blood tests were performed before and after zinc supplementation. Subjective symptoms and serum zinc levels were simultaneously evaluated. Zinc supplementation was performed using zinc acetate hydrate or Polaprezinc.

Conclusions

Total alkaline phosphatase activity levels were found to be associated with serum zinc levels and subjective symptoms. A further study with a higher number of patients is necessary to confirm whether total alkaline phosphatase activity levels more accurately reflect the amounts of zinc in the body than serum zinc levels.

Peer Review reports

Zinc deficiency in humans was recognized for the first time in 1961 [ 1 ]. Studies have reported that zinc deficiency is associated with taste disorder and glossodynia [ 2 , 3 , 4 ]. There are several other symptoms, such as bedsores, skin symptoms, delayed wound healing, fetal growth restriction, chronic diarrhea, anemia, and altered mental status [ 5 ]. The Zincage Project (research on the relationship between health/aging and zinc), an epidemiological survey in Europe, has shown that health status of older adults is positively associated with the amount of zinc in the body [ 6 ]. In the basic research field, zinc is considered an essential trace metal element, with approximately 2 g being present in the body. Zinc plays a role as the active center of 3000 types of enzymes and bioactive substances [ 7 ]. Recent human genome decoding projects have indicated that approximately 10% of genes have zinc-binding domains. Hence, researchers have focused their attention on the relationship between zinc and diverse physiological functions, including zinc transporters and zinc signals [ 8 ]. Sequelae of oral diseases caused by zinc deficiency lead to a frailty cycle. This cycle stems from appetite loss and decreased food consumption, causing undernutrition. This state results in weight loss and sarcopenia onset (Fig.  1 ).

Hypozincemia leads to frailty

To address this issue, accurate measurement of the zinc content in the body is required in clinical practice, highlighting the need to develop a method for accurate and rapid diagnosis of zinc deficiency. Zinc deficiency is known as the main factor contributing to taste disorder [ 9 ]. However, it is not well known that zinc deficiency can also cause several oral diseases, such as mouth ulcers and glossodynia, posing a diagnostic and treatment challenge in many cases [ 10 ]. Serum zinc levels are a commonly used indicator of zinc assessment in clinical practice. However, they do not accurately reflect the zinc content in the body, because they account for only less than 0.1% of the total zinc in the body [ 3 ]. Furthermore, they exhibit circadian rhythms and are easily influenced by several conditions. Owing to such disadvantages, they are not considered an absolute indicator [ 11 ]. In this study, we attempted to identify an indicator other than serum zinc levels for accurately measuring the amount of zinc in the body, focusing our attention on zinc-requiring enzymes, which show zinc-dependent activity. Zinc-requiring enzymes are activated after binding to zinc. The activity level of alkaline phosphatase (ALP), a zinc-requiring enzyme in the serum, is used as an indicator of zinc nutritional status; however, it does not correlate with serum zinc levels or subjective symptoms of taste disorder in many cases. To accurately evaluate the zinc nutritional status, we shifted our focus from serum ALP to total alkaline phosphatase [ 12 , 13 ]. Four ALP isozymes are  broadly expressed in various cells (Table  1 ). Previous studies using cultured cells and animals have shown that ALP, an enzyme that is activated by coordinating zinc at the active center, plays a role in suppressing inflammation by hydrolyzing adenosine triphosphate (ATP), which serves as a danger signal extracellularly, into adenosine. The results demonstrate that ALP is a zinc-requiring enzyme (zinc marker enzyme), enabling the accurate measurement of zinc content in the body [ 14 ].

Objective: Intervention is required to break the frailty cycle; however, the following questions remain unsolved: “Which indicators should be used for zinc supplementation?”, “How long should zinc supplementation be continued?”, and “How much zinc is required for the supplementation?” We raised the possibility of conducting translational research in which basic scientific findings are translated into clinical practice, with the aim of attaining a society where “older adults can enjoy meals.” This study aimed to evaluate total ALP activity levels in the saliva, serum zinc levels, and subjective symptoms before and after zinc supplementation in patients with oral diseases caused by zinc deficiency.

