the case study method in social inquiry

An official website of the United States government

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

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

Publications
Account settings

Preview improvements coming to the PMC website in October 2024. Learn More or Try it out now .

Advanced Search
Journal List

Progress in Social and Educational Inquiry Through Case Study: Generalization or Explanation?

Gary thomas.

University of Birmingham, Birmingham, B15 2TT UK

Although much of the most productive research in applied social science is case-based, there is still concern about the restricted utility of such research because of its limited power to offer generalizable findings. Such concern has contributed to a recent trend in policy-making circles—particularly those in education—to prefer experimentally orientated research for insights on policy. The argument is made here that concerns about generalization are exaggerated and that the focus upon them has allowed an evasion of issues about quality of explanation coming from different forms of social inquiry design. After discussing these generalization-based issues I proceed to define case study as an inquiry form, outlining its most significant ingredients and I offer a review of case study inquiries in education which exemplify its capacity for offering credible new insights on the questions being posed.

Introduction

There have been many recent injunctions, including those from national governments, for researchers to use particular kinds of quantitatively orientated and experimental research in social and educational inquiry (see, for example, Goldacre 2013a , b ; Prenzel 2009 ; Shavelson and Towne 2002 ; Slavin 2008 ; U.S. Department of Education 2004 ). Such research, it is sometimes asserted, provides “gold standard evidence.” I hope to make the case in this article, though, that the most influential, transformative education research comes not from the stable of experimental study but rather from explorations which are case orientated. Such research offers to education kinds of understanding which are inaccessible via formal kinds of trial and experiment. In using the “science of the singular” (Simons 1980 ) such inquiry promises to inform education practitioners in their own environments, where they can provide “research in practice, not research on practice,” as Friedman ( 2006 , p. 132) has put it (see also, Cochran-Smith and Lytle 2009 ).

Over half a century and more, the most iconic analyses of education have come about from case study research, which can provide a uniquely vivid kind of inquiry and furnish the quality of analysis which is impossible from other kinds of research. Early examples include Philip Jackson’s ( 1968 ) Life in Classrooms, Harry Wolcott’s ( 1978 ) The Man in the Principal’s Office , Stephen Ball’s ( 1981 ) Beachside Comprehensive and Paul Willis’s ( 1993 ) Learning to Labor, all of which have contributed enormously to our understanding of the ways that schools work, teachers teach, and students learn. I shall look at these exemplars, and other examples of first-rate case study in education, later in this article.

While the case study has a relatively recent history in education, it has a longer pedigree in other disciplines. Garvin notes ( 2003 ) that it was a lawyer who had, in 1870, named case study method, with the use of the case study at that time in undergraduate teaching. The case had begun to be used, though, around the same time and a little before, in explicating and analyzing social and psychological phenomena. At the beginning of the nineteenth century, Jean-Marc-Gaspard Itard described his now-celebrated work with Victor, the “wild boy of Aveyron”, and later in the century Frédéric Le Play made his highly influential studies of the working and living conditions of French miners in the Jura (see Mogey 1955 ).

The aim of these early inquirers was to report and theorize about a particular person or set of people. Analysis based on this kind of work began to chime, at the beginning of the twentieth century, with new thought about social inquiry and how it should be undertaken. It resonated with new ideas about interpretative inquiry, encapsulated in the new anthropology and symbolic interactionism, in such a way that it became a force in and of itself. The case study, exemplified in, for example, Thomas and Znaniecki’s ( 1927 /1958) explication of the life of American immigrants, The Polish Peasant in Europe and America , became an accepted and respected form of research.

Since then, the case study has been used increasingly to illuminate and explicate the social worlds we inhabit. And the different examples to which I have just been referring reveal very different kinds of case study with equally varied means of gathering data and analyzing it, from the use of people’s letters to each other, as in The Polish Peasant …, to rich, narrative accounts, as in Clifford Geertz’s ( 1973 ) notes on the Balinese cockfight. The fertility of the descriptions in these exemplars is sometimes quite striking—descriptions incorporating imagination, conjecture and theorization. The best case studies weave discussion and theorization with the presentation of the case account itself.

The case study presents a view of inquiry that takes a pragmatic view of knowledge—one that elevates a view of life in its complexity. It’s the realization that complexity in social affairs is often indivisible that has led to case study’s status as currently one of the most productive design frames open to the researcher. This is perhaps the reason behind its ongoing popularity among researchers in the field of education and other applied social sciences.

What is Case Study?

There are strong commonalities about what case study constitutes across disciplinary boundaries. Reviewing a number of definitions of case study, Simons ( 2009 ) concludes that what unites them is a commitment to studying the complexity that is involved in real situations, and to defining case study other than by the methods of data collection that it employs. On the basis of these commonalities she offers this definition: “Case study is an in-depth exploration from multiple perspectives of the complexity and uniqueness of a particular project, policy, institution, program or system in a ‘real life’ context” (p. 21).

The emphasis in Simons’s definition is on depth of analysis. In it, one finds a “trade-off”, as Hammersley and Gomm ( 2000 , p. 2) put it, between the rich, in-depth explanatory narrative emerging from a very restricted number of cases and the capacity for generalization that a larger sample of a wider population can offer. It is important to add to Simons’s definition the rider that case study should not be seen as a method in and of itself. Rather, it is a design frame that may incorporate a number of methods. Stake ( 2005 ) puts it thus:

Case study is not a methodological choice but a choice of what is to be studied … By whatever methods we choose to study the case . We could study it analytically or holistically, entirely by repeated measures or hermeneutically, organically or culturally, and by mixed methods—but we concentrate, at least for the time being, on the case. (p. 443)

Choice of method, then, does not define case study: analytical eclecticism in the in-depth study of a subject of interest is the key. Alongside holism and methodological eclecticism the case inquirer needs carefully to consider the nature of what is being studied, analytically speaking.

As I have discussed elsewhere (Thomas 2013 ), case study is one of the scaffolds that can help to structure the design of research. As I have defined them (Thomas 2011 ) case studies are

… analyses of persons, events, decisions, periods, projects, policies, institutions or other systems which are studied holistically by one or more methods. The case that is the subject of the inquiry will be an instance of a class of phenomena that provides an analytical frame—an object—within which the study is conducted and which the case illuminates and explicates.

The emphasis in this definition is on analysis; I try to make it clear that while case inquiry may often rely on observation, and to an extent description, these are not ends in themselves and the best case studies go much further than illumination. The definition makes a separation between the subject, the focus, of the study and the theoretical issue that this subject explicates. In it I have drawn on the work of Wieviorka ( 1992 ), who made the point that a case in a case study cannot be simply an instance of a class. Wieviorka unpacked in more detail the distinctions between the case and the class by noting that when we talk about a case we are in fact talking about two elements: first, there is what he calls a ‘practical, historical unity’ (p. 159). We might call this the subject . Second, there is what he calls the ‘theoretical, scientific basis’ of the case.

In other words, it is important for case inquirers to be clear about what the case study is a case study of. A case study, as a study (as distinct from a case illustration or a case history) must in some sense explicate a wider theme: it must help in our understanding of some theoretical issue.

Methodological Issues for the Case Study in Education

Generalization.

… situations are so varied that even a large number of cases may be a misleading sample … and none is comprehensible outside the historical sequence in which it grew. (Vickers 1965 , p. 173)

Here, Vickers states the principal reason for the sometimes suspect status of case study as a research design form. This suspicion stems principally from the assumed paucity of general understanding offered by case study. It is general understanding that is the key, and generality goes to the heart of the matter, for it is here, in generality or universals that we find issues of what social science, and particularly theory in social science, has distinctively to offer. This emphasis on generalized knowledge is a problem for case study, which appears to offer little in the way of generalizable information to social scientific inquiries.

Bassey ( 2001 ), however, writing from the context of education, notes that “it is possible to distinguish between two modes of research, namely search for generalities and study of singularities” (p. 6). He picks up Simons’s ( 1980 ) notion of the “singularity” of the educational situation—that singular status implying everything within the boundary of what is under study. It is, as Bassey puts it (ibid), “one set of circumstances and the events, people, places and things, which constitute that set of circumstances, [which] are treated in the study as an entity.”

Bassey firmly sets the issue of generalization in the context of the classroom. He says:

Open generalizations give reliable predictions and so are obviously valuable in the making of classroom decisions. But, in my view, they are scarce in number and so once these few have been mastered, and have become an integral part of a teacher’s way of operating, they appear obvious and no longer valuable.

He concludes that the education research community should

… distinguish between pedagogic research and other forms of educational research, and in relation to pedagogic research should eschew the pursuit of generalizations, unless their potential usefulness is apparent, and instead should actively encourage the descriptive and evaluative study of single pedagogic events.

I have continued the discussion about generalization elsewhere (Thomas 2011 ), noting that “the study must be framed not in the diluted constructs of generalizing natural science but rather in questioning and surprise, heuristic, particularity, analogy, consonance or dissonance with my own situation” (p. 33). The case study, I have concluded, is of course about understanding some phenomenon or construct, but understanding it in the context of what Gadamer ( 1975 ) calls one’s “horizon of meaning” (p. 269). The conclusion is that while precise forms of generalization are impossible—particularly the tight generalization of the natural scientist—the obverse of this observation is that no situation is unique: each is interpreted in the context of our own experience. To interpret in the context of one’s own experience is both legitimate and valid.

For me, the issue about generalization is less troublesome than many fear, for much scientific inquiry is not actually about generalization but, rather, understanding. This is true in any domain of inquiry. Scientists—from astronomers to zoologists—seek understandings on the basis of evidence, which is painstakingly sought, evaluated and used to make the best possible conjectures and explanations of the phenomena in question. While some of these explanations will require certain kinds of rigorous generalization, others do not.

Is It Science?

Atkinson and Delamont ( 1985 ) argue trenchantly for the need for case inquirers to develop a well formulated body of theory and methods in order to produce a coherent, cumulative research tradition. In doing this, they are developing a theme that has been much discussed in qualitative research. The issue is about science and legitimacy of this or that method (Thomas and James 2006 ) and here Kemmis ( 1980 ) makes the point that case studies are sometimes dismissed as purely subjective. They are thus seen as unscientific and are regarded with suspicion, even hostility, by some social scientists. He makes the point that case study is indeed science: it is truth-seeking and in the quest for public knowledge. In discussing the putative pillars of scientific credibility in social science—reliability and validity—he asks what estimates of reliability can be given for a field-note jotted down in the chaos of a classroom discussion.

Lather ( 2004 ) also takes on the theme of science, regretting the call for certain kinds of science in recent government reports—particularly in the discourse which stems from the landmark US piece of education legislation, No Child Left Behind , which demanded that teachers use only scientifically proven methods in their teaching. It’s a theme I have taken up myself (Thomas 2012 ): the point is that there is no core to scientific method, no charmed circle of precepts and processes that lead the incipiently scientific inquirer to the sunlit uplands of scientific inquiry. My argument, similar to Lather’s, is about the ways that we choose to be scientific in education inquiry and the consequences that such choices have for the nature and growth of our field of endeavor—our own science.

Stenhouse ( 1978 , 1980 ) conjoins discussion of these issues that concern the legitimacy of case study with concern about generalization. He sets case study in the context of research and what research should be. He is concerned in particular about verification and cumulation in case studies conducted in field settings in education, and he concludes that case study is a basis for generalization and hence cumulation of data. He proceeds to assert, in response to questions about the usefulness of case study that practice will improve when experience is systematically marshalled as history. He asks for the accumulation of an archive of case records. The concern is to provide a cumulative body of knowledge. But, as I have suggested elsewhere (Thomas 2012 ) expectation about cumulation in our scientific inquiry in education has to rest on an accumulation not of generalizable facts but of understandings drawn from and assessed in the context of one’s own experiences and the experiences of others. It rests, in other words, in the cultivation of provisional, tentative models for interpretation and analysis.

Smith ( 1978 ) described well the process of cultivating tentative models for interpretation in his account of the “miniature theories” (p. 363) which teachers develop and share (and see also Cochran-Smith and Lytle 2009 ). Ideas about how it can be conducted have traveled various avenues from Lewin’s ( 1946 ) action research to Checkland’s soft systems ( 1981 ) to Bryk et al’s ( 2015 ) improvement science.

Some Examples of Case Study in Educational Science

I have already mentioned three classic texts—Paul Willis’s Learning to Labor, Harry Wolcott’s The Man in the Principal’s Office and Stephen Ball’s Beachside Comprehensive —and it is worth going into some more detail on these before looking at other exemplars of the case study design frame.

Using case study, each of these researchers has done much for our understanding of the ways that schools work. They have achieved this by painting pictures in fine-grain detail about the encounters that occur in schools amongst staff and students.

Learning to Labour is often described as a classic ethnography. In it, Willis untangles how the young people at the “Hammertown” school—a school with a predominantly working class catchment in the English midlands—developed an antagonism towards school. They developed what Willis calls a counter school culture . They did this via what Willis calls differentiation . He says “ Differentiation is the process whereby the typical exchanges expected in the formal institutional paradigm are reinterpreted, separated and discriminated with respect to working class interests, feelings and meanings” (p. 62). He intertwines the development of the theoretical narrative about differentiation and counter culture with observations and illustrations from the case study itself. There is surely no way that such insights could have come from any frame of research other than case study here.

Ball ( 1981 ), in Beachside Comprehensive , presents a case study of a school and its pupils at a particular moment of change for education. He seeks to understand how the pupils “make sense of school as part of their whole life-world” (p. 109). His work is interesting as case study for the data-collection methods that he uses (questionnaires, diaries) and the ways that he simultaneously incorporates insights from the work of others. In an echo of the “differentiation” and “counter culture” of Willis, Ball reveals how, especially in the final year of compulsory education at a time when the school leaving age was rising, pupils accepted or rejected the goals of the school, and how those who more conspicuously rejected it were in turn viewed as failures by the teachers.

Before both of these studies, in 1973, was Wolcott’s The Man in the Principal’s Office: an Ethnography, which was one of the first detailed ethnographies undertaken in education. The work shows the range of data collection and analytical techniques open to the case inquirer. Wolcott notes the contradiction present in educators’ espoused wish to be seen as integrated with their communities while making their own subculture at school a relatively closed one.

Then there are case studies which reveal their power to change through enabling genuinely fresh theoretical insight. From the very beginning of Ferguson’s ( 1992 ) The Puzzle of Inclusion: a Case Study of Autistic Students in the Life of One High School the reader is immersed in the case. Immediately, we are encouraged to think about the situation itself, to hypothesize, to make our own assessments and judgements about what is happening. The author, therefore, relinquishes control over the interpretations, as Sparkes ( 2007 ) puts it—interpretations about the integration of autistic students into a mainstream school. The case is fascinating for the insights it offers on inclusion. Importantly for case study, Ferguson challenges any assumption that his case study school is in any way typical, nor need it be, he says. He concludes with a key statement:

Each high school … has its own set of unique events and specific personalities that interact with larger social forces and structures to construct its own pattern of understanding itself. Case studies are intended to reveal those patterns in as rich detail as possible. This does not mean that generalizations are impossible or even undesirable. Rather it simply places most of the responsibility for generalization to other settings on the readers themselves who know those other settings best. It is my responsibility as the writer to provide a thick enough description for the readers to make such judgments and comparisons. (p. 166)

Ferguson vividly illuminates the work of the case inquirer here. It reminds us that the work of the researcher in this form is truly theoretically grounded, with the constructs emerging from the research itself rather than being orphaned to some preordained theoretical construct.

In this, Ferguson’s work is like Wright’s ( 2010 ) case study of a small child and her mother. This chronicles, reflects upon and analyzes the emotional stasis and eventual thawing and trust of a little girl with whom Wright was working. Because of the case study approach, it is refreshingly free of the quasi-explanatory constructs that so often characterize accounts of breakdown in learning or emotional development at school. Wright’s explanation about the girl’s withdrawal comes directly from what he saw and what he knew. His intuitions about how to behave with her came from his own experiences as a person and a professional, one with experience of other people, and one who approaches others with humanity, understanding and a will to succeed. We, the readers, read in the context of our own experience, our own horizons of understanding.

In a study of reading failure, Johnston ( 1985 ) did something similar. He gave a case study examination of reading failure and found reasons for this failure more in students’ anxiety than in putative psychological deficits, where traditional educational and psychological science so often have sought within-child explanations. Like Ferguson and Wright, Johnston found failure at school to depend on the context and culture for learning. It is only through the rich and detailed study of individual cases that such analyses of children’s difficulties at school can be made. Such work shows that students’ success or failure at school is due less to “learning disabilities” and more to an array of factors around which acceptance and inclusion are constructed.

A similar set of new, rich explanations, divorced from the traditional starting points of the educator looking for explanation of why children fail come from Hart et al. ( 2004 ), who tell the story of one teacher, Julie. It’s one case study among nine in their book Learning without Limits , describing and analyzing how teachers developed alternative practices in their classrooms to move away from notions of fixed ability and disability, including “learning disability”. It shows how teachers use principles of “accessibility” and “emotional well-being” together with expectations about minimum levels of achievement for each child. Hart and her colleagues are putting into practice what Ferguson was suggesting—enabling through rich description an assessment by the reader of the transferability from one situation to another.

All of these case studies force serious re-thought about many of the pseudo-scientific constructs around which “failure” at school is often constructed. They do this by compelling a direct analysis of the case that is in front of the inquirer. The analyses come not from pre-packaged theorization that puts “failure” into this or that box with this or that label, but rather from insights which emerge from the authors’ own experiences as people and as professionals. We read their accounts and understand them in the contexts of our own experiences, our own horizons of understanding.

There are other examples of case study use in education that demonstrate well that this form of design need not follow an ethnographic route. Cremin et al. ( 2005 ) outline the use of what is sometimes called an n = 1 design, unusual in the case study genre for its employment of an experimental approach. As I have noted, methodologists such as Stake ( 2005 ; 443) have emphasized that case study is not a methodological choice but rather “a choice of what is to be studied” and Cremin et al. demonstrate this point in this experimental study. The researchers look at six classrooms in detail, examining the work of teaching assistants and in particular imposing three different kinds of organization for the work of those assistants in the classrooms. The different organizational methods are compared using a repeated measures experimental design and the findings of this are complemented by commentary from the staff participating in the study.

The terms “experiment” and “case study” are also juxtaposed by Driessen and Pyfer ( 1975 ), though here the “experiment” is an experiment only in the sense of trying something out. These researchers report on an evaluation of a program in adult basic education which was given in informal home settings instead of traditional classrooms. The aim was to meet the needs of “208 adults who wanted formal educational skills, but who found it neither comfortable nor appealing to participate in formal classroom settings” (p. 112). The whole trial is analyzed qualitatively. The use of the term “experiment” in this kind of study raises the issue of what a scientific experiment needs to look like in social science. It needn’t look like the experiments used in plant science and medicine. It can be far simpler, and I have discussed elsewhere the expropriation of the term “experiment” (Thomas 2016 ).

García et al. ( 2012 ) give literally a case history of the Oxnard schools in California—a history of what the authors call “mundane racism” (p. 2)—almost routine, taken-for-granted racism. Using school records and census records, they show how the school board’s decade-long “obsession” (p. 2) with segregation “effectively established a permanent dual schooling system that replicated racial hierarchy” (p. 2). This ingenious work both motivates and informs, providing not just a window on practices formative of some of today’s prejudices but also insights about how to move forward.

Two further examples demonstrate the value of the case study approach in education in the whole process of understanding teaching, learning and development. Duckworth ( 1986 ) reflects on a project in which she as a researcher and tutor asked teachers to engage in moon-watching—as a novel kind of task, the kind wherein empathy could be experienced with classroom learners—in order to reflect on their understanding of the sort of learning and teaching that might be expected at school. She concludes that “they make sense by trying out their own ideas, by explaining what they think and why, and seeing how this holds up in other people’s eyes, in their own eyes, and in the light of the phenomena they are trying to understand” (p. 487). This is summed up in the understanding of “teaching as research”. Hennessy, Mercer and Warwick do something similar ( 2011 ), showing how researchers and teachers could co-construct this process. They describe co-inquiry wherein, as the authors put it, “collaborative theory-building” (p. 1910) happened. Out of the process, pedagogical rationales were shifted and altered. The authors describe the ways that the case study enabled elucidatory work with teachers, suggesting that a rich set of perspectives could emerge: all the teachers would discuss insights which might develop as they orientated themselves to others’ perspectives.

I’ll finish this mini-sample of case studies in education with Jiménez and Gersten’s ( 1999 ) analysis of two distinct approaches to instruction provided by two bilingual teachers. They offer these as lessons and dilemmas which they have drawn from the literacy instruction of these two teachers. Their conclusion about the “method” of their work sums up much of the method of the case inquirer, for they say that their work aims to create what Wolcott called little theories. They note that Wolcott believed that education is best served by the generation of multiple insights tailored to specific situations and grounded in the expertise of those who work in those situations. These little theories, they suggest, are inductively derived conclusions concerning instruction and learning.