Patients and methods

Saliva samples were used because they can be collected repeatedly in a noninvasive manner. They were collected before and after zinc supplementation, and subjective symptoms of taste disorder and serum zinc levels were simultaneously evaluated. Saliva sample collection and blood tests were performed only in the morning. The gustatory testing (whole mouth) results are as follows: Four types of taste solutions [sucrose (S), sodium chloride (NaCl; N), tartaric acid (T), and quinine hydrochloride dihydrate (Q)] were dropped on the dorsum of the tongue at the following concentrations (No. 1: 2.9 μmol, No. 1.5: 5.8 μmol, No. 2: 8.8 μmol, No. 2.5: 17.5 μmol, No. 3: 29.2 μmol, No. 4: 58.4 μmol, and No. 5: 2337 μmol), and cognitive thresholds were tested by tasting the samples within 2–3 seconds. Taste perception threshold testing followed the criteria in the table below, and when No. 5 could not be recognized, it was considered taste loss. The efficacy of zinc supplementation in patients with taste disorder and those with burning mouth syndrome (BMS) was evaluated using the Visual Analog Scale [ 15 ] and Numerical Rating Scale [ 16 ], respectively. Zinc content was measured using ACCURAS AUTO Zn (Shino-Test Corporation, Osaka, Japan).

Zinc was measured using the Acurus Auto Zn (Shino-Test Corporation, Tokyo, Japan) based on the colorimetric method using an automated analyzer (Hitachi 7700 series; Hitachi High-technology Corporation, Tokyo, Japan). Measurement of ALP activity in saliva was performed as follows: 5 µl of saliva was used to measure ALP activity. A total of 100 μl of substrate solution [2 mg/ml disodium  p -nitrophenylphosphate hexahydrate ( p NPP); Wako Pure Chemicals in 1 M diethanolamine buffer pH 9.8 containing 0.5 mM MgCl 2 ] was added and incubated at 37 ℃ for 1 hour. The released  p -nitrophenol product was quantified by measuring the absorbance at 405 nm.

Calf intestinal ALP (Promega) was used to generate a standard curve. This study was approved by the Hokkaido University Hospital Independent Clinical Research Review Committee (Approval No. 019-0337) and approved by the Ethics Committee of Kyoto, University Graduate School and Faculty of Medicine (Approval No. R3275).

All study procedures were performed in accordance with the principles of the Declaration of Helsinki. Written informed consent was obtained from all participants.

Two patients experiencing hypozincemia were included. Patient 1 was a 69-year-old Japanese woman (Fig.  2 ). The patient presented to the Dentistry Center, Hokkaido University Hospital, with the chief complaint of hypogeusia. In addition to routine intraoral examination, the patient received gustatory testing, oral bacteria testing, blood tests, and chewing gum test. Intraoral examination showed mild xerostomia and tongue coating. The results of gustatory testing (whole mouth) were sweet (2.5), salty (4), sour (2), and bitter (2), indicating hypogeusia. Oral bacteria testing was unremarkable. The volume of saliva collected using the chewing gum test was 17.8 mL. Blood tests at the initial visit showed a serum zinc level of 65.6 μg/dL. Based on this low serum zinc level, the patient was diagnosed with zinc-deficient taste disorder. The total ALP activity level was 0.072 mU/5 μL. Zinc supplementation was continued for 2 months using zinc acetate hydrate. After the patient orally took zinc acetate hydrate 50 mg for 1 month, the serum zinc level improved to 115.3 μg/dL, and the total ALP activity level increased to 0.102 mU/5 μL. After the zinc acetate hydrate dose was reduced to 25 mg, the serum zinc level slightly decreased to 86 μg/dL. However, the total ALP activity level remained almost the same at 0.1 mU/5 μL.

69-year-old woman with taste disorder

Patient 2 was an 82-year-old Japanese woman (Fig.  3 ). The patient presented to the Dentistry Center, Hokkaido University Hospital, with the chief complaint of glossodynia. In addition to routine intraoral examination, she received gustatory testing, oral bacteria testing, and blood tests. Intraoral examination showed mild tongue coating. The results of gustatory testing (whole mouth) were sweet (1.5), salty (2.5), sour (2.5), and bitter (2), indicating hypogeusia. Results of oral bacteria testing were positive for Candida albicans . Administration of amphotericin B gargles eradicated C. albicans . However, glossodynia persisted after the eradication; therefore, the patient was diagnosed with BMS secondary to zinc deficiency. Blood tests at the initial visit showed a serum zinc level of 51.9 μg/dL. On the basis of this low serum zinc level, the patient was diagnosed with BMS secondary to zinc deficiency. The total ALP activity level was 0.045 mU/5 μL. Zinc supplementation was continued for 5 months using zinc acetate hydrate. After the patient orally took zinc acetate hydrate 50 mg for 1 month, the serum zinc level improved to 113.3 μg/dL, and the total ALP activity level increased to 0.05 mU/5 μL. The patient received a reduced zinc acetate hydrate dose of 25 mg for the subsequent month of zinc supplementation, and the serum zinc level and total ALP activity level 2 months after treatment initiation were 126.6 μg/dL and 0.03 mU/5 μL, respectively. Zinc acetate hydrate 25 mg was administered every other day over the third and fourth months after the initiation of zinc supplementation. Serum zinc and total ALP activity levels 4 months after treatment initiation were 71.3 μg/dL and 0.049 mU/5 μL, respectively. Zinc acetate hydrate 50 mg was administered for the fifth month after the initiation of zinc supplementation. Serum zinc and total ALP activity level 5 months after treatment initiation were 116.6 μg/dL and 0.056 mU/5 μL, respectively. The serum zinc level decreased transiently, but the total ALP activity level remained almost the same.

An 82-year-old woman with glossodynia

Discussion and conclusions

Unstable serum zinc levels.

Currently, zinc supplementation is performed on patients with taste disorder and glossodynia due to zinc deficiency based on serum zinc levels. Our previous study showed that the mean serum zinc level was 72 μg/dL in the taste disorder group and 74 μg/dL in the control group, with no relationship between taste disorder and serum zinc levels [ 17 ]. The proportion of patients with zinc deficiency in the taste disorder group was significantly higher ( p  < 0.05) only when a serum zinc level of < 60 μg/dL (that is, severe zinc deficiency) was used to identify patients with zinc deficiency. Possible explanations for the absence of an association between clinical symptoms and serum zinc levels include: (1) Serum zinc levels do not accurately reflect the zinc content in the body; (2) serum zinc levels exhibit a large fluctuation of circadian rhythms and are easily influenced by meals, stress, and hormone conditions, therefore making them problematic as an indicator of zinc deficiency; and (3) differences in serum zinc levels between laboratories (serum zinc levels tend to show a higher value in outsourcing examination than in-hospital examination owing to hemolysis). These disadvantages suggest that serum zinc levels may not reflect the bioavailability of zinc in the body in some cases. Thus, selecting an appropriate sample and developing a method to analyze the sample are important issues.

Taste disorder and zinc

The relationship between taste disorder and zinc deficiency plays an important role in regenerating taste bud cells. Taste buds, or taste sensors, are actively regenerated approximately every 10 days. Normal regeneration of taste bud cells is required to correctly recognize different tastes. Insufficient regeneration of taste bud cells due to zinc deficiency is associated with a decrease in the number of these cells, causing impairment of taste sensor function. Zinc plays an important role in protein formation that is required for cell regeneration and transmission of genetic information.

Glossodynia and zinc

Glossodynia is a traditionally well-known symptom of hypozincemia in clinical practice; however, its evident cause is unknown [ 18 ]. Zinc exerts analgesic effects when administered locally to the spinal nerves or peripheral nerves or systemically in patients with chronic pain in areas other than in the oral area, renal dysfunction, anemia, and itchy sensation on the skin [ 19 , 20 ]. The mechanism of this analgesic effect was reported in a study in 2011 [ 21 ]. In the said study, increased sensitivity to pain was observed in knockout mice whose zinc ion binding to the NMDA-type glutamate receptor was inactivated. The authors reported that C fibers were particularly affected as compared with Aδ fibers, resulting in difficulty in suppressing chronic pain. Chronic glossodynia signals are transmitted to the brain mainly via C fibers, suggesting that the association between hypozincemia and glossodynia may be mediated by NMDA receptors, although the details remain to be clarified.