Conclusions

Case study is about explanation through in-depth inquiry and insider accounts, producing “little theories” and “miniature theories”, via the “multiple realities” of Berger and Luckmann ( 1979 ). These prove to be the life-blood of serious, transformative inquiry in education. All of the studies I have drawn from in the previous section of this article force serious re-thought about many of the pseudo-scientific constructs around which ideas about students’ experience at school is often constructed. They do this by compelling a direct analysis of the case that is in front of the inquirer. The analyses come not from the kind of pre-packaged theorization which so often guides the understanding of putatively gold standard experimentation, but rather from insights which emerge from the authors’ own experiences as people and as professionals.

In whatever field, scientific inquiry seeks to answer questions and to solve puzzles. That is its purpose. It looks for explanations—clarification, illumination, enlightenment—about how and why things happen as they do. We conjoin ideas, make connections, test hypotheses, recognize themes, and build models of the way the world works. We seek, as Einstein put it, “in whatever manner is suitable, a simplified and lucid image of the world” (cited in Holton 1995 , p. 168). Our inquiries, our questions and answers, assist in building what Harré ( 2012 )—in explaining the purpose of social science—called “working models of some aspect of social life.” We do this eclectically, and we do it, natural scientists and social scientists alike, through case study as much as experimentation.

For social scientists also seek “a simplified and lucid image” of the worlds in which they work—in whatever way. There can be no specific, superior type of question; no sunlit path to the perfect inquiry. Rather, there is variety. But this variety should not be seen as social science’s Achilles’ heel, accompanied by a laying out of hierarchies of better and worse kinds of research. We should, cherish, not disown, methodological pluralism and value the insights and understandings which come from case study.

None of this, of course—none of the call for pluralism and complementarity, with appropriate respect afforded to case study, ethnographic or more generally qualitative social inquiry forms—is to deny the absolute need for rigor in the conduct and analysis of research. As sociologist Robert Merton ( 1976 ) argued some time ago, the need is for “disciplined eclecticism” (p. 169) and his entreaty is still relevant. Funders need to be convinced of the quality and the intermeshing contributions of different forms of inquiry. They need to be convinced, in other words, of the matrix-like nature of inquiry forms, as Hammersley ( 2015 ) put it. Many advocates of experimental methodology recognize this—recognize, in other words, the slenderness of insight provided by experimental work and incorporate case study and other qualitative elements into their design frameworks to provide such insights. The onus has to be on case inquirers to argue for the contribution of idiographic inquiry to the findings of such research, as well arguing for the analytic power demonstrated in the kinds of study I have reviewed in this paper.

is professor of inclusion and diversity at the University of Birmingham, UK. He has written widely on research methodology in the applied social sciences. His most recent book on case study is How to do Your Case Study (2nd ed.) (Sage).

Atkinson P, Delamont S. Bread and dreams or bread and circuses? A critique of ‘case study’ research in education. In: Shipman M, editor. Educational research: Principles, policies and practices. London: Falmer; 1985. pp. 26–45. [ Google Scholar ]
Ball S. Beachside comprehensive: A case-study of secondary schooling. Cambridge: Cambridge University Press; 1981. [ Google Scholar ]
Bassey M. A solution to the problem of generalization in educational research: Fuzzy prediction. Oxford Review of Education. 2001; 27 (1):5–22. doi: 10.1080/03054980123773. [ CrossRef ] [ Google Scholar ]
Berger PL, Luckmann T. The social construction of reality: A treatise in the sociology of knowledge. London: Penguin; 1979. [ Google Scholar ]
Bryk A, Gomez LM, Grunow A, LeMahieu PG. Learning to improve: How America’s schools can get better at getting better. Cambridge, MA: Harvard Education Press; 2015. [ Google Scholar ]
Checkland P. Systems thinking, systems practice. Chichester: Wiley; 1981. [ Google Scholar ]
Cochran-Smith M, Lytle SL. Inquiry as stance: Practitioner research in the next generation. New York: Teachers College Press; 2009. [ Google Scholar ]
Cremin H, Thomas G, Vincett K. Working with teaching assistants: Three models evaluated. Research Papers in Education. 2005; 20 (4):413–432. doi: 10.1080/02671520500335881. [ CrossRef ] [ Google Scholar ]
Driessen JJ, Pyfer JN. An unconventional setting for a conventional occasion: A case study of an experimental adult education program. Sociology of Education. 1975; 48 (1):111–125. doi: 10.2307/2112053. [ CrossRef ] [ Google Scholar ]
Duckworth E. Teaching as research. Harvard Educational Review. 1986; 56 (4):481–495. doi: 10.17763/haer.56.4.x07k810711514163. [ CrossRef ] [ Google Scholar ]
Ferguson P. The puzzle of inclusion. In: Ferguson PM, Ferguson DL, Taylor SJ, editors. Interpreting disability: A qualitative reader. New York: Teachers College Press; 1992. pp. 145–167. [ Google Scholar ]
Friedman VJ. Action science: Creating communities of inquiry in communities of practice. In: Reason P, Bradbury H, editors. Handbook of action research. Thousand Oaks, CA: Sage; 2006. pp. 131–143. [ Google Scholar ]
Gadamer H-G. Truth and method. New York: Seabury Press; 1975. [ Google Scholar ]
García DG, Yosso TJ, Barajas FP. “A few of the brightest, cleanest Mexican children”: School segregation as a form of mundane racism in Oxnard, California, 1900–1940. Harvard Educational Review. 2012; 82 (1):1–25. doi: 10.17763/haer.82.1.40328h635h7745r3. [ CrossRef ] [ Google Scholar ]
Garvin DA. Making the case: Professional education for the world of practice. Harvard Magazine. 2003; 106 (1):56–107. [ Google Scholar ]
Geertz C. The interpretation of cultures: Selected essays. New York: Basic Books; 1973. Deep play: Notes on the Balinese cockfight; pp. 412–453. [ Google Scholar ]
Goldacre, B. (2013a). Teachers! What would evidence based practice look like ? Retrieved from http://www.badscience.net/2013/03/heres-my-paper-on-evidence-and-teaching-for-the-education-minister/#comments
Goldacre, B. (2013b). Building evidence into education . London: Bad Science. Retrieved from http://media.education.gov.uk/assets/files/pdf/b/ben%20goldacre%20paper.pdf
Hammersley, M. (2015). Against ‘gold standards’ in research: On the problem of assessment criteria . Paper given at ‘Was heißt hier eigentlich “Evidenz”?’, Frühjahrstagung 2015 des AK Methoden in der Evaluation Gesellschaft für Evaluation (DeGEval), Fakultät für Sozialwissenschaften, Hochschule für Technik und Wirtschaft des Saarlandes, Saarbrücken, Germany, May. Retrieved from http://www.degeval.de/fileadmin/users/Arbeitskreise/AK_Methoden/Hammersley_Saarbrucken.pdf
Hammersley M, Gomm R. Introduction. In: Gomm R, Hammersley M, Foster P, editors. Case study method. London: SAGE; 2000. [ Google Scholar ]
Harré, R. (2012). Rom Harré on What is Social Science? Social Science Space . Retrieved from http://www.socialsciencespace.com/2012/05/rom-harre-on-what-is-social-science/
Hart S, Dixon A, Drummond MJ, Mcintyre D. Learning without limits. Maidenhead: Open University Press; 2004. pp. 137–147. [ Google Scholar ]
Hennessy S, Warwick P, Mercer N. A dialogic inquiry approach to working with teachers in developing classroom dialogue. Teachers College Record. 2011; 113 (9):1906–1959. [ Google Scholar ]
Holton G. The controversy over the end of science. Scientific American. 1995; 273 (4):168. doi: 10.1038/scientificamerican1095-191. [ CrossRef ] [ Google Scholar ]
Jackson P. Life in classrooms. New York: Holt, Rinehart and Winston; 1968. [ Google Scholar ]
Jimenez RT, Gersten R. Lessons and dilemmas derived from the literacy instruction of two Latina/o Teachers. American Educational Research Journal. 1999; 36 (2):265–302. doi: 10.3102/00028312036002265. [ CrossRef ] [ Google Scholar ]
Johnston PH. Understanding reading disability: A case study approach. Harvard Educational Review. 1985; 55 (2):153–177. doi: 10.17763/haer.55.2.v30pl5j823545780. [ CrossRef ] [ Google Scholar ]
Kemmis S. The imagination of the case and the invention of the study. In: Simons H, editor. Towards a science of the singular. Norwich: Centre for Applied Research in Education, University of East Anglia; 1980. pp. 96–142. [ Google Scholar ]
Lather P. This is your father’s paradigm: Government intrusion and the case of qualitative research in education’ Qualitative Inquiry. 2004; 10 (1):15–34. doi: 10.1177/1077800403256154. [ CrossRef ] [ Google Scholar ]
Lewin K. Action research and minority problems. Journal of Social Issues. 1946; 2 (4):34–46. doi: 10.1111/j.1540-4560.1946.tb02295.x. [ CrossRef ] [ Google Scholar ]
Merton RK. Sociological ambivalence. New York: The Free Press; 1976. [ Google Scholar ]
Mogey JM. The contribution of Frédéric Le Play to family research. Marriage and Family Living. 1955; 17 (4):310–315. doi: 10.2307/346940. [ CrossRef ] [ Google Scholar ]
Prenzel M. Vital questions: The contribution of European social science. European Science Foundation: Strasbourg; 2009. Challenges facing the educational system; pp. 30–33. [ Google Scholar ]
Shavelson RJ, Towne L, editors. Scientific research in education. Washington, DC: National Academies Press; 2002. [ Google Scholar ]
Simons H, editor. Towards a science of the singular. Norwich, UK: Centre for Applied Research in Education, University of East Anglia; 1980. [ Google Scholar ]
Simons H. Case study research in practice. London: SAGE; 2009. [ Google Scholar ]
Slavin RE. Perspectives on evidence-based research in education: What works? Issues in synthesizing educational program evaluations. Educational Researcher. 2008; 37 (1):5–14. doi: 10.3102/0013189X08314117. [ CrossRef ] [ Google Scholar ]
Smith LM. An evolving logic of participant observation, educational ethnography, and other case studies. Review of Research in Education. 1978; 6 (1):316–377. doi: 10.3102/0091732X006001316. [ CrossRef ] [ Google Scholar ]
Sparkes AC. Embodiment, academics, and the audit culture: A story seeking consideration. Qualitative Research. 2007; 7 (4):521–550. doi: 10.1177/1468794107082306. [ CrossRef ] [ Google Scholar ]
Stake RE. Qualitative case studies. In: Denzin NK, Lincoln YS, editors. The SAGE handbook of qualitative research. 3. Thousand Oaks: SAGE; 2005. [ Google Scholar ]
Stenhouse L. Case study and case records: Towards a contemporary history of education. British Educational Research Journal. 1978; 4 (2):21–39. doi: 10.1080/0141192780040202. [ CrossRef ] [ Google Scholar ]
Stenhouse L. The study of samples and the study of cases. British Educational Research Journal. 1980; 6 (1):1–6. doi: 10.1080/0141192800060101. [ CrossRef ] [ Google Scholar ]
Thomas G. The case: Generalization, theory and phronesis in case study. Oxford Review of Education. 2011; 37 (1):21–35. doi: 10.1080/03054985.2010.521622. [ CrossRef ] [ Google Scholar ]
Thomas G. Changing our landscape of inquiry for a new science of education. Harvard Educational Review. 2012; 82 (1):26–51. doi: 10.17763/haer.82.1.6t2r089l715x3377. [ CrossRef ] [ Google Scholar ]
Thomas G. How to do your research project—A guide for students in education and applied social science. 2. London: Sage; 2013. [ Google Scholar ]
Thomas, G. (2016). After the gold rush. Harvard Educational Review , 86 (3) (in press).
Thomas G, James D. Re-inventing grounded theory: Some questions about theory, ground and discovery. British Educational Research Journal. 2006; 32 (6):767–795. doi: 10.1080/01411920600989412. [ CrossRef ] [ Google Scholar ]
Thomas, W. I. & Znaniecki, F. (1927/1958) The Polish peasant in Europe and America (2nd ed.). New York: Dover.
U.S. Department of Education . Toolkit for teachers. Washington, DC: Department of Education; 2004. [ Google Scholar ]
Vickers G. The art of judgment: A study of policy making. London: Chapman and Hall; 1965. [ Google Scholar ]
Wieviorka M. Case studies: History or sociology? In: Ragin CC, Becker HS, editors. What is a case? Exploring the foundations of social inquiry. New York: Cambridge University Press; 1992. [ Google Scholar ]
Willis, P. (1993) Learning to labour (pp. 62–77). Aldershot: Ashgate (first published by Saxon House, 1978).
Wolcott H. The man in the principal’s office. Prospect Heights, IL: Waveland Press; 1978. [ Google Scholar ]
Wright T. Learning to laugh: A portrait of risk and resilience in early childhood. Harvard Educational Review. 2010; 80 (4):444–463. doi: 10.17763/haer.80.4.w18726475585x5t2. [ CrossRef ] [ Google Scholar ]

The Case Study Method in Social Inquiry

21,163 citations

View 1 citation excerpt

Cites background from "The Case Study Method in Social Inq..."

... • journalism (picking out more striking features of the case, thereby distorting the full account in order to emphasize these more sensational aspects); • selective reporting (selecting only that evidence which will support a particular conclusion, thereby misrepresenting the whole case); • an anecdotal style (degenerating into an endless series of low-level banal and tedious illustrations that take over from in-depth, rigorous analysis); one is reminded of Stake’s (1978) wry comment that ‘our scrapbooks are full of enlargements of enlargements’, alluding to the tendency of some case studies to over-emphasize detail to the detriment of seeing the whole picture; • pomposity (striving to derive or generate profound theories from low-level data, or by wrapping up accounts in high-sounding verbiage); • blandness (unquestioningly accepting only the respondents’ views, or only including those aspects of the case study on which people agree rather than areas on which they might disagree). ...

1,864 citations

1,509 citations

1,320 citations

Cites methods from "The Case Study Method in Social Inq..."

... Stake (1978), for example, used the term naturalistic generalization to refer to generalizations as a product of human experiences in which people identify ‘‘the similarities of objects and issues’’ (p. 6). ...

1,127 citations

10,916 citations

2,055 citations

1,162 citations

901 citations

628 citations

A qualitative study of rural healthcare providers’ views of social, cultural, and programmatic barriers to healthcare access

Nicholas C. Coombs 1 ,
Duncan G. Campbell 2 &
James Caringi 1

BMC Health Services Research volume 22 , Article number: 438 ( 2022 ) Cite this article

22k Accesses

19 Citations

10 Altmetric

Metrics details

Ensuring access to healthcare is a complex, multi-dimensional health challenge. Since the inception of the coronavirus pandemic, this challenge is more pressing. Some dimensions of access are difficult to quantify, namely characteristics that influence healthcare services to be both acceptable and appropriate. These link to a patient’s acceptance of services that they are to receive and ensuring appropriate fit between services and a patient’s specific healthcare needs. These dimensions of access are particularly evident in rural health systems where additional structural barriers make accessing healthcare more difficult. Thus, it is important to examine healthcare access barriers in rural-specific areas to understand their origin and implications for resolution.

We used qualitative methods and a convenience sample of healthcare providers who currently practice in the rural US state of Montana. Our sample included 12 healthcare providers from diverse training backgrounds and specialties. All were decision-makers in the development or revision of patients’ treatment plans. Semi-structured interviews and content analysis were used to explore barriers–appropriateness and acceptability–to healthcare access in their patient populations. Our analysis was both deductive and inductive and focused on three analytic domains: cultural considerations, patient-provider communication, and provider-provider communication. Member checks ensured credibility and trustworthiness of our findings.

Five key themes emerged from analysis: 1) a friction exists between aspects of patients’ rural identities and healthcare systems; 2) facilitating access to healthcare requires application of and respect for cultural differences; 3) communication between healthcare providers is systematically fragmented; 4) time and resource constraints disproportionately harm rural health systems; and 5) profits are prioritized over addressing barriers to healthcare access in the US.

Conclusions

Inadequate access to healthcare is an issue in the US, particularly in rural areas. Rural healthcare consumers compose a hard-to-reach patient population. Too few providers exist to meet population health needs, and fragmented communication impairs rural health systems’ ability to function. These issues exacerbate the difficulty of ensuring acceptable and appropriate delivery of healthcare services, which compound all other barriers to healthcare access for rural residents. Each dimension of access must be monitored to improve patient experiences and outcomes for rural Americans.

Peer Review reports

Unequal access to healthcare services is an important element of health disparities in the United States [ 1 ], and there remains much about access that is not fully understood. The lack of understanding is attributable, in part, to the lack of uniformity in how access is defined and evaluated, and the extent to which access is often oversimplified in research [ 2 ]. Subsequently, attempts to address population-level barriers to healthcare access are insufficient, and access remains an unresolved, complex health challenge [ 3 , 4 , 5 ]. This paper presents a study that aims to explore some of the less well studied barriers to healthcare access, particularly those that influence healthcare acceptability and appropriateness.

In truth, healthcare access entails a complicated calculus that combines characteristics of individuals, their households, and their social and physical environments with characteristics of healthcare delivery systems, organizations, and healthcare providers. For one to fully ‘access’ healthcare, they must have the means to identify their healthcare needs and have available to them care providers and the facilities where they work. Further, patients must then reach, obtain, and use the healthcare services in order to have their healthcare needs fulfilled. Levesque and colleagues critically examined access conceptualizations in 2013 and synthesized all ways in which access to healthcare was previously characterized; Levesque et al. proposed five dimensions of access: approachability, acceptability, availability, affordability and appropriateness [ 2 ]. These refer to the ability to perceive, seek, reach, pay for, and engage in services, respectively.

According to Levesque et al.’s framework, the five dimensions combine to facilitate access to care or serve as barriers. Approachability indicates that people facing health needs understand that healthcare services exist and might be helpful. Acceptability represents whether patients see healthcare services as consistent or inconsistent with their own social and cultural values and worldviews. Availability indicates that healthcare services are reached both physically and in a timely manner. Affordability simplifies one’s capacity to pay for healthcare services without compromising basic necessities, and finally, appropriateness represents the fit between healthcare services and a patient’s specific healthcare needs [ 2 ]. This study focused on the acceptability and appropriateness dimensions of access.

Before the novel coronavirus (SARS-CoV-2; COVID-19) pandemic, approximately 13.3% of adults in the US did not have a usual source of healthcare [ 6 ]. Millions more did not utilize services regularly, and close to two-thirds reported that they would be debilitated by an unexpected medical bill [ 7 , 8 , 9 ]. Findings like these emphasized a fragility in the financial security of the American population [ 10 ]. These concerns were exacerbated by the pandemic when a sudden surge in unemployment increased un- and under-insurance rates [ 11 ]. Indeed, employer-sponsored insurance covers close to half of Americans’ total cost of illness [ 12 ]. Unemployment linked to COVID-19 cut off the lone outlet to healthcare access for many. Health-related financial concerns expanded beyond individuals, as healthcare organizations were unequipped to manage a simultaneous increase in demand for specialized healthcare services and a steep drop off for routine revenue-generating healthcare services [ 13 ]. These consequences of the COVID-19 pandemic all put additional, unexpected pressure on an already fragmented US healthcare system.

Other structural barriers to healthcare access exist in relation to the rural–urban divide. Less than 10% of US healthcare resources are located in rural areas where approximately 20% of the American population resides [ 14 ]. In a country with substantially fewer providers per capita compared to many other developed countries, persons in rural areas experience uniquely pressing healthcare provider shortages [ 15 , 16 ]. Rural inhabitants also tend to have lower household income, higher rates of un- or under-insurance, and more difficulty with travel to healthcare clinics than urban dwellers [ 17 ]. Subsequently, persons in rural communities use healthcare services at lower rates, and potentially preventable hospitalizations are more prevalent [ 18 ]. This disparity often leads rural residents to use services primarily for more urgent needs and less so for routine care [ 19 , 20 , 21 ].

The differences in how rural and urban healthcare systems function warranted a federal initiative to focus exclusively on rural health priorities and serve as counterpart to Healthy People objectives [ 22 ]. The rural determinants of health, a more specific expression of general social determinants, add issues of geography and topography to the well-documented social, economic and political factors that influence all Americans’ access to healthcare [ 23 ]. As a result, access is consistently regarded as a top priority in rural areas, and many research efforts have explored the intersection between access and rurality, namely within its less understood dimensions (acceptability and appropriateness) [ 22 ].