Total ALP activity levels

Both patients experienced a transient decrease in serum zinc levels, but total ALP activity levels did not change. Total ALP activity is involved in the dephosphorylation of various physiological substrates and has vital physiological functions, including extraskeletal functions such as neuronal development, detoxification of lipopolysaccharide, an anti-inflammatory role, bile pH regulation, and maintenance of the blood–brain barrier. Total ALP activity has also been reported to be involved in cardiovascular calcification, chronic kidney disease, and type 2 diabetes [ 22 ]. In particular, it is a logical clinical target to attenuate vascular calcification. Total ALP activity has gained attention as a clinical marker in several diseases. The relationship between total ALP activity levels and changes in zinc content in the body has been evaluated only in studies using cultured cells and animals. Thus, this is the first study to report the relationship in humans. Furthermore, this study used saliva samples; therefore, the results are extremely useful because these samples can be collected repeatedly in a noninvasive manner. Further cross-sectional or cohort studies are required to clarify the relationship between serum zinc levels and zinc-requiring enzymes, including total ALP activity, to interrupt the disease cycle due to zinc deficiency and improve the health status. This study suggests that total ALP activity may be a new diagnostic marker alternative to serum zinc levels. Furthermore, it may be used as an indicator when assessing the efficacy of zinc supplementation.

Availability of data and materials

No new data were created or analyzed in this study. Data sharing is not applicable to this article.

Abbreviations

Alkaline phosphatase

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Acknowledgements

I would like to give my heartfelt thanks to Prof. Kitagawa whose comments and suggestions were immeasurably valuable throughout the course of my study. I am also in debt to Prof. Yamazaki whose meticulous comments were enormously helpful. I would like to express my gratitude to Mr. Taiho Kambe and Ayako Hashimoto, for the valuable advice for evaluating zinc content in the body. I would also like to thank my family for their moral support and warm encouragement.

This study was partially supported by Lotte Co., Ltd., Tokyo, Japan.

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Department of Oral Diagnosis and Medicine, Division of Oral Pathobiological Science, Faculty of Dental Medicine and Graduate School of Dental Medicine, Hokkaido University, Sapporo, Japan

Ken-ichiro Sakata, Jun Sato, Noritaka Ohga, Itagaki Tatsuki, Mai Okada, Okura Taro, Hiroshi Hikasa & Yoshimasa Kitagawa

Department of Food and Nutrition, Faculty of Home Economics, Kyoto Women’s University, Kyoto, Japan

Ayako Hashimoto

Department of Applied Molecular Biology, Division of Integrated Life Science, Graduate School of Biostudies, Kyoto University, Kyoto, Japan

Taiho Kambe

Department of Gerodontology, Division of Oral Health Science, Faculty of Dental Medicine and Graduate School of Dental Medicine, Hokkaido University, Sapporo, Japan

Yutaka Yamazaki

Department of Oral Pathobiological Science and Surgery, Tokyo Dental College, Tokyo, Japan

Masahide Koyachi

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Contributions

Conceptualization: KS and JS. Methodology/formal analysis: AH and TK. Investigation: OT and TI. Resources: KS and NP. Data curation: KS. Writing—original draft preparation: KS. Writing—review and editing: YY. Visualization: NO, MO, and HH. Supervision: YK. Project administration: KM. All authors have read and agreed to the published version of the manuscript.

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Correspondence to Ken-ichiro Sakata .

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In this report, we anonymized personal information and ensured the protection of privacy. This study was approved by the Hokkaido University Hospital Independent Clinical Research Review Committee (Approval No. 019–0337) and approved by the Ethics Committee of Kyoto, University Graduate School and Faculty of Medicine (Approval No. R3275). Written informed consent was obtained from all participants.

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Written informed consent was obtained from the patients for  publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.

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The authors declare no competing interests.