Acceptability-related barriers to care

Acceptability represents the dimension of healthcare access that affects a patient’s ability to seek healthcare, particularly linked to one’s professional values, norms and culture [ 2 ]. Access to health information is an influential factor for acceptable healthcare and is essential to promote and maintain a healthy population [ 24 ]. According to the Centers for Disease Control and Prevention, health literacy or a high ‘health IQ’ is the degree to which individuals have the ability to find, understand, and use information and services to inform health-related decisions and actions for themselves and others, which impacts healthcare use and system navigation [ 25 ]. The literature indicates that lower levels of health literacy contribute to health disparities among rural populations [ 26 , 27 , 28 ]. Evidence points to a need for effective health communication between healthcare organizations and patients to improve health literacy [ 24 ]. However, little research has been done in this area, particularly as it relates to technologically-based interventions to disseminate health information [ 29 ].

Stigma, an undesirable position of perceived diminished status in an individual’s social position, is another challenge that influences healthcare acceptability [ 30 ]. Those who may experience stigma fear negative social consequences in relation to care seeking. They are more likely to delay seeking care, especially among ethnic minority populations [ 31 , 32 ]. Social media presents opportunities for the dissemination of misleading medical information; this runs further risk for stigma [ 33 ]. Stigma is difficult to undo, but research has shown that developing a positive relationship with a healthcare provider or organization can work to reduce stigma among patients, thus promoting healthcare acceptability [ 34 ].

A provider’s attempts to engage patients and empower them to be active decision-makers regarding their treatment has also been shown to improve healthcare acceptability. One study found that patients with heart disease who completed a daily diary of weight and self-assessment of symptoms, per correspondence with their provider, had better care outcomes than those who did not [ 35 ]. Engaging with household family members and involved community healers also mitigates barriers to care, emphasizing the importance of a team-based approach that extends beyond those who typically provide healthcare services [ 36 , 37 ]. One study, for instance, explored how individuals closest to a pregnant woman affect the woman’s decision to seek maternity care; partners, female relatives, and community health-workers were among the most influential in promoting negative views, all of which reduced a woman’s likelihood to access care [ 38 ].

Appropriateness-related barriers to care

Appropriateness marks the dimension of healthcare access that affects a patient’s ability to engage, and according to Levesque et al., is of relevance once all other dimensions (the ability to perceive, seek, reach and pay for) are achieved [ 2 ]. The ability to engage in healthcare is influenced by a patient’s level of empowerment, adherence to information, and support received by their healthcare provider. Thus, barriers to healthcare access that relate to appropriateness are often those that indicate a breakdown in communication between a patient with their healthcare provider. Such breakdown can involve a patient experiencing miscommunication, confrontation, and/or a discrepancy between their provider’s goals and their own goals for healthcare. Appropriateness represents a dimension of healthcare access that is widely acknowledged as an area in need of improvement, which indicates a need to rethink how healthcare providers and organizations can adapt to serve the healthcare needs of their communities [ 39 ]. This is especially true for rural, ethnic minority populations, which disproportionately experience an abundance of other barriers to healthcare access. Culturally appropriate care is especially important for members of minority populations [ 40 , 41 , 42 ]. Ultimately, patients value a patient-provider relationship characterized by a welcoming, non-judgmental atmosphere [ 43 , 44 ]. In rural settings especially, level of trust and familiarity are common factors that affect service utilization [ 45 ]. Evidence suggests that kind treatment by a healthcare provider who promotes patient-centered care can have a greater overall effect on a patient’s experience than a provider’s degree of medical knowledge or use of modern equipment [ 46 ]. Of course, investing the time needed to nurture close and caring interpersonal connections is particularly difficult in under-resourced, time-pressured rural health systems [ 47 , 48 ].

The most effective way to evaluate access to healthcare largely depends on which dimensions are explored. For instance, a population-based survey can be used to measure the barrier of healthcare affordability. Survey questions can inquire directly about health insurance coverage, care-related financial burden, concern about healthcare costs, and the feared financial impacts of illness and/or disability. Many national organizations have employed such surveys to measure affordability-related barriers to healthcare. For example, a question may ask explicitly about financial concerns: ‘If you get sick or have an accident, how worried are you that you will not be able to pay your medical bills?’ [ 49 ]. Approachability and availability dimensions of access are also studied using quantitative analysis of survey questions, such as ‘Is there a place that you usually go to when you are sick or need advice about your health?’ or ‘Have you ever delayed getting medical care because you couldn’t get through on the telephone?’ In contrast, the remaining two dimensions–acceptability and appropriateness–require a qualitative approach, as the social and cultural factors that determine a patient’s likelihood of accepting aspects of the services that are to be received (acceptability) and the fit between those services and the patient’s specific healthcare needs (appropriateness) can be more abstract [ 50 , 51 ]. In social science, qualitative methods are appropriate to generate knowledge of what social events mean to individuals and how those individuals interact within them; these methods allow for an exploration of depth rather than breadth [ 52 , 53 ]. Qualitative methods, therefore, are appropriate tools for understanding the depth of healthcare providers’ experiences in the inherently social context of seeking and engaging in healthcare.

In sum, acceptability- and appropriateness-related barriers to healthcare access are multi-layered, complex and abundant. Ensuring access becomes even more challenging if structural barriers to access are factored in. In this study, we aimed to explore barriers to healthcare access among persons in Montana, a historically underserved, under-resourced, rural region of the US. Montana is the fourth largest and third least densely populated state in the country; more than 80% of Montana counties are classified as non-core (the lowest level of urban/rural classification), and over 90% are designated as health professional shortage areas [ 54 , 55 ]. Qualitative methods supported our inquiry to explore barriers to healthcare access related to acceptability and appropriateness.

Participants

Qualitative methods were utilized for this interpretive, exploratory study because knowledge regarding barriers to healthcare access within Montana’s rural health systems is limited. We chose Montana healthcare providers, rather than patients, as the population of interest so we may explore barriers to healthcare access from the perspective of those who serve many persons in rural settings. Inclusion criteria required study participants to provide direct healthcare to patients at least one-half of their time. We defined ‘provider’ as a healthcare organization employee with clinical decision-making power and the qualifications to develop or revise patients’ treatment plans. In an attempt to capture a group of providers with diverse experience, we included providers across several types and specialties. These included advanced practice registered nurses (APRNs), physicians (MDs and DOs), and physician assistants (PAs) who worked in critical care medicine, emergency medicine, family medicine, hospital medicine, internal medicine, pain medicine, palliative medicine, pediatrics, psychiatry, and urgent care medicine. We also included licensed clinical social workers (LCSWs) and clinical psychologists who specialize in behavioral healthcare provision.

Recruitment and Data Collection

We recruited participants via email using a snowball sampling approach [ 56 ]. We opted for this approach because of its effectiveness in time-pressured contexts, such as the COVID-19 pandemic, which has made healthcare provider populations hard to reach [ 57 ]. Considering additional constraints with the pandemic and the rural nature of Montana, interviews were administered virtually via Zoom video or telephone conferencing with Zoom’s audio recording function enabled. All interviews were conducted by the first author between January and September 2021. The average length of interviews was 50 min, ranging from 35 to 70 min. There were occasional challenges experienced during interviews (poor cell phone reception from participants, dropped calls), in which case the interviewer remained on the line until adequate communication was resumed. All interviews were included for analysis and transcribed verbatim into NVivo Version 12 software. All qualitative data were saved and stored on a password-protected University of Montana server. Hard-copy field notes were securely stored in a locked office on the university’s main campus.

Data analysis included a deductive followed by an inductive approach. This dual analysis adheres to Levesque’s framework for qualitative methods, which is discussed in the Definition of Analytic Domains sub-section below. Original synthesis of the literature informed the development of our initial deductive codebook. The deductive approach was derived from a theory-driven hypothesis, which consisted of synthesizing previous research findings regarding acceptability- and appropriateness-related barriers to care. Although the locations, patient populations and specific type of healthcare services varied by study in the existing literature, several recurring barriers to healthcare access were identified. We then operationalized three analytic domains based on these findings: cultural considerations, patient-provider communication, and provider-provider communication. These domains were chosen for two reasons: 1) the terms ‘culture’ and ‘communication’ were the most frequently documented characteristics across the studies examined, and 2) they each align closely with the acceptability and appropriateness dimensions of access to healthcare, respectively. In addition, ‘culture’ is included in the definition of acceptability and ‘communication’ is a quintessential aspect of appropriateness. These domains guided the deductive portion of our analysis, which facilitated the development of an interview guide used for this study.

Interviews were semi-structured to allow broad interpretations from participants and expand the open-ended characterization of study findings. Data were analyzed through a flexible coding approach proposed by Deterding and Waters [ 58 ]. Qualitative content analysis was used, a method particularly beneficial for analyzing large amounts of qualitative data collected through interviews that offers possibility of quantifying categories to identify emerging themes [ 52 , 59 ]. After fifty percent of data were analyzed, we used an inductive approach as a formative check and repeated until data saturation, or the point at which no new information was gathered in interviews [ 60 ]. At each point of inductive analysis, interview questions were added, removed, or revised in consideration of findings gathered [ 61 ]. The Standards for Reporting Qualitative Research (SRQR) was used for reporting all qualitative data for this study [ 62 ]. The first and third authors served as primary and secondary analysts of the qualitative data and collaborated to triangulate these findings. An audit approach was employed, which consisted of coding completed by the first author and then reviewed by the third author. After analyses were complete, member checks ensured credibility and trustworthiness of findings [ 63 ]. Member checks consisted of contacting each study participant to explain the study’s findings; one-third of participants responded and confirmed all findings. All study procedures were reviewed and approved by the Human Subjects Committee of the authors’ institution’s Institutional Review Board.

Definitions of Analytic Domains

Cultural considerations.

Western health systems often fail to consider aspects of patients’ cultural perspectives and histories. This can manifest in the form of a providers’ lack of cultural humility. Cultural humility is a process of preventing imposition of one’s worldview and cultural beliefs on others and recognizing that everyone’s conception of the world is valid. Humility cultivates sensitive approaches in treating patients [ 64 ]. A lack of cultural humility impedes the delivery of acceptable and appropriate healthcare [ 65 ], which can involve low empathy or respect for patients, or dismissal of culture and traditions as superstitions that interfere with standard treatments [ 66 , 67 ]. Ensuring cultural humility among all healthcare employees is a step toward optimal healthcare delivery. Cultural humility is often accomplished through training that can be tailored to particular cultural- or gender-specific populations [ 68 , 69 ]. Since cultural identities and humility have been marked as factors that can heavily influence patients’ access to care, cultural considerations composed our first analytic domain. To assess this domain, we asked participants how they address the unique needs of their patients, how they react when they observe a cultural behavior or attitude from a patient that may not directly align with their treatment plan, and if they have received any multicultural training or training on cultural considerations in their current role.

Patient-provider communication

Other barriers to healthcare access can be linked to ineffective patient-provider communication. Patients who do not feel involved in healthcare decisions are less likely to adhere to treatment recommendations [ 70 ]. Patients who experience communication difficulties with providers may feel coerced, which generates disempowerment and leads patients to employ more covert ways of engagement [ 71 , 72 ]. Language barriers can further compromise communication and hinder outcomes or patient progress [ 73 , 74 ]. Any miscommunication between a patient and provider can affect one’s access to healthcare, namely affecting appropriateness-related barriers. For these reasons, patient-provider communication composed our second analytic domain. We asked participants to highlight the challenges they experience when communicating with their patients, how those complications are addressed, and how communication strategies inform confidentiality in their practice. Confidentiality is a core ethical principle in healthcare, especially in rural areas that have smaller, interconnected patient populations [ 75 ].

Provider-Provider Communication

A patient’s journey through the healthcare system necessitates sufficient correspondence between patients, primary, and secondary providers after discharge and care encounters [ 76 ]. Inter-provider and patient-provider communication are areas of healthcare that are acknowledged to have some gaps. Inconsistent mechanisms for follow up communication with patients in primary care have been documented and emphasized as a concern among those with chronic illness who require close monitoring [ 68 , 77 ]. Similar inconsistencies exist between providers, which can lead to unclear care goals, extended hospital stays, and increased medical costs [ 78 ]. For these reasons, provider-provider communication composed our third analytic domain. We asked participants to describe the approaches they take to streamline communication after a patient’s hospital visit, the methods they use to ensure collaborative communication between primary or secondary providers, and where communication challenges exist.

Healthcare provider characteristics

Our sample included 12 providers: four in family medicine (1 MD, 1 DO, 1 PA & 1 APRN), three in pediatrics (2 MD with specialty in hospital medicine & 1 DO), three in palliative medicine (2 MDs & 1 APRN with specialty in wound care), one in critical care medicine (DO with specialty in pediatric pulmonology) and one in behavioral health (1 LCSW with specialty in trauma). Our participants averaged 9 years (range 2–15) as a healthcare provider; most reported more than 5 years in their current professional role. The diversity of participants extended to their patient populations as well, with each participant reporting a unique distribution of age, race and level of medical complexity among their patients. Most participants reported that a portion of their patients travel up to five hours, sometimes across county- or state-lines, to receive care.

Theme 1: A friction exists between aspects of patients’ rural identities and healthcare systems

Our participants comprised a collection of medical professions and reported variability among health-related reasons their patients seek care. However, most participants acknowledged similar characteristics that influence their patients’ challenges to healthcare access. These identified factors formed categories from which the first theme emerged. There exists a great deal of ‘rugged individualism’ among Montanans, which reflects a self-sufficient and self-reliant way of life. Stoicism marked a primary factor to characterize this quality. One participant explained:

True Montanans are difficult to treat medically because they tend to be a tough group. They don’t see doctors. They don’t want to go, and they don’t want to be sick. That’s an aspect of Montana that makes health culture a little bit difficult.

Another participant echoed this finding by stating:

The backwoods Montana range guy who has an identity of being strong and independent probably doesn’t seek out a lot of medical care or take a lot of medications. Their sense of vitality, independence and identity really come from being able to take care and rely on themselves. When that is threatened, that’s going to create a unique experience of illness.

Similar responses were shared by all twelve participants; stoicism seemed to be heavily embedded in many patient populations in Montana and serves as a key determinant of healthcare acceptability. There are additional factors, however, that may interact with stoicism but are multiply determined. Stigma is an example of this, presented in this context as one’s concern about judgement by the healthcare system. Respondents were openly critical of this perception of the healthcare system as it was widely discussed in interviews. One participant stated:

There is a real perception of a punitive nature in the medical community, particularly if I observe a health issue other than the primary reason for one’s hospital visit, whether that may be predicated on medical neglect, delay of care, or something that may warrant a report to social services. For many of the patients and families I see, it’s not a positive experience and one that is sometimes an uphill barrier that I work hard to circumnavigate.

Analysis of these factors suggest that low use of healthcare services may link to several characteristics, including access problems. Separately, a patient’s perceived stigma from healthcare providers may also impact a patient’s willingness to receive services. One participant put it best by stating

Sometimes, families assume that I didn’t want to see them because they will come in for follow up to meet with me but end up meeting with another provider, which is frustrating because I want to maintain patients on my panel but available time and resource occasionally limits me from doing so. It could be really hard adapting to those needs on the fly, but it’s an honest miss.

When a patient arrives for a healthcare visit and experiences this frustration, it may elicit a patient’s perceptions of neglect or disorganization. This ‘honest miss’ may, in turn, exacerbate other acceptable-related barriers to care.

Theme 2: Facilitating access to healthcare requires application of and respect for cultural differences

The biomedical model is the standard of care utilized in Western medicine [ 79 , 80 ]. However, the US comprises people with diverse social and cultural identities that may not directly align with Western conceptions of health and wellness. Approximately 11.5% of the Montana population falls within an ethnic minority group. 6.4% are of American Indian or Alaska Native origin, 0.5% are of Black or African American origin, 0.8% are of Asian origin and 3.8% are of multiple or other origins. [ 81 ]. Cultural insensitivity is acknowledged in health services research as an active deterrent for appropriate healthcare delivery [ 65 ]. Participants for this study were asked how they react when a patient brings up a cultural attitude or behavior that may impact the proposed treatment plan. Eight participants noted a necessity for humility when this occurs. One participant conceptualized this by stating:

When this happens, I learn about individuals and a way of life that is different to the way I grew up. There is a lot of beauty and health in a non-patriarchal, non-dominating, non-sexist framework, and when we can engage in such, it is really expansive for my own learning process.

The participants who expressed humility emphasized that it is best to work in tandem with their patient, congruently. Especially for those with contrasting worldviews, a provider and a patient working as a team poses an opportunity to develop trust. Without it, a patient can easily fall out of the system, further hindering their ability to access healthcare services in the future. One participant stated:

The approach that ends up being successful for a lot of patients is when we understand their modalities, and they have a sense we understand those things. We have to show understanding and they have to trust. From there, we can make recommendations to help get them there, not decisions for them to obey, rather views based on our experiences and understanding of medicine.

Curiosity was another reaction noted by a handful of participants. One participant said:

I believe patients and their caregivers can be engaged and loving in different ways that don’t always follow the prescribed approach in the ways I’ve been trained, but that doesn’t necessarily mean that they are detrimental. I love what I do, and I love learning new things or new approaches, but I also love being surprised. My style of medicine is not to predict peoples’ lives, rather to empower and support what makes life meaningful for them.

Participants mentioned several other characteristics that they use in practice to prevent cultural insensitivity and support a collaborative approach to healthcare. Table 1 lists these facilitating characteristics and quotes to explain the substance of their benefit.

Consensus among participants indicated that the use of these protective factors to promote cultural sensitivity and apply them in practice is not standardized. When asked, all but two participants said they had not received any culturally-based training since beginning their practice. Instead, they referred to developing skills through “on the job training” or “off the cuff learning.” The general way of medicine, one participant remarked, was to “throw you to the fire.” This suggested that use of standardized cultural humility training modules for healthcare providers was not common practice. Many attributed this to time constraints.

Individual efforts to gain culturally appropriate skills or enhance cultural humility were mentioned, however. For example, three participants reported that they attended medical conferences to discuss cultural challenges within medicine, one participant sought out cultural education within their organization, and another was invited by Native American community members to engage in traditional peace ceremonies. Participants described these additional efforts as uncommon and outside the parameters of a provider’s job responsibilities, as they require time commitments without compensation.

Additionally, eight participants said they share their personal contact information with patients so they may call them directly for medical needs. The conditions and frequency with which this is done was variable and more common among providers in specialized areas of medicine or those who described having a manageable patient panel. All who reported that they shared their personal contact information described it as an aspect of rural health service delivery that is atypical in other, non-rural healthcare systems.

Theme 3: Communication between healthcare providers is systematically fragmented

Healthcare is complex and multi-disciplinary, and patients’ treatment is rarely overseen by a single provider [ 82 ]. The array of provider types and specialties is vast, as is the range of responsibilities ascribed to providers. Thus, open communication among providers both within and between healthcare systems is vital for the success of collaborative healthcare [ 83 ]. Without effective communication achieved between healthcare providers, the appropriate delivery of healthcare services may be become compromised. Our participants noted that they face multiple challenges that complicate communication with other providers. Miscommunication between departments, often implicating the Emergency Department (ED), was a recurring point noted among participants. One participant who is a primary care physician said:

If one of my patients goes to the ER, I don’t always get the notes. They’re supposed to send them to the patient’s primary care doc. The same thing happens with general admissions, but again, I often find out from somebody else that my patient was admitted to the hospital.

This failure to communicate can negatively impact the patient, particularly if time sensitivity or medical complexity is essential to treatment. A patient’s primary care physician is the most accurate source of their medical history; without an effective way to obtain and synthesize a patient’s health information, there may be increased risk of medical error. One participant in a specialty field stated:

One of the biggest barriers I see is obtaining a concise description of a patient’s history and needs. You can imagine if you’re a mom and you’ve got a complicated kid. You head to the ER. The ER doc looks at you with really wide eyes, not knowing how to get information about your child that’s really important.

This concern was highlighted with a specific example from a different participant:

I have been unable to troubleshoot instances when I send people to the ER with a pretty clear indication for admission, and then they’re sent home. For instance, I had an older fellow with pretty severe chronic kidney disease. He presented to another practitioner in my office with shortness of breath and swelling and appeared to have newly onset decompensated heart failure. When I figured this out, I sent him to the ER, called and gave my report. The patient later came back for follow up to find out not only that they had not been admitted but they lost no weight with outpatient dialysis . I feel like a real opportunity was missed to try to optimize the care of the patient simply because there was poor communication between myself and the ER. This poor guy… He ended up going to the ER four times before he got admitted for COVID-19.

In some cases, communication breakdown was reported as the sole cause of a poor outcome. When communication is effective, each essential member of the healthcare team is engaged and collaborating with the same information. Some participants called this process ‘rounds’ when a regularly scheduled meeting is staged between a group of providers to ensure access to accurate patient information. Accurate communication may also help build trust and improve a patient’s experience. In contrast, ineffective communication can result in poor clarity regarding providers’ responsibilities or lost information. Appropriate delivery of healthcare considers the fit between providers and a patient’s specific healthcare needs; the factors noted here suggest that provider-provider miscommunication can adversely affect this dimension of healthcare access.

Another important mechanism of communication is the sharing of electronic medical records (EMRs), a process that continues to shift with technological advances. Innovation is still recent enough, however, for several of our study participants to be able to recall a time when paper charts were standard. Widespread adoption and embrace of the improvements inherent in electronic medical records expanded in the late 2000’s [ 84 ]. EMRs vastly improved the ability to retain, organize, safeguard, and transfer health information. Every participant highlighted EMRs at one point or another and often did so with an underlying sense of anger or frustration. Systematic issues and problems with EMRs were discussed. One participant provided historical context to such records:

Years back, the government aimed to buy an electronic medical record system, whichever was the best, and a number of companies created their own. Each were a reasonable system, so they all got their checks and now we have four completely separate operating systems that do not talk to each other. The idea was to make a router or some type of relay that can share information back and forth. There was no money in that though, so of course, no one did anything about it. Depending on what hospital, clinic or agency you work for, you will most likely work within one of these systems. It was a great idea; it just didn’t get finished.

Seven participants confirmed these points and their impacts on making coordination more difficult, relying on outdated communication strategies more often than not. Many noted this even occurs between facilities within the same city and in separate small metropolitan areas across the state. One participant said:

If my hospital decides to contract with one EMR and the hospital across town contracts with another, correspondence between these hospitals goes back to traditional faxing. As a provider, you’re just taking a ‘fingered crossed’ approach hoping that the fax worked, is picked up, was put in the appropriate inbox and was actually looked at. Information acquisition and making sure it’s timely are unforeseen between EMRs.

Participants reported an “astronomic” number of daily faxes and telephone calls to complete the communication EMRs were initially designed to handle. These challenges are even more burdensome if a patient moves from out of town or out of state; obtaining their medical records was repeatedly referred to as a “chore” so onerous that it often remains undone. Another recurring concern brought up by participants regarded accuracy within EMRs to lend a false sense of security. They are not frequently updated, not designed to be family-centered and not set up to do anything automatically. One participant highlighted these limitations by stating:

I was very proud of a change I made in our EMR system [EPIC], even though it was one I never should have had to make. I was getting very upset because I would find out from my nursing assistant who read the obituary that one of my patients had died. There was a real problem with the way the EMR was notifying PCP’s, so I got an EPIC-level automated notification built into our EMR so that any time a patient died, their status would be changed to deceased and a notification would be sent to their PCP. It’s just really awful to find out a week later that your patient died, especially when you know these people and their families really well. It’s not good care to have blind follow up.

Whether it be a physical or electronic miscommunication between healthcare providers, the appropriate delivery of healthcare can be called to question

Theme 4: Time and resource constraints disproportionately harm rural health systems

Several measures of system capacity suggest the healthcare system in the US is under-resourced. There are fewer physicians and hospital beds per capita compared to most comparable countries, and the growth of healthcare provider populations has stagnated over time [ 15 ]. Rural areas, in particular, are subject to resource limitations [ 16 ]. All participants discussed provider shortages in detail. They described how shortages impact time allocation in their day-to-day operations. Tasks like patient intakes, critical assessments, and recovering information from EMRs take time, of which most participants claimed to not have enough of. There was also a consensus in having inadequate time to spend on medically complex cases. Time pressures were reported to subsequently influence quality of care. One participant stated:

With the constant pace of medicine, time is not on your side. A provider cannot always participate in an enriching dialogue with their patients, so rather than listen and learn, we are often coerced into the mindset of ‘getting through’ this patient so we can move on. This echoes for patient education during discharge, making the whole process more arduous than it otherwise could be if time and resources were not as sparse.

Depending on provider type, specialty, and the size of patient panels, four participants said they have the luxury of extending patient visits to 40 + minutes. Any flexibility with patient visits was regarded as just that: a luxury. Very few providers described the ability to coordinate their schedules as such. This led some study participants to limit the number of patients they serve. One participant said:

We simply don’t have enough clinicians, which is a shame because these people are really skilled, exceptional, brilliant providers but are performing way below their capacity. Because of this, I have a smaller case load so I can engage in a level of care that I feel is in the best interest of my patients. Everything is a tradeoff. Time has to be sacrificed at one point or another. This compromise sets our system up to do ‘ok’ work, not great work.

Of course, managing an overly large number of patients with high complexity is challenging. Especially while enduring the burden of a persisting global pandemic, participants reflected that the general outlook of administering healthcare in the US is to “do more with less.” This often forces providers to delegate responsibilities, which participants noted has potential downsides. One participant described how delegating patient care can cause problems.

Very often will a patient schedule a follow up that needs to happen within a certain time frame, but I am unable to see them myself. So, they are then placed with one of my mid-level providers. However, if additional health issues are introduced, which often happens, there is a high-risk of bounce-back or need to return once again to the hospital. It’s an inefficient vetting process that falls to people who may not have specific training in the labs and imaging that are often included in follow up visits. Unfortunately, it’s a forlorn hope to have a primary care physician be able to attend all levels of a patient’s care.

Several participants described how time constraints stretch all healthcare staff thin and complicate patient care. This was particularly important among participants who reported having a patient panel exceeding 1000. There were some participants, however, who praised the relationships they have with their nurse practitioners and physician’s assistants and mark transparency as the most effective way to coordinate care. Collectively, these clinical relationships were built over long standing periods of time, a disadvantage to providers at the start of their medical career. All but one participant with over a decade of clinical experience mentioned the usefulness of these relationships. The factors discussed in Theme 4 are directly linked to the Availability dimension of access to healthcare. A patient’s ability to reach care is subject to the capacity of their healthcare provider(s). Additionally, further analysis suggests these factors also link to the Appropriateness dimension because the quality of patient-provider relationships may be negatively impacted if a provider’s time is compromised.

Theme 5: Profits are prioritized over addressing barriers to healthcare access in the US.

The US healthcare system functions partially for-profit in the public and private sectors. The federal government provides funding for national programs such as Medicare, but a majority of Americans access healthcare through private employer plans [ 85 ]. As a result, uninsurance rates influence healthcare access. Though the rate of the uninsured has dropped over the last decade through expansion of the Affordable Care Act, it remains above 8 percent [ 86 ]. Historically, there has been ethical criticism in the literature of a for-profit system as it is said to exacerbate healthcare disparities and constitute unfair competition against nonprofit institutions. Specifically, the US healthcare system treats healthcare as a commodity instead of a right, enables organizational controls that adversely affect patient-provider relationships, undermines medical education, and constitutes a medical-industrial complex that threatens influence on healthcare-related public policy [ 87 ]. Though unprompted by the interviewer, participants raised many of these concerns. One participant shared their views on how priorities stand in their practice:

A lot of the higher-ups in the healthcare system where I work see each patient visit as a number. It’s not that they don’t have the capacity to think beyond that, but that’s what their role is, making sure we’re profitable. That’s part of why our healthcare system in the US is as broken as it is. It’s accentuated focus on financially and capitalistically driven factors versus understanding all these other barriers to care.

Eight participants echoed a similar concept, that addressing barriers to healthcare access in their organizations is largely complicated because so much attention is directed on matters that have nothing to do with patients. A few other participants supported this by alluding to a “cherry-picking” process by which those at the top of the hierarchy devote their attention to the easiest tasks. One participant shared an experience where contrasting work demands between administrators and front-line clinical providers produces adverse effects:

We had a new administrator in our hospital. I had been really frustrated with the lack of cultural awareness and curiosity from our other leaders in the past, so I offered to meet and take them on a tour of the reservation. This was meant to introduce them to kids, families and Tribal leaders who live in the area and their interface with healthcare. They declined, which I thought was disappointing and eye-opening.

Analysis of these factors suggest that those who work directly with patients understand patient needs better than those who serve in management roles. This same participant went on to suggest an ulterior motive for a push towards telemedicine, as administrators primarily highlight the benefit of billing for virtual visits instead of the nature of the visits themselves.

This study explored barriers and facilitators to healthcare access from the perspective of rural healthcare providers in Montana. Our qualitative analysis uncovered five key themes: 1) a friction exists between aspects of patients’ rural identities and healthcare systems; 2) facilitating access to healthcare requires application of and respect for cultural differences; 3) communication between healthcare providers is systematically fragmented; 4) time and resource constraints disproportionately harm rural health systems; and 5) profits are prioritized over addressing barriers to healthcare access in the US. Themes 2 and 3 were directly supported by earlier qualitative studies that applied Levesque’s framework, specifically regarding healthcare providers’ poor interpersonal quality and lack of collaboration with other providers that are suspected to result from a lack of provider training [ 67 , 70 ]. This ties back to the importance of cultural humility, which many previous culture-based trainings have referred to as cultural competence. Cultural competence is achieved through a plethora of trainings designed to expose providers to different cultures’ beliefs and values but induces risk of stereotyping and stigmatizing a patient’s views. Therefore, cultural humility is the preferred idea, by which providers reflect and gain open-ended appreciation for a patient’s culture [ 88 ].

Implications for Practice

Perhaps the most substantial takeaway is how embedded rugged individualism is within rural patient populations and how difficult that makes the delivery of care in rural health systems. We heard from participants that stoicism and perceptions of stigma within the system contribute to this, but other resulting factors may be influential at the provider- and organizational-levels. Stoicism and perceived stigma both appear to arise, in part, from an understandable knowledge gap regarding the care system. For instance, healthcare providers understand the relations between primary and secondary care, but many patients may perceive both concepts as elements of a single healthcare system [ 89 ]. Any issue experienced by a patient when tasked to see both a primary and secondary provider may result in a patient becoming confused [ 90 ]. This may also overlap with our third theme, as a disjointed means of communication between healthcare providers can exacerbate patients’ negative experiences. One consideration to improve this is to incorporate telehealth programs into an existing referral framework to reduce unnecessary interfacility transfers; telehealth programs have proven effective in rural and remote settings [ 91 ].

In fact, telehealth has been rolled out in a variety of virtual platforms throughout its evolution, its innovation matched with continued technological advancement. Simply put, telehealth allows health service delivery from a distance; it allows knowledge and practice of clinical care to be in a different space than a patient. Because of this, a primary benefit of telehealth is its impact on improving patient-centered outcomes among those living in rural areas. For instance, text messaging technology improves early infant diagnosis, adherence to recommended diagnostic testing, and participant engagement in lifestyle change interventions [ 92 , 93 , 94 ]. More sophisticated interventions have found their way into smartphone-based technology, some of which are accessible even without an internet connection [ 95 , 96 ]. Internet accessibility is important because a number of study participants noted internet connectivity as a barrier for patients who live in low resource communities. Videoconferencing is another function of telehealth that has delivered a variety of health services, including those which are mental health-specific [ 97 ], and mobile health clinics have been used in rural, hard-to-reach settings to show the delivery of quality healthcare is both feasible and acceptable [ 98 , 99 , 100 ]. While telehealth has potential to reduce a number of healthcare access barriers, it may not always address the most pressing healthcare needs [ 101 ]. However, telehealth does serve as a viable, cost-effective alternative for rural populations with limited physical access to specialized services [ 102 ]. With time and resource limitations acknowledged as a key theme in our study, an emphasis on expanding telehealth services is encouraged as it will likely have significant involvement on advancing healthcare in the future, especially as the COVID-19 pandemic persists [ 103 ].

Implications for Policy

One could argue that most of the areas of fragmentation in the US healthcare system can be linked to the very philosophy on which it is based: an emphasis on profits as highest priority. Americans are, therefore, forced to navigate a health service system that does not work solely in their best interests. It is not surprising to observe lower rates of healthcare usage in rural areas, which may be a result from rural persons’ negative views of the US healthcare system or a perception that the system does not exist to support wellness. These perceptions may interact with ‘rugged individualism’ to squelch rural residents’ engagement in healthcare. Many of the providers we interviewed for this study appeared to understand this and strived to improve their patients’ experiences and outcomes. Though these efforts are admirable, they may not characterize all providers who serve in rural areas of the US. From a policy standpoint, it is important to recognize these expansive efforts from providers. If incentives were offered to encourage maximum efforts be made, it may lessen burden due to physician burnout and fatigue. Of course, there is no easy fix to the persisting limit of time and resources for providers, problems that require workforce expansion. Ultimately, though, the current structure of the US healthcare system is failing rural America and doing little to help the practice of rural healthcare providers.

Implications for Future Research

It is important for future health systems research efforts to consider issues that arise from both individual- and system-level access barriers and where the two intersect. Oftentimes, challenges that appear linked to a patient or provider may actually stem from an overarching system failure. If failures are critically and properly addressed, we may refine our understanding of what we can do in our professional spaces to improve care as practitioners, workforce developers, researchers and advocates. This qualitative study was exploratory in nature. It represents a step forward in knowledge generation regarding challenges in access to healthcare for rural Americans. Although mental health did not come up by design in this study, future efforts exploring barriers to healthcare access in rural systems should focus on access to mental healthcare. In many rural areas, Montana included, rates of suicide, substance use and other mental health disorders are highly prevalent. These characteristics should be part of the overall discussion of access to healthcare in rural areas. Optimally, barriers to healthcare access should continue to be explored through qualitative and mixed study designs to honor its multi-dimensional stature.

Strengths and Limitations

It is important to note first that this study interviewed healthcare providers instead of patients, which served as both a strength and limitation. Healthcare providers were able to draw on numerous patient-provider experiences, enabling an account of the aggregate which would have been impossible for a patient population. However, accounts of healthcare providers’ perceptions of barriers to healthcare access for their patients may differ from patients’ specific views. Future research should examine acceptability- and appropriateness-related barriers to healthcare access in patient populations. Second, study participants were recruited through convenience sampling methods, so results may be biased towards healthcare providers who are more invested in addressing barriers to healthcare access. Particularly, the providers interviewed for this study represented a subset who go beyond expectations of their job descriptions by engaging with their communities and spending additional uncompensated time with their patients. It is likely that a provider who exhibits these behavioral traits is more likely to participate in research aimed at addressing barriers to healthcare access. Third, the inability to conduct face-to-face interviews for our qualitative study may have posed an additional limitation. It is possible, for example, that in-person interviews might have resulted in increased rapport with study participants. Notwithstanding this possibility, the remote interview format was necessary to accommodate health risks to the ongoing COVID-19 pandemic. Ultimately, given our qualitative approach, results from our study cannot be generalizable to all rural providers’ views or other rural health systems. In addition, no causality can be inferred regarding the influence of aspects of rurality on access. The purpose of this exploratory qualitative study was to probe research questions for future efforts. We also acknowledge the authors’ roles in the research, also known as reflexivity. The first author was the only author who administered interviews and had no prior relationships with all but one study participant. Assumptions and pre-dispositions to interview content by the first author were regularly addressed throughout data analysis to maintain study integrity. This was achieved by conducting analysis by unique interview question, rather than by unique participant, and recoding the numerical order of participants for each question. Our commitment to rigorous qualitative methods was a strength for the study for multiple reasons. Conducting member checks with participants ensured trustworthiness of findings. Continuing data collection to data saturation ensured dependability of findings, which was achieved after 10 interviews and confirmed after 2 additional interviews. We further recognize the heterogeneity in our sample of participants, which helped generate variability in responses. To remain consistent with appropriate means of presenting results in qualitative research however, we shared minimal demographic information about our study participants to ensure confidentiality.

The divide between urban and rural health stretches beyond a disproportionate allocation of resources. Rural health systems serve a more complicated and hard-to-reach patient population. They lack sufficient numbers of providers to meet population health needs. These disparities impact collaboration between patients and providers as well as the delivery of acceptable and appropriate healthcare. The marker of rurality complicates the already cumbersome challenge of administering acceptable and appropriate healthcare and impediments stemming from rurality require continued monitoring to improve patient experiences and outcomes. Our qualitative study explored rural healthcare providers’ views on some of the social, cultural, and programmatic factors that influence access to healthcare among their patient populations. We identified five key themes: 1) a friction exists between aspects of patients’ rural identities and healthcare systems; 2) facilitating access to healthcare requires application of and respect for cultural differences; 3) communication between healthcare providers is systematically fragmented; 4) time and resource constraints disproportionately harm rural health systems; and 5) profits are prioritized over addressing barriers to healthcare access in the US. This study provides implications that may shift the landscape of a healthcare provider’s approach to delivering healthcare. Further exploration is required to understand the effects these characteristics have on measurable patient-centered outcomes in rural areas.

Availability of data and materials

The datasets generated and/or analyzed during the current study are not publicly available due to individual privacy could be compromised but are available from the corresponding author on reasonable request.

Ethics approval and consent to participate.

All study procedures and methods were carried out in accordance with relevant guidelines and regulations from the World Medical Association Declaration of Helsinki. Ethics approval was given by exempt review from the Institutional Review Board (IRB) at the University of Montana (IRB Protocol No.: 186–20). Participants received oral and written information about the study prior to interview, which allowed them to provide informed consent for the interviews to be recorded and used for qualitative research purposes. No ethical concerns were experienced in this study pertaining to human subjects.

Consent for publication.

The participants consented to the publication of de-identified material from the interviews.

Riley WJ. Health Disparities: Gaps in Access, Quality and Affordability of Medical Care. Trans Am Clin Climatol Assoc. 2012;123:167–74.

PubMed PubMed Central Google Scholar

Levesque J, Harris MF, Russell G. Patient-centred access to health care: conceptualising access at the interface of health systems and populations. Int J Equity Health. 2013;12:18. https://doi.org/10.1186/1475-9276-12-18 .

Article PubMed PubMed Central Google Scholar

Serban N. A Multidimensional Framework for Measuring Access. In: Serban N. Healthcare System Access: Measurement, Inference, and Intervention. New Jersey: John Wiley & Sons; 2019. p. 13–59.

Google Scholar

Roncarolo F, Boivin A, Denis JL, et al. What do we know about the needs and challenges of health systems? A scoping review of the international literature. BMC Health Serv Res. 2017;17:636. https://doi.org/10.1186/s12913-017-2585-5 .

Cabrera-Barona P, Blaschke T. Kienberger S. Explaining Accessibility and Satisfaction Related to Healthcare: A Mixed-Methods Approach. Soc Indic Res. 2017;133,719–739. https://doi.org/10.1007/s11205-016-1371-9 .

Coombs NC, Meriwether WE, Caringi J, Newcomer SR. Barriers to healthcare access among U.S. adults with mental health challenges: A population-based study. SSM Popul Health. 2021;15:100847. https://doi.org/10.1016/j.ssmph.2021.100847 .

Farietta TP, Lu B, Tumin R. Ohio’s Medicaid Expansion and Unmet Health Needs Among Low-Income Women of Reproductive Age. Matern Child Health. 2018;22(12):1771–9. https://doi.org/10.1007/s10995-018-2575-1 .

Article Google Scholar

Sommers BD, Blendon RJ, Orav EJ, Epstein AM. Changes in Utilization and Health Among Low-Income Adults After Medicaid Expansion or Expanded Private Insurance. JAMA Intern Med. 2016;1;176(10):1501–1509. https://doi.org/10.1001/jamainternmed.2016.4419 .

National Alliance on Mental Illness: The Doctor is Out. Continuing Disparities in Access to Mental and Physical Health Care. 2017. https://www.nami.org/Support-Education/Publications-Reports/Public-Policy-Reports/The-Doctor-is-Out . Accessed 29 Aug 2021.

Pollitz K, Lopes L, Kearney A, Rae M, Cox C, Fehr F, Rousseau D, Kaiser Family Foundation. US Statistics on Surprise Medical Billing. JAMA. 2020;323(6):498. https://doi.org/10.1001/jama.2020.0065 .

Kahraman C, Orobello C, Cirella GT. hanging Dynamics with COVID-19: Future Outlook. In: XX Cirella GT, editor. Human Settlements: Urbanization, Smart Sector Development, and Future Outlook. Singapore: Springer; 2022. p. 235–52.

Book Google Scholar

Blumenthal D, Fowler EJ, Abrams M, Collins SR. Covid-19 — Implications for the Health Care System. N Engl J Med. 2020;383(15):1483–8. https://doi.org/10.1056/NEJMsb2021088 .

Article CAS PubMed Google Scholar

Defêche J, Azarzar S, Mesdagh A, Dellot P, Tytgat A, Bureau F, Gillet L, Belhadj Y, Bontems S, Hayette M-P, Schils R, Rahmouni S, Ernst M, Moutschen M, Darcis G. In-Depth Longitudinal Comparison of Clinical Specimens to Detect SARS-CoV-2. Pathogens. 2021;10(11):1362. https://doi.org/10.3390/pathogens10111362 .