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Sakata, Ki., Hashimoto, A., Kambe, T. et al. Expression analysis of zinc-metabolizing enzymes in the saliva as a new method of evaluating zinc content in the body: two case reports and a review of the literature. J Med Case Reports 18 , 198 (2024). https://doi.org/10.1186/s13256-024-04463-w

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Received : 20 November 2023

Accepted : 16 February 2024

Published : 04 April 2024

DOI : https://doi.org/10.1186/s13256-024-04463-w

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Prostate cancer cases worldwide likely to double by 2040, analysis finds

Largest study of its kind predicts 85% increase in deaths from the disease in same period as more men live longer

The number of men diagnosed with prostate cancer worldwide is projected to double to 2.9 million a year by 2040, with annual deaths predicted to rise by 85%, according to the largest study of its kind.

Prostate cancer is already a major cause of death and disability, and the most common form of male cancer in more than 100 countries. But with populations ageing and life expectancy rising globally, a new analysis forecasts a dramatic surge in cases and deaths over the next 15 years.

Diagnoses are projected to increase from 1.4m a year in 2020 to 2.9m by 2040, which will mean about 330 men being told they have the disease every hour.

The number of deaths worldwide is predicted to rise by 85% over the 20-year period, from 375,000 in 2020 to almost 700,000 by 2040. The true death toll will probably be higher, experts say, because of underdiagnosis and missing data in low- and middle-income countries.

The findings were published in the Lancet as part of its landmark commission on prostate cancer, and will be presented at the European Association of Urology’s annual congress in Paris on Saturday.

Ageing populations and increasing life expectancy mean the number of older men worldwide who are living for longer is rising. As the main risk factors for prostate cancer – such as being 50 or older and having a family history of the disease – are unavoidable, experts say it will be impossible to prevent the surge in cases simply via lifestyle changes or public health interventions.

However, wider awareness of the symptoms of the disease, access to testing initiatives, earlier diagnosis, and advances in treatments could still help reduce the burden and save lives, according to the authors of the 40-page report.

“As more and more men around the world live to middle and old age, there will be an inevitable rise in the number of prostate cancer cases,” said Prof Nick James, the lead author of the study. “We know this surge in cases is coming, so we need to start planning and take action now.”

“Evidence-based interventions, such as improved early detection and education programmes, will help to save lives and prevent ill health from prostate cancer in the years to come,” added James, a professor of prostate cancer research at the Institute of Cancer Research, London, and a consultant clinical oncologist at the Royal Marsden NHS foundation trust.

James said there was a global need for new and improved ways to test for the disease, to reduce overdiagnosis and overtreatment while detecting potentially lethal tumours earlier.

Boosting knowledge among men and their families of signs to look for was also key, according to the report.

Symptoms of prostate cancer can include needing to urinate more frequently, often during the night; needing to rush to the toilet; difficulty in starting to pee; feeling that your bladder has not emptied fully, and blood in your urine or semen.

These symptoms do not always mean you have prostate cancer. Many men’s prostates become larger as they get older because of a condition called benign prostate enlargement. Signs that prostate cancer may have spread include testicle, back or bone pain, a loss of appetite, and unintentional weight loss.

The study also highlighted the need for more research to better understand prostate cancer in black men, as most research has focused on white men.

Alfred Samuels was 54 when he learned he had advanced prostate cancer in 2012. He had worked in the entertainment industry for three decades, providing security for celebrities including Beyoncé and Bob Dylan – but the shock diagnosis ended his career overnight. Doctors ruled out surgery when tests showed his cancer had spread, and the father of six started to lose hope.

However, he then joined a clinical trial and began treatment with a drug that is now extending the lives of thousands of men worldwide. Twelve years later, Samuels, from Harrow in north-west London, has welcomed six grandchildren to the world and pivoted to a second career raising awareness of cancer research.

“Due to the late stage that my prostate cancer was diagnosed, I wouldn’t be here today if I hadn’t been able to access a clinical trial. It was my lifeline,” said Samuels, now 66. “This report has been a long time coming. Now it needs to be mandatory to record ethnicity in clinical trials, and trials must reflect the ethnic diversity of the population, so that we can find better treatments for people like me.”

Amy Rylance, the head of improving care at the charity Prostate Cancer UK, said the Lancet report was a “a timely call to action”. She added that healthcare systems must do better at recognising those at highest risk: black men and men with a family history of prostate cancer or genetic risk factors such as BRCA variations .

• Prostate cancer
• Cancer research
• Medical research
• Men's health

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