Article CAS PubMed PubMed Central Google Scholar

Rosenblatt RA, Hart LG. Physicians and rural America. West J Med. 2000;173(5):348–51. https://doi.org/10.1136/ewjm.173.5.348 .

Kaiser Family Foundation Analysis of OECD Data. 2020. https://www.healthsystemtracker.org/chart-collection/u-s-health-care-resources-compare-countries/#item-physicians-density-per-1000-population-2000-2018 . Accessed 31 Oct 2021.

Government Accounting Office. Physician Workforce: Locations and Types of Graduate Training Were Largely Unchanged, and Federal Efforts May Not Be Sufficient to Meet Needs. 2017. https://www.gao.gov/assets/gao-17-411.pdf . Accessed 31 Oct 2021.

The Kaiser Family Foundation: The Uninsured in Rural America. 2003. https://www.kff.org/wp-content/uploads/2013/01/the-uninsured-in-rural-america-update-pdf.pdf . Accessed 15 Sept 2021.

Wright B, Potter AJ, Trivedi AN, Mueller KJ. The Relationship Between Rural Health Clinic Use and Potentially Preventable Hospitalizations and Emergency Department Visits Among Medicare Beneficiaries. J Rural Health. 2018;34(4):423–30. https://doi.org/10.1111/jrh.12253 .

Article PubMed Google Scholar

Weichelt B, Bendixsen C, Patrick T. A Model for Assessing Necessary Conditions for Rural Health Care’s Mobile Health Readiness: Qualitative Assessment of Clinician-Perceived Barriers. JMIR Mhealth Uhealth. 2019;7(11): e11915. https://doi.org/10.2196/11915 .

Mangundu M, Roets L, Janse van Rensberg E. Accessibility of healthcare in rural Zimbabwe: The perspective of nurses and healthcare users. Afr J Prim Health Care Fam Med. 2020;12(1):e1-e7. https://doi.org/10.4102/phcfm.v12i1.2245 .

Rahayu YYS, Araki T, Rosleine D. Factors affecting the use of herbal medicines in the universal health coverage system in Indonesia. J Ethnopharmacol. 2020;260: 112974. https://doi.org/10.1016/j.jep.2020.112974 .

Bolin JN, Bellamy GR, Ferdinand AO, et al. Rural Healthy People 2020: New Decade, Same Challenges. Journal of Rural Health. 2015;31(3):326–33.

Reid S. The rural determinants of health: using critical realism as a theoretical framework. Rural Remote Health. 2019;19(3):5184. https://doi.org/10.22605/RRH5184 .

Wynia MK, Osborn CY. Health literacy and communication quality in health care organizations. J Health Commun. 2010;15 Suppl 2(Suppl 2):102–115. https://doi.org/10.1080/10810730.2010.499981 .

Centers for Disease Control and Prevention. What is Health Literacy? 2022. https://www.cdc.gov/healthliteracy/learn/index.html . Accessed 25 Feb 2022.

Davis TC, Arnold CL, Rademaker A, et al. Differences in barriers to mammography between rural and urban women. J Womens Health (Larchmt). 2012;21(7):748–55. https://doi.org/10.1089/jwh.2011.3397 .

Halverson J, Martinez-Donate A, Trentham-Dietz A, et al. Health literacy and urbanicity among cancer patients. J Rural Health. 2013;29(4):392–402. https://doi.org/10.1111/jrh.12018 .

Zahnd WE, Scaife SL, Francis ML. Health literacy skills in rural and urban populations. Am J Health Behav. 2009;33(5):550–7. https://doi.org/10.5993/ajhb.33.5.8 .

Dogba MJ, Dossa AR, Breton E, Gandonou-Migan R. Using information and communication technologies to involve patients and the public in health education in rural and remote areas: a scoping review. BMC Health Serv Res. 2019;19(1):128. https://doi.org/10.1186/s12913-019-3906-7 .

Committee on the Science of Changing Behavioral Health Social Norms, Board on Behavioral, Cognitive, and Sensory Sciences, Division of Behavioral and Social Sciences and Education; National Academies of Sciences, Engineering, and Medicine. In: Ending Discrimination Against People with Mental and Substance Use Disorders: The Evidence for Stigma Change. Washington: National Academics Press; 2016. p. 33–52.

Wu Y, Zhou H, Wang Q, Cao M, Medina A, Rozelle S. Use of maternal health services among women in the ethnic rural areas of western China. BMC Health Serv Res. 2019;19(1):179. https://doi.org/10.1186/s12913-019-3996-2 .

Meyer E, Hennink M, Rochat R, et al. Working Towards Safe Motherhood: Delays and Barriers to Prenatal Care for Women in Rural and Peri-Urban Areas of Georgia. Matern Child Health J. 2016;20(7):1358–65. https://doi.org/10.1007/s10995-016-1997-x .

Heinrich S. Medical science faces the post-truth era: a plea for the grassroot values of science. Curr Opin Anaesthesiol. 2020;33(2):198–202. https://doi.org/10.1097/ACO.0000000000000833 .

Esquivel MM, Chen JC, Woo RK, et al. Why do patients receive care from a short-term medical mission? Survey study from rural Guatemala. J Surg Res. 2017;215:160–6. https://doi.org/10.1016/j.jss.2017.03.056 .

Park LG, Dracup K, Whooley MA, et al. Symptom Diary Use and Improved Survival for Patients With Heart Failure [published correction appears in Circ Heart Fail. 2017 Dec;10(12):]. Circ Heart Fail. 2017;10(11):e003874. https://doi.org/10.1161/CIRCHEARTFAILURE.117.003874 .

Taleb F, Perkins J, Ali NA, et al. Transforming maternal and newborn health social norms and practices to increase utilization of health services in rural Bangladesh: a qualitative review. BMC Pregnancy Childbirth. 2015;15:75. https://doi.org/10.1186/s12884-015-0501-8 .

Billah SM, Hoque DE, Rahman M, et al. Feasibility of engaging “Village Doctors” in the Community-based Integrated Management of Childhood Illness (C-IMCI): experience from rural Bangladesh. J Glob Health. 2018;8(2): 020413. https://doi.org/10.7189/jogh.08.020413 .

Kaiser JL, Fong RM, Hamer DH, et al. How a woman’s interpersonal relationships can delay care-seeking and access during the maternity period in rural Zambia: An intersection of the Social Ecological Model with the Three Delays Framework. Soc Sci Med. 2019;220:312–21. https://doi.org/10.1016/j.socscimed.2018.11.011 .

Rao KD, Sheffel A. Quality of clinical care and bypassing of primary health centers in India. Soc Sci Med. 2018;207:80–8. https://doi.org/10.1016/j.socscimed.2018.04.040 .

Lee YT, Lee YH, Kaplan WA. Is Taiwan’s National Health Insurance a perfect system? Problems related to health care utilization of the aboriginal population in rural townships. Int J Health Plann Manage. 2019;34(1):e6–10. https://doi.org/10.1002/hpm.2653 .

Lyford M, Haigh MM, Baxi S, Cheetham S, Shahid S, Thompson SC. An Exploration of Underrepresentation of Aboriginal Cancer Patients Attending a Regional Radiotherapy Service in Western Australia. Int J Environ Res Public Health. 2018;15(2):337. https://doi.org/10.3390/ijerph15020337 .

Article PubMed Central Google Scholar

Rohr JM, Spears KL, Geske J, Khandalavala B, Lacey MJ. Utilization of Health Care Resources by the Amish of a Rural County in Nebraska. J Community Health. 2019;44(6):1090–7. https://doi.org/10.1007/s10900-019-00696-9 .

Johnston K, Harvey C, Matich P, et al. Increasing access to sexual health care for rural and regional young people: Similarities and differences in the views of young people and service providers. Aust J Rural Health. 2015;23(5):257–64. https://doi.org/10.1111/ajr.12186 .

Legido-Quigley H, Naheed A, de Silva HA, et al. Patients’ experiences on accessing health care services for management of hypertension in rural Bangladesh, Pakistan and Sri Lanka: A qualitative study. PLoS ONE. 2019;14(1): e0211100. https://doi.org/10.1371/journal.pone.0211100 .

Shaw B, Amouzou A, Miller NP, Bryce J, Surkan PJ. A qualitative exploration of care-seeking pathways for sick children in the rural Oromia region of Ethiopia. BMC Health Serv Res. 2017;17(1):184. https://doi.org/10.1186/s12913-017-2123-5 .

Larson E, Vail D, Mbaruku GM, Kimweri A, Freedman LP, Kruk ME. Moving Toward Patient-Centered Care in Africa: A Discrete Choice Experiment of Preferences for Delivery Care among 3,003 Tanzanian Women. PLoS ONE. 2015;10(8): e0135621. https://doi.org/10.1371/journal.pone.0135621 .

Spleen AM, Lengerich EJ, Camacho FT, Vanderpool RC. Health care avoidance among rural populations: results from a nationally representative survey. J Rural Health. 2014;30(1):79–88. https://doi.org/10.1111/jrh.12032 .

Weisgrau S. Issues in rural health: access, hospitals, and reform. Health Care Financ Rev. 1995;17(1):1–14.

CAS PubMed PubMed Central Google Scholar

National Center for Health Statistics. 2018. https://www.cdc.gov/nchs/surveys.htm . Accessed 29 Aug 2021.

Sekhon M, Cartwright M, Francis JJ. Acceptability of healthcare interventions: an overview of reviews and development of a theoretical framework. BMC Health Serv Res. 2017;17(1):88. https://doi.org/10.1186/s12913-017-2031-8 .

Dyer TA, Owens J, Robinson PG. The acceptability of healthcare: from satisfaction to trust. Community Dent Health. 2016;33(4):242–51. https://doi.org/10.1922/CDH_3902Dyer10 .

Padgett DK. Qualitative and Mixed Methods in Public Health. Thousand Oaks, California: SAGE Publications Inc.; 2012.

Tolley EE, Ulin PR, Mack N, Robinson ET, Succop SM. Qualitative Methods in Public Health: A Field Guide for Applied Research. 2nd ed. San Francisco, California: John Wiley & Sons, Inc.; 2016.

Ingram DD, Franco SJ. 2013 NCHS urban-rural classification scheme for counties. In: National Center for Health Statistics: Vital Health Statistics. 2014. https://www.cdc.gov/nchs/data/series/sr_02/sr02_166.pdf . Accessed 31 Oct 2021.

Health Resources & Services Administration. Health Professional Shortage Area Find. 2021. https://data.hrsa.gov/tools/shortage-area/hpsa-find . Accessed 31 Oct 2021.

Shaghaghi A, Bhopal RS, Sheikh A. Approaches to Recruiting “Hard-To-Reach” Populations into Re-search: A Review of the Literature. Health Promot Perspect. 2011;1(2):86–94. https://doi.org/10.5681/hpp.2011.009 .

Sadler GR, Lee HC, Lim RS, Fullerton J. Recruitment of hard-to-reach population subgroups via adaptations of the snowball sampling strategy. Nurs Health Sci. 2010;12(3):369–74. https://doi.org/10.1111/j.1442-2018.2010.00541.x .

Deterding NM, Waters MC. Flexible Coding of In-depth Interviews: A Twenty-first-century Approach. Sociological Methods & Research. 2021;50(2):708–39. https://doi.org/10.1177/0049124118799377 .

Schreier M, Stamann C, Janssen M, Dahl T, Whittal A. Qualitative Content Analysis: Conceptualizations and Challenges in Research Practice-Introduction to the FQS Special Issue" Qualitative Content Analysis I". InForum Qualitative Sozialforschung/Forum: Qualitative Social Research. 2019;20:26 DEU.

Guest G, Namey E, Chen M. A simple method to assess and report thematic saturation in qualitative research. PLoS ONE. 2020;15(5): e0232076. https://doi.org/10.1371/journal.pone.0232076 .

Mayring P. Qualitative Content Analysis. Forum Qualitative Sozialforschung/Forum: Qualitative Social Research. 2000;1(2). https://doi.org/10.17169/fqs-1.2.1089 .

O'Brien BC, Harris IB, Beckman TJ, Reed DA, Cook DA. Standards for reporting qualitative research: a synthesis of recommendations. Academic Medicine, Vol. 89, No. 9 / Sept 2014. https://doi.org/10.1097/ACM.0000000000000388 .

Carter N, Bryant-Lukosius D, DiCenso A, Blythe J, Neville AJ. The use of triangulation in qualitative research. Oncol Nurs Forum. 2014;41(5):545–7. https://doi.org/10.1188/14.ONF.545-547 .

Miller S. Cultural humility is the first step to becoming global care providers. J Obstet Gynecol Neonatal Nurs. 2009;38(1):92–3. https://doi.org/10.1111/j.1552-6909.2008.00311.x .

Prasad SJ, Nair P, Gadhvi K, Barai I, Danish HS, Philip AB. Cultural humility: treating the patient, not the illness. Med Educ Online. 2016;21:30908. https://doi.org/10.3402/meo.v21.30908 .

George MS, Davey R, Mohanty I, Upton P. “Everything is provided free, but they are still hesitant to access healthcare services”: why does the indigenous community in Attapadi, Kerala continue to experience poor access to healthcare? Int J Equity Health. 2020;19(1):105. https://doi.org/10.1186/s12939-020-01216-1 .

Romanelli M, Hudson KD. Individual and systemic barriers to health care: Perspectives of lesbian, gay, bisexual, and transgender adults. Am J Orthopsychiatry. 2017;87(6):714–28. https://doi.org/10.1037/ort0000306 .

Bailie J, Schierhout G, Laycock A, et al. Determinants of access to chronic illness care: a mixed-methods evaluation of a national multifaceted chronic disease package for Indigenous Australians. BMJ Open. 2015;5(11): e008103. https://doi.org/10.1136/bmjopen-2015-008103 .

Reeve C, Humphreys J, Wakerman J, Carter M, Carroll V, Reeve D. Strengthening primary health care: achieving health gains in a remote region of Australia. Med J Aust. 2015;202(9):483–7. https://doi.org/10.5694/mja14.00894 .

Swan LET, Auerbach SL, Ely GE, Agbemenu K, Mencia J, Araf NR. Family Planning Practices in Appalachia: Focus Group Perspectives on Service Needs in the Context of Regional Substance Abuse. Int J Environ Res Public Health. 2020;17(4):1198. https://doi.org/10.3390/ijerph17041198 .

Kabia E, Mbau R, Oyando R, et al. “We are called the et cetera”: experiences of the poor with health financing reforms that target them in Kenya. Int J Equity Health. 2019;18(1):98. https://doi.org/10.1186/s12939-019-1006-2 .

Ho JW, Kuluski K, Im J. “It’s a fight to get anything you need” - Accessing care in the community from the perspectives of people with multimorbidity. Health Expect. 2017;20(6):1311–9. https://doi.org/10.1111/hex.12571 .

Latif A, Mandane B, Ali A, Ghumra S, Gulzar N. A Qualitative Exploration to Understand Access to Pharmacy Medication Reviews: Views from Marginalized Patient Groups. Pharmacy (Basel). 2020;8(2):73. https://doi.org/10.3390/pharmacy8020073 .

Tschirhart N, Diaz E, Ottersen T. Accessing public healthcare in Oslo, Norway: the experiences of Thai immigrant masseuses. BMC Health Serv Res. 2019;19(1):722. https://doi.org/10.1186/s12913-019-4560-9 .

Ireland S, Belton S, Doran F. “I didn’t feel judged”: exploring women’s access to telemedicine abortion in rural Australia. J Prim Health Care. 2020;12(1):49–56. https://doi.org/10.1071/HC19050 .

Stokes T, Tumilty E, Latu ATF, et al. Improving access to health care for people with severe chronic obstructive pulmonary disease (COPD) in Southern New Zealand: qualitative study of the views of health professional stakeholders and patients. BMJ Open. 2019;9(11): e033524. https://doi.org/10.1136/bmjopen-2019-033524 .

Jafar TH, Ramakrishnan C, John O, et al. Access to CKD Care in Rural Communities of India: a qualitative study exploring the barriers and potential facilitators. BMC Nephrol. 2020;21(1):26. https://doi.org/10.1186/s12882-020-1702-6 .

Doetsch J, Pilot E, Santana P, Krafft T. Potential barriers in healthcare access of the elderly population influenced by the economic crisis and the troika agreement: a qualitative case study in Lisbon, Portugal. Int J Equity Health. 2017;16(1):184. https://doi.org/10.1186/s12939-017-0679-7 .

Engel GL. The need for a new medical model: a challenge for biomedicine. Science. 1977;196(4286):129–36. https://doi.org/10.1126/science.847460 .

Risberg G, Hamberg K, Johansson E.E. Gender perspective in medicine: a vital part of medical scientific rationality. A useful model for comprehending structures and hierarchies within medical science. BMC Med. 2006;4(1):1.

Montana Census & Economic Information Center. 2021. https://ceic.mt.gov/ . Accessed 18 Sept 2021.

Smith M, Saunders R, Stuckhardt L, McGinnis JM, Committee on the Learning Health Care System in America, Institute of Medicine. Best Care at Lower Cost: The Path to Continuously Learning Health Care in America. Washington: National Academies Press; 2013.

O’Daniel M, Rosenstein AH, Professional Communication and Team Collaboration. In: Hughes RG, editor. Chapter 33: Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Agency for Healthcare Research and Quality: Rockville; 2008.

Evans RS. Electronic Health Records: Then, Now, and in the Future. Yearb Med Inform. 2016;Suppl 1(Suppl 1):S48-S61. https://doi.org/10.15265/IYS-2016-s006 .

Tikkanen R, Osborn R, Mossialos E, Djordjevic A, Wharton GA. International Health Care System Profiles: United States. The Commonwealth Fund. 2020. https://www.commonwealthfund.org/international-health-policy-center/countries/united-states . Accessed 19 Sept 2021.

Berchick ER, Barnett JC, Upton RD. Health Insurance Coverage in the United States. Washington: United States Census Bureau; 2018.

Brock DW, Buchanan A. Ethical Issues in For-Profit Health Care. In: Gray BH, editor. For-Profit Enterprise in Health Care. Washington: National Academics Press; 1986.

Lekas HM, Pahl K, Fuller Lewis C. Rethinking Cultural Competence: Shifting to Cultural Humility. Health Serv Insights. 2020;13:1178632920970580. https://doi.org/10.1177/1178632920970580 .

Beaulieu MD. Primary and secondary care: Breaking down barriers for our patients with chronic diseases. Can Fam Physician. 2013;59(2):221.

Crafford L, Jenkins LS. Why seek a second consultation at an emergency centre? A qualitative study. Afr J Prim Health Care Fam Med. 2017;9(1):e1–8. https://doi.org/10.4102/phcfm.v9i1.1397 .

Sorensen MJ, von Recklinghausen FM, Fulton G, et al. Secondary overtriage: The burden of unnecessary interfacility transfers in a rural trauma system. JAMA Surg. 2013;148:763–8.

Sutcliffe CG, Thuma PE, van Dijk JH, et al. Use of mobile phones and text messaging to decrease the turnaround time for early infant HIV diagnosis and notification in rural Zambia: an observational study. BMC Pediatr. 2017;17(1):66. https://doi.org/10.1186/s12887-017-0822-z .

Baldwin LM, Morrison C, Griffin J, et al. Bidirectional Text Messaging to Improve Adherence to Recommended Lipid Testing. J Am Board Fam Med. 2017;30(5):608–14. https://doi.org/10.3122/jabfm.2017.05.170088 .

Albright K, Krantz MJ, Backlund Jarquín P, DeAlleaume L, Coronel-Mockler S, Estacio RO. Health Promotion Text Messaging Preferences and Acceptability Among the Medically Underserved. Health Promot Pract. 2015;16(4):523–32. https://doi.org/10.1177/1524839914566850 .

Cramer ME, Mollard EK, Ford AL, Kupzyk KA, Wilson FA. The feasibility and promise of mobile technology with community health worker reinforcement to reduce rural preterm birth. Public Health Nurs. 2018;35(6):508–16. https://doi.org/10.1111/phn.12543 .

Gbadamosi SO, Eze C, Olawepo JO, et al. A Patient-Held Smartcard With a Unique Identifier and an mHealth Platform to Improve the Availability of Prenatal Test Results in Rural Nigeria: Demonstration Study. J Med Internet Res. 2018;20(1): e18. https://doi.org/10.2196/jmir.8716 .

Trondsen MV, Tjora A, Broom A, Scambler G. The symbolic affordances of a video-mediated gaze in emergency psychiatry. Soc Sci Med. 2018;197:87–94. https://doi.org/10.1016/j.socscimed.2017.11.056 .

Schwitters A, Lederer P, Zilversmit L, et al. Barriers to health care in rural Mozambique: a rapid ethnographic assessment of planned mobile health clinics for ART. Glob Health Sci Pract. 2015;3(1):109–16. https://doi.org/10.9745/GHSP-D-14-00145 .

Kojima N, Krupp K, Ravi K, et al. Implementing and sustaining a mobile medical clinic for prenatal care and sexually transmitted infection prevention in rural Mysore, India. BMC Infect Dis. 2017;17(1):189. https://doi.org/10.1186/s12879-017-2282-3 .

Gorman SE, Martinez JM, Olson J. An assessment of HIV treatment outcomes among utilizers of semi-mobile clinics in rural Kenya. AIDS Care. 2015;27(5):665–8. https://doi.org/10.1080/09540121.2014.986053 .

Lee S, Black D, Held ML. Factors Associated with Telehealth Service Utilization among Rural Populations. J Health Care Poor Underserved. 2019;30(4):1259–72. https://doi.org/10.1353/hpu.2019.0104 .

Agha Z, Schapira RM, Maker AH. Cost effectiveness of telemedicine for the delivery of outpatient pulmonary care to a rural population. Telemed J E Health. 2002;8(3):281–91. https://doi.org/10.1089/15305620260353171 .

Doraiswamy S, Abraham A, Mamtani R, Cheema S. Use of Telehealth During the COVID-19 Pandemic: Scoping Review. J Med Internet Res. 2020;22(12): e24087. https://doi.org/10.2196/24087 .

Download references

Acknowledgements

This research was supported by the Center for Biomedical Research Excellence award (P20GM130418) from the National Institute of General Medical Sciences of the National Institute of Health. The first author was also supported by the University of Montana Burnham Population Health Fellowship. We would like to thank Dr. Christopher Dietrich, Dr. Jennifer Robohm and Dr. Eric Arzubi for their contributions on determining inclusion criteria for the healthcare provider population used for this study.

This research did not receive any specific grant from funding agencies in the public, commercial, and not-for-profit sectors.

Author information

Authors and affiliations.

School of Public & Community Health Sciences, University of Montana, 32 Campus Dr, Missoula, MT, 59812, USA

Nicholas C. Coombs & James Caringi

Department of Psychology, University of Montana, 32 Campus Dr, Missoula, MT, 59812, USA

Duncan G. Campbell

You can also search for this author in PubMed Google Scholar

Contributions

The authors confirm contribution to the paper as follows: study conception and design: NC and JC; data collection: NC; analysis and interpretation of results: NC and JC; draft manuscript preparation: NC, DC and JC; and manuscript editing: NC, DC and JC. All authors reviewed the results and approved the final version of the manuscript.

Corresponding author

Correspondence to Nicholas C. Coombs .

Ethics declarations

Competing interests.

The authors declare that they have no competing interests.

Additional information

Publisher's note.

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

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/ . The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/ ) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Cite this article.

Coombs, N.C., Campbell, D.G. & Caringi, J. A qualitative study of rural healthcare providers’ views of social, cultural, and programmatic barriers to healthcare access. BMC Health Serv Res 22 , 438 (2022). https://doi.org/10.1186/s12913-022-07829-2

Download citation

Received : 11 January 2022

Accepted : 21 March 2022

Published : 02 April 2022

DOI : https://doi.org/10.1186/s12913-022-07829-2

Share this article

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

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

Provided by the Springer Nature SharedIt content-sharing initiative

Access to healthcare
Rural health
Qualitative methods

BMC Health Services Research

ISSN: 1472-6963

General enquiries: [email protected]

Open access
Published: 17 February 2022

Effectiveness of problem-based learning methodology in undergraduate medical education: a scoping review

Joan Carles Trullàs ORCID: orcid.org/0000-0002-7380-3475 1 , 2 , 3 ,
Carles Blay ORCID: orcid.org/0000-0003-3962-5887 1 , 4 ,
Elisabet Sarri ORCID: orcid.org/0000-0002-2435-399X 3 &
Ramon Pujol ORCID: orcid.org/0000-0003-2527-385X 1

BMC Medical Education volume 22 , Article number: 104 ( 2022 ) Cite this article

31k Accesses

78 Citations

10 Altmetric

Metrics details

Problem-based learning (PBL) is a pedagogical approach that shifts the role of the teacher to the student (student-centered) and is based on self-directed learning. Although PBL has been adopted in undergraduate and postgraduate medical education, the effectiveness of the method is still under discussion. The author’s purpose was to appraise available international evidence concerning to the effectiveness and usefulness of PBL methodology in undergraduate medical teaching programs.

The authors applied the Arksey and O’Malley framework to undertake a scoping review. The search was carried out in February 2021 in PubMed and Web of Science including all publications in English and Spanish with no limits on publication date, study design or country of origin.

The literature search identified one hundred and twenty-four publications eligible for this review. Despite the fact that this review included many studies, their design was heterogeneous and only a few provided a high scientific evidence methodology (randomized design and/or systematic reviews with meta-analysis). Furthermore, most were single-center experiences with small sample size and there were no large multi-center studies. PBL methodology obtained a high level of satisfaction, especially among students. It was more effective than other more traditional (or lecture-based methods) at improving social and communication skills, problem-solving and self-learning skills. Knowledge retention and academic performance weren’t worse (and in many studies were better) than with traditional methods. PBL was not universally widespread, probably because requires greater human resources and continuous training for its implementation.

PBL is an effective and satisfactory methodology for medical education. It is likely that through PBL medical students will not only acquire knowledge but also other competencies that are needed in medical professionalism.

Peer Review reports

There has always been enormous interest in identifying the best learning methods. In the mid-twentieth century, US educator Edgar Dale proposed which actions would lead to deeper learning than others and published the well-known (and at the same time controversial) “Cone of Experience or Cone of Dale”. At the apex of the cone are oral representations (verbal descriptions, written descriptions, etc.) and at the base is direct experience (based on a person carrying out the activity that they aim to learn), which represents the greatest depth of our learning. In other words, each level of the cone corresponds to various learning methods. At the base are the most effective, participative methods (what we do and what we say) and at the apex are the least effective, abstract methods (what we read and what we hear) [ 1 ]. In 1990, psychologist George Miller proposed a framework pyramid to assess clinical competence. At the lowest level of the pyramid is knowledge (knows), followed by the competence (knows how), execution (shows how) and finally the action (does) [ 2 ]. Both Miller’s pyramid and Dale’s cone propose a very efficient way of training and, at the same time, of evaluation. Miller suggested that the learning curve passes through various levels, from the acquisition of theoretical knowledge to knowing how to put this knowledge into practice and demonstrate it. Dale stated that to remember a high percentage of the acquired knowledge, a theatrical representation should be carried out or real experiences should be simulated. It is difficult to situate methodologies such as problem-based learning (PBL), case-based learning (CBL) and team-based learning (TBL) in the context of these learning frameworks.

In the last 50 years, various university education models have emerged and have attempted to reconcile teaching with learning, according to the principle that students should lead their own learning process. Perhaps one of the most successful models is PBL that came out of the English-speaking environment. There are many descriptions of PBL in the literature, but in practice there is great variability in what people understand by this methodology. The original conception of PBL as an educational strategy in medicine was initiated at McMaster University (Canada) in 1969, leaving aside the traditional methodology (which is often based on lectures) and introducing student-centered learning. The new formulation of medical education proposed by McMaster did not separate the basic sciences from the clinical sciences, and partially abandoned theoretical classes, which were taught after the presentation of the problem. In its original version, PBL is a methodology in which the starting point is a problem or a problematic situation. The situation enables students to develop a hypothesis and identify learning needs so that they can better understand the problem and meet the established learning objectives [ 3 , 4 ]. PBL is taught using small groups (usually around 8–10 students) with a tutor. The aim of the group sessions is to identify a problem or scenario, define the key concepts identified, brainstorm ideas and discuss key learning objectives, research these and share this information with each other at subsequent sessions. Tutors are used to guide students, so they stay on track with the learning objectives of the task. Contemporary medical education also employs other small group learning methods including CBL and TBL. Characteristics common to the pedagogy of both CBL and TBL include the use of an authentic clinical case, active small-group learning, activation of existing knowledge and application of newly acquired knowledge. In CBL students are encouraged to engage in peer learning and apply new knowledge to these authentic clinical problems under the guidance of a facilitator. CBL encourages a structured and critical approach to clinical problem-solving, and, in contrast to PBL, is designed to allow the facilitator to correct and redirect students [ 5 ]. On the other hand, TBL offers a student-centered, instructional approach for large classes of students who are divided into small teams of typically five to seven students to solve clinically relevant problems. The overall similarities between PBL and TBL relate to the use of professionally relevant problems and small group learning, while the main difference relates to one teacher facilitating interactions between multiple self-managed teams in TBL, whereas each small group in PBL is facilitated by one teacher. Further differences are related to mandatory pre-reading assignments in TBL, testing of prior knowledge in TBL and activating prior knowledge in PBL, teacher-initiated clarifying of concepts that students struggled with in TBL versus students-generated issues that need further study in PBL, inter-team discussions in TBL and structured feedback and problems with related questions in TBL [ 6 ].

In the present study we have focused on PBL methodology, and, as attractive as the method may seem, we should consider whether it is really useful and effective as a learning method. Although PBL has been adopted in undergraduate and postgraduate medical education, the effectiveness (in terms of academic performance and/or skill improvement) of the method is still under discussion. This is due partly to the methodological difficulty in comparing PBL with traditional curricula based on lectures. To our knowledge, there is no systematic scoping review in the literature that has analyzed these aspects.

The main motivation for carrying out this research and writing this article was scientific but also professional interest. We believe that reviewing the state of the art of this methodology once it was already underway in our young Faculty of Medicine, could allow us to know if we were on the right track and if we should implement changes in the training of future doctors.

The primary goal of this study was to appraise available international evidence concerning to the effectiveness and usefulness of PBL methodology in undergraduate medical teaching programs. As the intention was to synthesize the scattered evidence available, the option was to conduct a scoping review. A scoping study tends to address broader topics where many different study designs might be applicable. Scoping studies may be particularly relevant to disciplines, such as medical education, in which the paucity of randomized controlled trials makes it difficult for researchers to undertake systematic reviews [ 7 , 8 ]. Even though the scoping review methodology is not widely used in medical education, it is well established for synthesizing heterogeneous research evidence [ 9 ].

The specific aims were: 1) to determine the effectiveness of PBL in academic performance (learning and retention of knowledge) in medical education; 2) to determine the effectiveness of PBL in other skills (social and communication skills, problem solving or self-learning) in medical education; 3) to know the level of satisfaction perceived by the medical students (and/or tutors) when they are taught with the PBL methodology (or when they teach in case of tutors).

This review was guided by Arksey and O’Malley’s methodological framework for conducting scoping reviews. The five main stages of the framework are: (1) identifying the research question; (2) ascertaining relevant studies; (3) determining study selection; (4) charting the data; and (5) collating, summarizing and reporting the results [ 7 ]. We reported our process according to the PRISMA Extension for Scoping Reviews [ 10 ].

Stage 1: Identifying the research question

With the goals of the study established, the four members of the research team established the research questions. The primary research question was “What is the effectiveness of PBL methodology for learning in undergraduate medicine?” and the secondary question “What is the perception and satisfaction of medical students and tutors in relation to PBL methodology?”.

Stage 2: Identifying relevant studies

After the research questions and a search strategy were defined, the searches were conducted in PubMed and Web of Science using the MeSH terms “problem-based learning” and “Medicine” (the Boolean operator “AND” was applied to the search terms). No limits were set on language, publication date, study design or country of origin. The search was carried out on 14th February 2021. Citations were uploaded to the reference manager software Mendeley Desktop (version 1.19.8) for title and abstract screening, and data characterization.

Stage 3: Study selection

The searching strategy in our scoping study generated a total of 2399 references. The literature search and screening of title, abstract and full text for suitability was performed independently by one author (JCT) based on predetermined inclusion criteria. The inclusion criteria were: 1) PBL methodology was the major research topic; 2) participants were undergraduate medical students or tutors; 3) the main outcome was academic performance (learning and knowledge retention); 4) the secondary outcomes were one of the following: social and communication skills, problem solving or self-learning and/or student/tutor satisfaction; 5) all types of studies were included including descriptive papers, qualitative, quantitative and mixed studies methods, perspectives, opinion, commentary pieces and editorials. Exclusion criteria were studies including other types of participants such as postgraduate medical students, residents and other health non-medical specialties such as pharmacy, veterinary, dentistry or nursing. Studies published in languages other than Spanish and English were also excluded. Situations in which uncertainty arose, all authors (CB, ES, RP) discussed the publication together to reach a final consensus. The outcomes of the search results and screening are presented in Fig. 1 . One-hundred and twenty-four articles met the inclusion criteria and were included in the final analysis.

Study flow PRISMA diagram. Details the review process through the different stages of the review; includes the number of records identified, included and excluded

Stage 4: Charting the data

A data extraction table was developed by the research team. Data extracted from each of the 124 publications included general publication details (year, author, and country), sample size, study population, design/methodology, main and secondary outcomes and relevant results and/or conclusions. We compiled all data into a single spreadsheet in Microsoft Excel for coding and analysis. The characteristics and the study subject of the 124 articles included in this review are summarized in Tables 1 and 2 . The detailed results of the Microsoft Excel file is also available in Additional file 1 .

Stage 5: Collating, summarizing and reporting the results

As indicated in the search strategy (Fig. 1 ) this review resulted in the inclusion of 124 publications. Publication years of the final sample ranged from 1990 to 2020, the majority of the publications (51, 41%) were identified for the years 2010–2020 and the years in which there were more publications were 2001, 2009 and 2015. Countries from the six continents were represented in this review. Most of the publications were from Asia (especially China and Saudi Arabia) and North America followed by Europe, and few studies were from Africa, Oceania and South America. The country with more publications was the United States of America ( n = 27). The most frequent designs of the selected studies were surveys or questionnaires ( n = 45) and comparative studies ( n = 48, only 16 were randomized) with traditional or lecture-based learning methodologies (in two studies the comparison was with simulation) and the most frequently measured outcomes were academic performance followed by student satisfaction (48 studies measured more than one outcome). The few studies with the highest level of scientific evidence (systematic review and meta-analysis and randomized studies) were conducted mostly in Asian countries (Tables 1 and 2 ). The study subject was specified in 81 publications finding a high variability but at the same time great representability of almost all disciplines of the medical studies.

The sample size was available in 99 publications and the median [range] of the participants was 132 [14–2061]. According to study population, there were more participants in the students’ focused studies (median 134 and range 16–2061) in comparison with the tutors’ studies (median 53 and range 14–494).

Finally, after reviewing in detail the measured outcomes (main and secondary) according to the study design (Table 2 and Additional file 1 ) we present a narrative overview and a synthesis of the main findings.

Main outcome: academic performance (learning and knowledge retention)

Seventy-one of the 124 publications had learning and/or knowledge retention as a measured outcome, most of them ( n = 45) were comparative studies with traditional or lecture-based learning and 16 were randomized. These studies were varied in their methodology, were performed in different geographic zones, and normally analyzed the experience of just one education center. Most studies ( n = 49) reported superiority of PBL in learning and knowledge acquisition [ 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 , 50 , 51 , 52 , 53 , 54 , 55 , 56 , 57 , 58 , 59 ] but there was no difference between traditional and PBL curriculums in another 19 studies [ 60 , 61 , 62 , 63 , 64 , 65 , 66 , 67 , 68 , 69 , 70 , 71 , 72 , 73 , 74 , 75 , 76 , 77 , 78 ]. Only three studies reported that PBL was less effective [ 79 , 80 , 81 ], two of them were randomized (in one case favoring simulation-based learning [ 80 ] and another favoring lectures [ 81 ]) and the remaining study was based on tutors’ opinion rather than real academic performance [ 79 ]. It is noteworthy that the four systematic reviews and meta-analysis included in this scoping review, all carried out in China, found that PBL was more effective than lecture-based learning in improving knowledge and other skills (clinical, problem-solving, self-learning and collaborative) [ 40 , 51 , 53 , 58 ]. Another relevant example of the superiority of the PBL method over the traditional method is the experience reported by Hoffman et al. from the University of Missouri-Columbia. The authors analyzed the impact of implementing the PBL methodology in its Faculty of Medicine and revealed an improvement in the academic results that lasted for over a decade [ 31 ].

Secondary outcomes

Social and communication skills.

We found five studies in this scoping review that focused on these outcomes and all of them described that a curriculum centered on PBL seems to instill more confidence in social and communication skills among students. Students perceived PBL positively for teamwork, communication skills and interpersonal relations [ 44 , 45 , 67 , 75 , 82 ].

Student satisfaction

Sixty publications analyzed student satisfaction with PBL methodology. The most frequent methodology were surveys or questionnaires (30 studies) followed by comparative studies with traditional or lecture-based methodology (19 studies, 7 of them were randomized). Almost all the studies (51) have shown that PBL is generally well-received [ 11 , 13 , 18 , 19 , 20 , 21 , 22 , 26 , 29 , 34 , 37 , 39 , 41 , 42 , 46 , 50 , 56 , 58 , 63 , 64 , 66 , 78 , 82 , 83 , 84 , 85 , 86 , 87 , 88 , 89 , 90 , 91 , 92 , 93 , 94 , 95 , 96 , 97 , 98 , 99 , 100 , 101 , 102 , 103 , 104 , 105 , 106 , 107 , 108 , 109 , 110 ] but in 9 studies the overall satisfaction scores for the PBL program were neutral [ 76 , 111 , 112 , 113 , 114 , 115 , 116 ] or negative [ 117 , 118 ]. Some factors that have been identified as key components for PBL to be successful include: a small group size, the use of scenarios of realistic cases and good management of group dynamics. Despite a mostly positive assessment of the PBL methodology by the students, there were some negative aspects that could be criticized or improved. These include unclear communication of the learning methodology, objectives and assessment method; bad management and organization of the sessions; tutors having little experience of the method; and a lack of standardization in the implementation of the method by the tutors.

Tutor satisfaction

There are only 15 publications that analyze the satisfaction of tutors, most of them surveys or questionnaires [ 85 , 88 , 92 , 98 , 108 , 110 , 119 ]. In comparison with the satisfaction of the students, here the results are more neutral [ 112 , 113 , 115 , 120 , 121 ] and even unfavorable to the PBL methodology in two publications [ 117 , 122 ]. PBL teaching was favored by tutors when the institutions train them in the subject, when there was administrative support and adequate infrastructure and coordination [ 123 ]. In some experiences, the PBL modules created an unacceptable toll of anxiety, unhappiness and strained relations.

Other skills (problem solving and self-learning)

The effectiveness of the PBL methodology has also been explored in other outcomes such as the ability to solve problems and to self-directed learning. All studies have shown that PBL is more effective than lecture-based learning in problem-solving and self-learning skills [ 18 , 24 , 40 , 48 , 67 , 75 , 93 , 104 , 124 ]. One single study found a poor accuracy of the students’ self-assessment when compared to their own performance [ 125 ]. In addition, there are studies that support PBL methodology for integration between basic and clinical sciences [ 126 ].

Finally, other publications have reported the experience of some faculties in the implementation of the PBL methodology. Different experiences have demonstrated that it is both possible and feasible to shift from a traditional curriculum to a PBL program, recognizing that PBL methodology is complex to plan and structure, needs a large number of human and material resources, requiring an immense teacher effort [ 28 , 31 , 94 , 127 , 128 , 129 , 130 , 131 , 132 , 133 ]. In addition, and despite its cost implication, a PBL curriculum can be successfully implemented in resource-constrained settings [ 134 , 135 ].

We conducted this scoping review to explore the effectiveness and satisfaction of PBL methodology for teaching in undergraduate medicine and, to our knowledge, it is the only study of its kind (systematic scoping review) that has been carried out in the last years. Similarly, Vernon et al. conducted a meta-analysis of articles published between 1970 and 1992 and their results generally supported the superiority of the PBL approach over more traditional methods of medical education [ 136 ]. PBL methodology is implemented in medical studies on the six continents but there is more experience (or at least more publications) from Asian countries and North America. Despite its apparent difficulties on implementation, a PBL curriculum can be successfully implemented in resource-constrained settings [ 134 , 135 ]. Although it is true that the few studies with the highest level of scientific evidence (randomized studies and meta-analysis) were carried out mainly in Asian countries (and some in North America and Europe), there were no significant differences in the main results according to geographical origin.

In this scoping review we have included a large number of publications that, despite their heterogeneity, tend to show favorable results for the usefulness of the PBL methodology in teaching and learning medicine. The results tend to be especially favorable to PBL methodology when it is compared with traditional or lecture-based teaching methods, but when compared with simulation it is not so clear. There are two studies that show neutral [ 71 ] or superior [ 80 ] results to simulation for the acquisition of specific clinical skills. It seems important to highlight that the four meta-analysis included in this review, which included a high number of participants, show results that are clearly favorable to the PBL methodology in terms of knowledge, clinical skills, problem-solving, self-learning and satisfaction [ 40 , 51 , 53 , 58 ].

Regarding the level of satisfaction described in the surveys or questionnaires, the overall satisfaction rate was higher in the PBL students when compared with traditional learning students. Students work in small groups, allowing and promoting teamwork and facilitating social and communication skills. As sessions are more attractive and dynamic than traditional classes, this could lead to a greater degree of motivation for learning.

These satisfaction results are not so favorable when tutors are asked and this may be due to different reasons; first, some studies are from the 90s, when the methodology was not yet fully implemented; second, the number of tutors included in these studies is low; and third, and perhaps most importantly, the complaints are not usually due to the methodology itself, but rather due to lack of administrative support, and/or work overload. PBL methodology implies more human and material resources. The lack of experience in guided self-learning by lecturers requires more training. Some teachers may not feel comfortable with the method and therefore do not apply it correctly.

Despite how effective and/or attractive the PBL methodology may seem, some (not many) authors are clearly detractors and have published opinion articles with fierce criticism to this methodology. Some of the arguments against are as follows: clinical problem solving is the wrong task for preclinical medical students, self-directed learning interpreted as self-teaching is not appropriate in undergraduate medical education, relegation to the role of facilitators is a misuse of the faculty, small-group experience is inherently variable and sometimes dysfunctional, etc. [ 137 ].

In light of the results found in our study, we believe that PBL is an adequate methodology for the training of future doctors and reinforces the idea that the PBL should have an important weight in the curriculum of our medical school. It is likely that training through PBL, the doctors of the future will not only have great knowledge but may also acquire greater capacity for communication, problem solving and self-learning, all of which are characteristics that are required in medical professionalism. For this purpose, Koh et al. analyzed the effect that PBL during medical school had on physician competencies after graduation, finding a positive effect mainly in social and cognitive dimensions [ 138 ].

Despite its defects and limitations, we must not abandon this methodology and, in any case, perhaps PBL should evolve, adapt, and improve to enhance its strengths and improve its weaknesses. It is likely that the new generations, trained in schools using new technologies and methodologies far from lectures, will feel more comfortable (either as students or as tutors) with methodologies more like PBL (small groups and work focused on problems or projects). It would be interesting to examine the implementation of technologies and even social media into PBL sessions, an issue that has been poorly explorer [ 139 ].

Limitations

Scoping reviews are not without limitations. Our review includes 124 articles from the 2399 initially identified and despite our efforts to be as comprehensive as possible, we may have missed some (probably few) articles. Even though this review includes many studies, their design is very heterogeneous, only a few include a large sample size and high scientific evidence methodology. Furthermore, most are single-center experiences and there are no large multi-center studies. Finally, the frequency of the PBL sessions (from once or twice a year to the whole curriculum) was not considered, in part, because most of the revised studies did not specify this information. This factor could affect the efficiency of PBL and the perceptions of students and tutors about PBL. However, the adoption of a scoping review methodology was effective in terms of summarizing the research findings, identifying limitations in studies’ methodologies and findings and provided a more rigorous vision of the international state of the art.

Conclusions

This systematic scoping review provides a broad overview of the efficacy of PBL methodology in undergraduate medicine teaching from different countries and institutions. PBL is not a new teaching method given that it has already been 50 years since it was implemented in medicine courses. It is a method that shifts the leading role from teachers to students and is based on guided self-learning. If it is applied properly, the degree of satisfaction is high, especially for students. PBL is more effective than traditional methods (based mainly on lectures) at improving social and communication skills, problem-solving and self-learning skills, and has no worse results (and in many studies better results) in relation to academic performance. Despite that, its use is not universally widespread, probably because it requires greater human resources and continuous training for its implementation. In any case, more comparative and randomized studies and/or other systematic reviews and meta-analysis are required to determine which educational strategies could be most suitable for the training of future doctors.

Abbreviations

Problem-based learning

Case-based learning

Team-based learning

References:

Dale E. Methods for analyzing the content of motion pictures. J Educ Sociol. 1932;6:244–50.

Google Scholar

Miller GE. The assessment of clinical skills/competence/performance. Acad Med. 1990;65(9 Suppl):S63–7. https://doi.org/10.1097/00001888-199009000-00045 .

Article Google Scholar

Bodagh N, Bloomfield J, Birch P, Ricketts W. Problem-based learning: a review. Br J Hosp Med (Lond). 2017;78:C167–70. https://doi.org/10.12968/hmed.2017.78.11.C167 .

- Branda LA. El abc del ABP: Lo esencial del aprendizaje basado en problemas. In: Fundación Dr. Esteve, Cuadernos de la fundación Dr. Antonio Esteve nº27: El aprendizaje basado en problemas en sus textos, pp.1–16. 2013. Barcelona.

Burgess A, Matar E, Roberts C, et al. Scaffolding medical student knowledge and skills: team-based learning (TBL) and case-based learning (CBL). BMC Med Educ. 2021;21:238. https://doi.org/10.1186/s12909-021-02638-3 .

Dolmans D, Michaelsen L, van Merriënboer J, van der Vleuten C. Should we choose between problem-based learning and team-based learning? No, combine the best of both worlds! Med Teach. 2015;37:354–9. https://doi.org/10.3109/0142159X.2014.948828 .

Arksey H, O’Malley L. Scoping studies: towards a methodological framework. In J Soc Res Methodol. 2005;8:19–32. https://doi.org/10.1080/1364557032000119616 .

Levac D, Colquhoun H, O’Brien KK. Scoping studies: advancing the methodology. Implement Sci. 2010;5:69. https://doi.org/10.1186/1748-5908-5-69 .

Pham MT, Rajić A, Greig JD, Sargeant JM, Papadopoulos A, McEwen SA. A scoping review of scoping reviews: advancing the approach and enhancing the consistency. Res Synth Methods. 2014;5:371–85. https://doi.org/10.1002/jrsm.1123 .

Tricco AC, Lillie E, Zarin W, et al. PRISMA extension for scoping reviews (PRISMA-ScR): checklist and explanation. Ann Intern Med. 2018;169:467–73. https://doi.org/10.7326/M18-0850 .

Sokas RK, Diserens D, Johnston MA. Integrating occupational-health into the internal medicine clerkship using problem-based learning. Clin Res. 1990;38:A735.

Richards BF, Ober KP, Cariaga-Lo L, et al. Ratings of students’ performances in a third-year internal medicine clerkship: a comparison between problem-based and lecture-based curricula. Acad Med. 1996;71:187–9. https://doi.org/10.1097/00001888-199602000-00028 .

Gresham CL, Philp JR. Problem-based learning in clinical medicine. Teach Learn Med. 1996;8:111–5. https://doi.org/10.1080/10401339609539776 .

Hill J, Rolfe IE, Pearson SA, Heathcote A. Do junior doctors feel they are prepared for hospital practice? A study of graduates from traditional and non-traditional medical schools. Med Educ. 1998;32:19–24. https://doi.org/10.1046/j.1365-2923.1998.00152.x .

Blake RL, Parkison L. Faculty evaluation of the clinical performances of students in a problem-based learning curriculum. Teach Learn Med. 1998;10:69–73. https://doi.org/10.1207/S15328015TLM1002\_3 .

Hmelo CE. Problem-based learning: effects on the early acquisition of cognitive skill in medicine. J Learn Sc. 1998;7:173–208. https://doi.org/10.1207/s15327809jls0702\_2 .

Finch PN. The effect of problem-based learning on the academic performance of students studying podiatric medicine in Ontario. Med Educ. 1999;33:411–7.

Casassus P, Hivon R, Gagnayre R, d’Ivernois JF. An initial experiment in haematology instruction using the problem-based learning method in third-year medical training in France. Hematol Cell Ther. 1999;41:137–44. https://doi.org/10.1007/s00282-999-0137-0 .

Purdy RA, Benstead TJ, Holmes DB, Kaufman DM. Using problem-based learning in neurosciences education for medical students. Can J Neurol Sci. 1999;26:211–6. https://doi.org/10.1017/S0317167100000287 .

Farrell TA, Albanese MA, Pomrehn PRJ. Problem-based learning in ophthalmology: a pilot program for curricular renewal. Arch Ophthalmol. 1999;117:1223–6. https://doi.org/10.1001/archopht.117.9.1223 .

Curtis JA, Indyk D, Taylor B. Successful use of problem-based learning in a third-year pediatric clerkship. Ambul Pediatr. 2001;1:132–5. https://doi.org/10.1367/1539-4409(2001)001%3c0132:suopbl%3e2.0.co;2 .

Trevena LJ, Clarke RM. Self-directed learning in population health. a clinically relevant approach for medical students. Am J Prev Med. 2002;22:59–65. https://doi.org/10.1016/s0749-3797(01)00395-6 .

Astin J, Jenkins T, Moore L. Medical students’ perspective on the teaching of medical statistics in the undergraduate medical curriculum. Stat Med. 2002;21:1003–7. https://doi.org/10.1002/sim.1132 .

Whitfield CR, Manger EA, Zwicker J, Lehman EB. Differences between students in problem-based and lecture-based curricula measured by clerkship performance ratings at the beginning of the third year. Teach Learn Med. 2002;14:211–7. https://doi.org/10.1207/S15328015TLM1404\_2 .

McParland M, Noble LM, Livingston G. The effectiveness of problem-based learning compared to traditional teaching in undergraduate psychiatry. Med Educ. 2004;38:859–67. https://doi.org/10.1111/j.1365-2929.2004.01818.x .

Casey PM, Magrane D, Lesnick TG. Improved performance and student satisfaction after implementation of a problem-based preclinical obstetrics and gynecology curriculum. Am J Obstet Gynecol. 2005;193:1874–8. https://doi.org/10.1016/j.ajog.2005.07.061 .

Gurpinar E, Musal B, Aksakoglu G, Ucku R. Comparison of knowledge scores of medical students in problem-based learning and traditional curriculum on public health topics. BMC Med Educ. 2005;5:7. https://doi.org/10.1186/1472-6920-5-7 .

Tamblyn R, Abrahamowicz M, Dauphinee D, et al. Effect of a community oriented problem based learning curriculum on quality of primary care delivered by graduates: historical cohort comparison study. BMJ. 2005;331:1002. https://doi.org/10.1136/bmj.38636.582546.7C .

Abu-Hijleh MF, Chakravarty M, Al-Shboul Q, Kassab S, Hamdy H. Integrating applied anatomy in surgical clerkship in a problem-based learning curriculum. Surg Radiol Anat. 2005;27:152–7. https://doi.org/10.1007/s00276-004-0293-4 .

Distlehorst LH, Dawson E, Robbs RS, Barrows HS. Problem-based learning outcomes: the glass half-full. Acad Med. 2005;80:294–9. https://doi.org/10.1097/00001888-200503000-00020 .

Hoffman K, Hosokawa M, Blake R Jr, Headrick L, Johnson G. Problem-based learning outcomes: ten years of experience at the University of Missouri-Columbia school of medicine. Acad Med. 2006;81:617–25. https://doi.org/10.1097/01.ACM.0000232411.97399.c6 .

Kong J, Li X, Wang Y, Sun W, Zhang J. Effect of digital problem-based learning cases on student learning outcomes in ophthalmology courses. Arch Ophthalmol. 2009;127:1211–4. https://doi.org/10.1001/archophthalmol.2009.110 .

Tsou KI, Cho SL, Lin CS, et al. Short-term outcomes of a near-full PBL curriculum in a new Taiwan medical school. Kaohsiung J Med Sci. 2009;25:282–93. https://doi.org/10.1016/S1607-551X(09)70075-0 .

Wang J, Zhang W, Qin L, et al. Problem-based learning in regional anatomy education at Peking University. Anat Sci Educ. 2010;3:121–6. https://doi.org/10.1002/ase.151 .

Abou-Elhamd KA, Rashad UM, Al-Sultan AI. Applying problem-based learning to otolaryngology teaching. J Laryngol Otol. 2011;125:117–20. https://doi.org/10.1017/S0022215110001702 .

Urrutia Aguilar ME, Hamui-Sutton A, Castaneda Figueiras S, van der Goes TI, Guevara-Guzman R. Impact of problem-based learning on the cognitive processes of medical students. Gac Med Mex. 2011;147:385–93.

Tian J-H, Yang K-H, Liu A-P. Problem-based learning in evidence-based medicine courses at Lanzhou University. Med Teach. 2012;34:341. https://doi.org/10.3109/0142159X.2011.531169 .

Hoover CR, Wong CC, Azzam A. From primary care to public health: using problem-based Learning and the ecological model to teach public health to first year medical students. J Community Health. 2012;37:647–52. https://doi.org/10.1007/s10900-011-9495-y .

Li J, Li QL, Li J, et al. Comparison of three problem-based learning conditions (real patients, digital and paper) with lecture-based learning in a dermatology course: a prospective randomized study from China. Med Teach. 2013;35:e963–70. https://doi.org/10.3109/0142159X.2012.719651 .

Ding X, Zhao L, Chu H, et al. Assessing the effectiveness of problem-based learning of preventive medicine education in China. Sci Rep. 2014;4:5126. https://doi.org/10.1038/srep05126 .

Meo SA. Undergraduate medical student’s perceptions on traditional and problem based curricula: pilot study. J Pak Med Assoc. 2014;64:775–9.

Khoshnevisasl P, Sadeghzadeh M, Mazloomzadeh S, Hashemi Feshareki R, Ahmadiafshar A. Comparison of problem-based learning with lecture-based learning. Iran Red Crescent Med J. 2014;16: e5186. https://doi.org/10.5812/ircmj.5186 .

Al-Drees AA, Khalil MS, Irshad M, Abdulghani HM. Students’ perception towards the problem based learning tutorial session in a system-based hybrid curriculum. Saudi Med J. 2015;36:341–8. https://doi.org/10.15537/smj.2015.3.10216 .

Al-Shaikh G, Al Mussaed EM, Altamimi TN, Elmorshedy H, Syed S, Habib F. Perception of medical students regarding problem based learning. Kuwait Med J. 2015;47:133–8.

Hande S, Mohammed CA, Komattil R. Acquisition of knowledge, generic skills and attitudes through problem-based learning: student perspectives in a hybrid curriculum. J Taibah Univ Medical Sci. 2015;10:21–5. https://doi.org/10.1016/j.jtumed.2014.01.008 .

González Mirasol E, Gómez García MT, Lobo Abascal P, Moreno Selva R, Fuentes Rozalén AM, González MG. Analysis of perception of training in graduates of the faculty of medicine at Universidad de Castilla-Mancha. Eval Program Plann. 2015;52:169–75. https://doi.org/10.1016/j.evalprogplan.2015.06.001 .

Yanamadala M, Kaprielian VS, O’Connor Grochowski C, Reed T, Heflin MT. A problem-based learning curriculum in geriatrics for medical students. Gerontol Geriatr Educ. 2018;39:122–31. https://doi.org/10.1080/02701960.2016.1152268 .

Balendran K, John L. Comparison of learning outcomes in problem based learning and lecture based learning in teaching forensic medicine. J Evol Med Dent Sci. 2017;6:89–92. https://doi.org/10.14260/jemds/2017/22 .

Chang H-C, Wang N-Y, Ko W-R, Yu Y-T, Lin L-Y, Tsai H-F. The effectiveness of clinical problem-based learning model of medico-jurisprudence education on general law knowledge for obstetrics/gynecological interns. Taiwan J Obstet Gynecol. 2017;56:325–30. https://doi.org/10.1016/j.tjog.2017.04.011 .

Eltony SA, El-Sayed NH, El-Araby SE-S, Kassab SE. Implementation and evaluation of a patient safety course in a problem-based learning program. Educ Heal. 2017;30:44–9. https://doi.org/10.4103/1357-6283.210512 .

Zhang S, Xu J, Wang H, Zhang D, Zhang Q, Zou L. Effects of problem-based learning in Chinese radiology education: a systematic review and meta-analysis. Medicine (Baltimore). 2018;97: e0069. https://doi.org/10.1097/MD.0000000000010069 .

Hincapie Parra DA, Ramos Monobe A, Chrino-Barcelo V. Problem based learning as an active learning strategy and its impact on academic performance and critical thinking of medical students. Rev Complut Educ. 2018;29:665–81. https://doi.org/10.5209/RCED.53581 .

Ma Y, Lu X. The effectiveness of problem-based learning in pediatric medical education in China: a meta-analysis of randomized controlled trials. Medicine (Baltimore). 2019;98: e14052. https://doi.org/10.1097/MD.0000000000014052 .

Berger C, Brinkrolf P, Ertmer C, et al. Combination of problem-based learning with high-fidelity simulation in CPR training improves short and long-term CPR skills: a randomised single blinded trial. BMC Med Educ. 2019;19:180. https://doi.org/10.1186/s12909-019-1626-7 .

Aboonq M, Alquliti A, Abdulmonem I, Alpuq N, Jalali K, Arabi S. Students’ approaches to learning and perception of learning environment: a comparison between traditional and problem-based learning medical curricula. Indo Am J Pharm Sci. 2019;6:3610–9. https://doi.org/10.5281/zenodo.2562660 .

Li X, Xie F, Li X, et al. Development, application, and evaluation of a problem-based learning method in clinical laboratory education. Clin Chim ACTA. 2020;510:681–4. https://doi.org/10.1016/j.cca.2020.08.037 .

Zhao W, He L, Deng W, Zhu J, Su A, Zhang Y. The effectiveness of the combined problem-based learning (PBL) and case-based learning (CBL) teaching method in the clinical practical teaching of thyroid disease. BMC Med Educ. 2020;20:381. https://doi.org/10.1186/s12909-020-02306 .

Liu C-X, Ouyang W-W, Wang X-W, Chen D, Jiang Z-L. Comparing hybrid problem-based and lecture learning (PBL plus LBL) with LBL pedagogy on clinical curriculum learning for medical students in China: a meta-analysis of randomized controlled trials. Medicine (Baltimore). 2020;99:e19687. https://doi.org/10.1097/MD.0000000000019687 .

Margolius SW, Papp KK, Altose MD, Wilson-Delfosse AL. Students perceive skills learned in pre-clerkship PBL valuable in core clinical rotations. Med Teach. 2020;42:902–8. https://doi.org/10.1080/0142159X.2020.1762031 .

Schwartz RW, Donnelly MB, Nash PP, Young B. Developing students cognitive skills in a problem-based surgery clerkship. Acad Med. 1992;67:694–6. https://doi.org/10.1097/00001888-199210000-00016 .

Mennin SP, Friedman M, Skipper B, Kalishman S, Snyder J. Performances on the NBME-I, NBME-II, and NBME-III by medical-students in the problem-based learning and conventional tracks at the university-of-new-mexico. Acad Med. 1993;68:616–24. https://doi.org/10.1097/00001888-199308000-00012 .

Kaufman DM, Mann KV. Comparing achievement on the medical council of Canada qualifying examination part I of students in conventional and problem-based learning curricula. Acad Med. 1998;73:1211–3. https://doi.org/10.1097/00001888-199811000-00022 .

Kaufman DM, Mann KV. Achievement of students in a conventional and Problem-Based Learning (PBL) curriculum. Adv Heal Sci Educ. 1999;4:245–60. https://doi.org/10.1023/A:1009829831978 .

Antepohl W, Herzig S. Problem-based learning versus lecture-based learning in a course of basic pharmacology: a controlled, randomized study. Med Educ. 1999;33:106–13. https://doi.org/10.1046/j.1365-2923.1999.00289.x .

Dyke P, Jamrozik K, Plant AJ. A randomized trial of a problem-based learning approach for teaching epidemiology. Acad Med. 2001;76:373–9. https://doi.org/10.1097/00001888-200104000-00016 .

Brewer DW. Endocrine PBL in the year 2000. Adv Physiol Educ. 2001;25:249–55. https://doi.org/10.1152/advances.2001.25.4.249 .

Seneviratne RD, Samarasekera DD, Karunathilake IM, Ponnamperuma GG. Students’ perception of problem-based learning in the medical curriculum of the faculty of medicine, University of Colombo. Ann Acad Med Singapore. 2001;30:379–81.

Alleyne T, Shirley A, Bennett C, et al. Problem-based compared with traditional methods at the faculty of medical sciences, University of the West Indies: a model study. Med Teach. 2002;24:273–9. https://doi.org/10.1080/01421590220125286 .

Norman GR, Wenghofer E, Klass D. Predicting doctor performance outcomes of curriculum interventions: problem-based learning and continuing competence. Med Educ. 2008;42:794–9. https://doi.org/10.1111/j.1365-2923.2008.03131.x .

Cohen-Schotanus J, Muijtjens AMM, Schoenrock-Adema J, Geertsma J, van der Vleuten CPM. Effects of conventional and problem-based learning on clinical and general competencies and career development. Med Educ. 2008;42:256–65. https://doi.org/10.1111/j.1365-2923.2007.02959.x .

Wenk M, Waurick R, Schotes D, et al. Simulation-based medical education is no better than problem-based discussions and induces misjudgment in self-assessment. Adv Health Sci Educ Theory Pract. 2009;14:159–71. https://doi.org/10.1007/s10459-008-9098-2 .

Collard A, Gelaes S, Vanbelle S, et al. Reasoning versus knowledge retention and ascertainment throughout a problem-based learning curriculum. Med Educ. 2009;43:854–65. https://doi.org/10.1111/j.1365-2923.2009.03410.x .

Nouns Z, Schauber S, Witt C, Kingreen H, Schuettpelz-Brauns K. Development of knowledge in basic sciences: a comparison of two medical curricula. Med Educ. 2012;46:1206–14. https://doi.org/10.1111/medu.12047 .

Saloojee S, van Wyk J. The impact of a problem-based learning curriculum on the psychiatric knowledge and skills of final-year students at the Nelson R Mandela school of medicine. South African J Psychiatry. 2012;18:116.

Mughal AM, Shaikh SH. Assessment of collaborative problem solving skills in undergraduate medical students at Ziauddin college of medicine. Karachi Pakistan J Med Sci. 2018;34:185–9. https://doi.org/10.12669/pjms.341.13485 .

Hu X, Zhang H, Song Y, et al. Implementation of flipped classroom combined with problem-based learning: an approach to promote learning about hyperthyroidism in the endocrinology internship. BMC Med Educ. 2019;19:290. https://doi.org/10.1186/s12909-019-1714-8 .

Thompson KL, Gendreau JL, Strickling JE, Young HE. Cadaveric dissection in relation to problem-based learning case sequencing: a report of medical student musculoskeletal examination performances and self-confidence. Anat Sci Educ. 2019;12:619–26. https://doi.org/10.1002/ase.1891 .

Chang G, Cook D, Maguire T, Skakun E, Yakimets WW, Warnock GL. Problem-based learning: its role in undergraduate surgical education. Can J Surg. 1995;38:13–21.

Vernon DTA, Hosokawa MC. Faculty attitudes and opinions about problem-based learning. Acad Med. 1996;71:1233–8. https://doi.org/10.1097/00001888-199611000-00020 .

Steadman RH, Coates WC, Huang YM, et al. Simulation-based training is superior to problem-based learning for the acquisition of critical assessment and management skills. Crit Care Med. 2006;34:151–7. https://doi.org/10.1097/01.CCM.0000190619.42013.94 .

Johnston JM, Schooling CM, Leung GM. A randomised-controlled trial of two educational modes for undergraduate evidence-based medicine learning in Asia. BMC Med Educ. 2009;9:63. https://doi.org/10.1186/1472-6920-9-63 .

Suleman W, Iqbal R, Alsultan A, Baig SM. Perception of 4(th) year medical students about problem based learning. Pakistan J Med Sci. 2010;26:871–4.

Blosser A, Jones B. Problem-based learning in a surgery clerkship. Med Teach. 1991;13:289–93. https://doi.org/10.3109/01421599109089907 .

Usherwood T, Joesbury H, Hannay D. Student-directed problem-based learning in general-practice and public-health medicine. Med Educ. 1991;25:421–9. https://doi.org/10.1111/j.1365-2923.1991.tb00090.x .

Bernstein P, Tipping J, Bercovitz K, Skinner HA. Shifting students and faculty to a PBL curriculum - attitudes changed and lessons learned. Acad Med. 1995;70:245–7. https://doi.org/10.1097/00001888-199503000-00019 .

Kaufman DM, Mann KV. Comparing students’ attitudes in problem-based and conventional curricula. Acad Med. 1996;71:1096–9. https://doi.org/10.1097/00001888-199610000-00018 .

Kalaian HA, Mullan PB. Exploratory factor analysis of students’ ratings of a problem-based learning curriculum. Acad Med. 1996;71:390–2. https://doi.org/10.1097/00001888-199604000-00019 .

Vincelette J, Lalande R, Delorme P, Goudreau J, Lalonde V, Jean P. A pilot course as a model for implementing a PBL curriculum. Acad Med. 1997;72:698–701. https://doi.org/10.1097/00001888-199708000-00015 .

Ghosh S, Dawka V. Combination of didactic lecture with problem-based learning sessions in physiology teaching in a developing medical college in Nepal. Adv Physiol Educ. 2000;24:8–12.

Walters MR. Problem-based learning within endocrine physiology lectures. Adv Physiol Educ. 2001;25:225–7. https://doi.org/10.1152/advances.2001.25.4.225 .

Leung GM, Lam TH, Hedley AJ. Problem-based public health learning - from the classroom to the community. Med Educ. 2001;35:1071–2.

Khoo HE, Chhem RK, Gwee MCE, Balasubramaniam P. Introduction of problem-based learning in a traditional medical curriculum in Singapore - students’ and tutors’ perspectives. Ann Acad Med Singapore. 2001;30:371–4.

Villamor MCA. Problem-based learning (PBL) as an approach in the teaching of biochemistry of the endocrine system at the Angeles University College of Medicine. Ann Acad Med Singapore. 2001;30:382–6.

Chang C-H, Yang C-Y, See L-C, Lui P-W. High satisfaction with problem-based learning for anesthesia. Chang Gung Med J. 2004;27:654–62.

McLean M. A comparison of students who chose a traditional or a problem-based learning curriculum after failing year 2 in the traditional curriculum: a unique case study at the Nelson R. Mandela school of medicine. Teach Learn Med. 2004;16:301–3. https://doi.org/10.1207/s15328015tlm1603\_15 .

Lucas M, García Guasch R, Moret E, Llasera R, Melero A. Canet J [Problem-based learning in an undergraduate medical school course on anesthesiology, recovery care, and pain management]. Rev Esp Anestesiol Reanim. 2006;53:419–25.

Burgun A, Darmoni S, Le Duff F, Weber J. Problem-based learning in medical informatics for undergraduate medical students: an experiment in two medical schools. Int J Med Inform. 2006;75:396–402. https://doi.org/10.1016/j.ijmedinf.2005.07.014 .

Gurpinar E, Senol Y, Aktekin MR. Evaluation of problem based learning by tutors and students in a medical faculty of Turkey. Kuwait Med J. 2009;41:123–7.

Elzubeir MA. Teaching of the renal system in an integrated, problem-based curriculum. Saudi J Kidney Dis Transpl. 2012;23:93–8.

Sulaiman N, Hamdy H. Problem-based learning: where are we now? Guide supplement 36.3–practical application. Med Teach. 2013;35:160–2. https://doi.org/10.3109/0142159X.2012.737965 .

Albarrak AI, Mohammed R, Abalhassan MF, Almutairi NK. Academic satisfaction among traditional and problem based learning medical students a comparative study. Saudi Med J. 2013;34:1179–88.

Nosair E, Mirghani Z, Mostafa RM. Measuring students’ perceptions of educational environment in the PBL program of Sharjah Medical College. J Med Educ Curric Dev. 2015;2:71–9. https://doi.org/10.4137/JMECDECDECD.S29926 .

Tshitenge ST, Ndhlovu CE, Ogundipe R. Evaluation of problem-based learning curriculum implementation in a clerkship rotation of a newly established African medical training institution: lessons from the University of Botswana. Pan Afr Med J. 2017;27:13. https://doi.org/10.11604/pamj.2017.27.13.10623 .

Yadav RL, Piryani RM, Deo GP, Shah DK, Yadav LK, Islam MN. Attitude and perception of undergraduate medical students toward the problem-based learning in Chitwan Medical College. Nepal Adv Med Educ Pract. 2018;9:317–22. https://doi.org/10.2147/AMEP.S160814 .

Asad MR, Tadvi N, Amir KM, Afzal K, Irfan A, Hussain SA. Medical student’s feedback towards problem based learning and interactive lectures as a teaching and learning method in an outcome-based curriculum. Int J Med Res & Heal Sci. 2019;8:78–84. https://doi.org/10.33844/ijol.2019.60392 .

Mpalanyi M, Nalweyiso ID, Mubuuke AG. Perceptions of radiography students toward problem-based learning almost two decades after its introduction at Makerere University. Uganda J Med imaging Radiat Sci. 2020;51:639–44. https://doi.org/10.1016/j.jmir.2020.06.009 .

Korkmaz NS, Ozcelik S. Evaluation of the opinions of the first, second and third term medical students about problem based learning sessions in Bezmialem Vakif University. Bezmialem Sci. 2020;8:144–9. https://doi.org/10.14235/bas.galenos.2019.3471 .

McGrew MC, Skipper B, Palley T, Kaufman A. Student and faculty perceptions of problem-based learning on a family medicine clerkship. Fam Med. 1999;31:171–6.

Kelly AM. A problem-based learning resource in emergency medicine for medical students. J Accid Emerg Med. 2000;17:320–3. https://doi.org/10.1136/emj.17.5.320 .

Bui-Mansfield LT, Chew FS. Radiologists as clinical tutors in a problem-based medical school curriculum. Acad Radiol. 2001;8:657–63. https://doi.org/10.1016/S1076-6332(03)80693-1 .

Macallan DC, Kent A, Holmes SC, Farmer EA, McCrorie P. A model of clinical problem-based learning for clinical attachments in medicine. Med Educ. 2009;43:799–807. https://doi.org/10.1111/j.1365-2923.2009.03406.x .

Grisham JW, Martiniuk ALC, Negin J, Wright EP. Problem-based learning (PBL) and public health: an initial exploration of perceptions of PBL in Vietnam. Asia-Pacific J public Heal. 2015;27:NP2019-27. https://doi.org/10.1177/1010539512436875 .

Khan IA, Al-Swailmi FK. Perceptions of faculty and students regarding Problem Based Learning: a mixed methods study. J Pak Med Assoc. 2015;65:1334–8.

Alduraywish AA, Mohager MO, Alenezi MJ, Nail AM, Aljafari AS. Evaluation of students’ experience with Problem-based Learning (PBL) applied at the College of Medicine, Al-Jouf University. Saudi Arabia J Pak Med Assoc. 2017;67:1870–3.

Yoo DM, Cho AR, Kim S. Satisfaction with and suitability of the problem-based learning program at the Catholic University of Korea College of Medicine. J Educ Eval Health Prof. 2019;16:20. https://doi.org/10.3352/jeehp.2019.16.20 .

Aldayel AA, Alali AO, Altuwaim AA, et al. Problem-based learning: medical students’ perception toward their educational environment at Al-Imam Mohammad Ibn Saud Islamic University. Adv Med Educ Pract. 2019;10:95–104. https://doi.org/10.2147/AMEP.S189062 .

DeLowerntal E. An evaluation of a module in problem-based learning. Int J Educ Dev. 1996;16:303–7. https://doi.org/10.1016/0738-0593(96)00001-6 .

Tufts MA, Higgins-Opitz SB. What makes the learning of physiology in a PBL medical curriculum challenging? Student perceptions. Adv Physiol Educ. 2009;33:187–95. https://doi.org/10.1152/advan.90214.2008 .

Aboonq M. Perception of the faculty regarding problem-based learning as an educational approach in Northwestern Saudi Arabia. Saudi Med J. 2015;36:1329–35. https://doi.org/10.15537/smj.2015.11.12263 .

Subramaniam RM, Scally P, Gibson R. Problem-based learning and medical student radiology teaching. Australas Radiol. 2004;48:335–8. https://doi.org/10.1111/j.0004-8461.2004.01317.x .

Chang BJ. Problem-based learning in medical school: a student’s perspective. Ann Med Surg. 2016;12:88–9. https://doi.org/10.1016/j.amsu.2016.11.011 .

Griffith CD, Blue AV, Mainous AG, DeSimone PA. Housestaff attitudes toward a problem-based clerkship. Med Teach. 1996;18:133–4. https://doi.org/10.3109/01421599609034147 .

Navarro HN, Zamora SJ. The opinion of teachers about tutorial problem based learning. Rev Med Chil. 2014;142:989–97. https://doi.org/10.4067/S0034-98872014000800006 .

Demiroren M, Turan S, Oztuna D. Medical students’ self-efficacy in problem-based learning and its relationship with self-regulated learning. Med Educ Online. 2016;21:30049. https://doi.org/10.3402/meo.v21.30049 .

Tousignant M, DesMarchais JE. Accuracy of student self-assessment ability compared to their own performance in a problem-based learning medical program: a correlation study. Adv Heal Sci Educ. 2002;7:19–27. https://doi.org/10.1023/A:1014516206120 .

Brynhildsen J, Dahle LO, Behrbohm Fallsberg M, Rundquist I, Hammar M. Attitudes among students and teachers on vertical integration between clinical medicine and basic science within a problem-based undergraduate medical curriculum. Med Teach. 2002;24:286–8. https://doi.org/10.1080/01421590220134105 .

Desmarchais JE. A student-centered, problem-based curriculum - 5 years experience. Can Med Assoc J. 1993;148:1567–72.

Doig K, Werner E. The marriage of a traditional lecture-based curriculum and problem-based learning: are the offspring vigorous? Med Teach. 2000;22:173–8.

Kemahli S. Hematology education in a problem-based curriculum. Hematology. 2005;10(Suppl 1):161–3. https://doi.org/10.1080/10245330512331390267 .

Grkovic I. Transition of the medical curriculum from classical to integrated: problem-based approach and Australian way of keeping academia in medicine. Croat Med J. 2005;46:16–20.

Bosch-Barrera J, Briceno Garcia HC, Capella D, et al. Teaching bioethics to students of medicine with Problem-Based Learning (PBL). Cuad Bioet. 2015;26:303–9.

Lin Y-C, Huang Y-S, Lai C-S, Yen J-H, Tsai W-C. Problem-based learning curriculum in medical education at Kaohsiung Medical University. Kaohsiung J Med Sci. 2009;25:264–9. https://doi.org/10.1016/S1607-551X(09)70072-5 .

Salinas Sánchez AS, Hernández Millán I, Virseda Rodríguez JA, et al. Problem-based learning in urology training the faculty of medicine of the Universidad de Castilla-La Mancha model. Actas Urol Esp. 2005;29:8–15. https://doi.org/10.1016/s0210-4806(05)73193-4 .

Amoako-Sakyi D, Amonoo-Kuofi H. Problem-based learning in resource-poor settings: lessons from a medical school in Ghana. BMC Med Educ. 2015;15:221. https://doi.org/10.1186/s12909-015-0501-4 .

Carrera LI, Tellez TE, D’Ottavio AE. Implementing a problem-based learning curriculum in an Argentinean medical school: implications for developing countries. Acad Med. 2003;78:798–801. https://doi.org/10.1097/00001888-200308000-00010 .

Vernon DT, Blake RL. Does problem-based learning work? A meta-analysis of evaluative research. Acad Med. 1993;68:550–63. https://doi.org/10.1097/00001888-199307000-00015 .

Shanley PF. Viewpoint: leaving the “empty glass” of problem-based learning behind: new assumptions and a revised model for case study in preclinical medical education. Acad Med. 2007;82:479–85. https://doi.org/10.1097/ACM.0b013e31803eac4c .

Koh GC, Khoo HE, Wong ML, Koh D. The effects of problem-based learning during medical school on physician competency: a systematic review. CMAJ. 2008;178:34–41. https://doi.org/10.1503/cmaj.070565 .

Awan ZA, Awan AA, Alshawwa L, Tekian A, Park YS. Assisting the integration of social media in problem-based learning sessions in the faculty of medicine at King Abdulaziz University. Med Teach. 2018;40:S37–42. https://doi.org/10.1080/0142159X.2018.1465179 .

Download references

Acknowledgements

Not applicable

No funding was received for conducting this study.

Author information

Authors and affiliations.

Medical Education Cathedra, School of Medicine, University of Vic-Central University of Catalonia, Vic, Barcelona, Spain

Joan Carles Trullàs, Carles Blay & Ramon Pujol

Internal Medicine Service, Hospital de Olot i Comarcal de La Garrotxa, Olot, Girona, Spain

Joan Carles Trullàs

The Tissue Repair and Regeneration Laboratory (TR2Lab), University of Vic-Central University of Catalonia, Vic, Barcelona, Spain

Joan Carles Trullàs & Elisabet Sarri

Catalan Institute of Health (ICS) – Catalunya Central, Barcelona, Spain

Carles Blay

You can also search for this author in PubMed Google Scholar

Contributions

JCT had the idea for the article, performed the literature search and data analysis and drafted the first version of the manuscript. CB, ES and RP contributed to the data analysis and suggested revisions to the manuscript. All authors read and approved the final manuscript.

Ethics declarations

Availability of data and materials.

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

Ethics approval and consent to participate

Not applicable for a literature review.

Consent for publication

Competing interests.

All authors declare that they have no conflict of interest.

Additional information

Publisher’s note.

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

Supplementary Information

Additional file 1..

Characteristics ofthe 124 included studies.

Rights and permissions

Reprints and permissions

About this article

Cite this article.

Trullàs, J.C., Blay, C., Sarri, E. et al. Effectiveness of problem-based learning methodology in undergraduate medical education: a scoping review. BMC Med Educ 22 , 104 (2022). https://doi.org/10.1186/s12909-022-03154-8

Download citation

Received : 03 October 2021

Accepted : 02 February 2022

Published : 17 February 2022

DOI : https://doi.org/10.1186/s12909-022-03154-8

Share this article

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

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

Provided by the Springer Nature SharedIt content-sharing initiative

Systematic review

BMC Medical Education

ISSN: 1472-6920

Submission enquiries: [email protected]
General enquiries: [email protected]

Case Study Research

First Online: 29 September 2022

Cite this chapter

Robert E. White ORCID: orcid.org/0000-0002-8045-164X 3 &
Karyn Cooper 4

1219 Accesses

As a footnote to the previous chapter, there is such a beast known as the ethnographic case study. Ethnographic case study has found its way into this chapter rather than into the previous one because of grammatical considerations. Simply put, the “case study” part of the phrase is the noun (with “case” as an adjective defining what kind of study it is), while the “ethnographic” part of the phrase is an adjective defining the type of case study that is being conducted. As such, the case study becomes the methodology, while the ethnography part refers to a method, mode or approach relating to the development of the study.

The experiential account that we get from a case study or qualitative research of a similar vein is just so necessary. How things happen over time and the degree to which they are subject to personality and how they are only gradually perceived as tolerable or intolerable by the communities and the groups that are involved is so important. Robert Stake, University of Illinois, Urbana-Champaign

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

Available as PDF
Read on any device
Instant download
Own it forever
Available as EPUB and PDF
Compact, lightweight edition
Dispatched in 3 to 5 business days
Free shipping worldwide - see info

Tax calculation will be finalised at checkout

Purchases are for personal use only

Institutional subscriptions

Bartlett, L., & Vavrus, F. (2017). Rethinking case study research . Routledge.

Google Scholar

Bauman, Z. (2000). Liquid modernity . Polity Press.

Bhaskar, R., & Danermark, B. (2006). Metatheory, interdisciplinarity and disability research: A critical realist perspective. Scandinavian Journal of Disability Research, 8 (4), 278–297.

Article Google Scholar

Bulmer, M. (1986). The Chicago School of sociology: Institutionalization, diversity, and the rise of sociological research . University of Chicago Press.

Campbell, D. T. (1975). Degrees of freedom and the case study. Comparative Political Studies, 8 (1), 178–191.

Campbell, D. T., & Stanley, J. C. (1966). Experimental and quasi-experimental designs for research . Houghton Mifflin.

Chua, W. F. (1986). Radical developments in accounting thought. The Accounting Review, 61 (4), 601–632.

Creswell, J. W. (2013). Research design: Qualitative, quantitative, and mixed methods approaches (4th ed.). Sage.

Creswell, J. W., & Poth, C. N. (2017). Qualitative inquiry and research design . Sage.

Davey, L. (1991). The application of case study evaluations. Practical Assessment, Research, & Evaluation 2 (9) . Retrieved May 28, 2018, from http://PAREonline.net/getvn.asp?v=2&n=9

Demetriou, H. (2017). The case study. In E. Wilson (Ed.), School-based research: A guide for education students (pp. 124–138). Sage.

Denzin, N. K., & Lincoln, Y. S. (2005). The Sage handbook of qualitative research . Sage.

Flyvbjerg, B. (2004). Five misunderstandings about case-study research. In C. Seale, G. Gobo, J. F. Gubrium, & D. Silverman (Eds.), Qualitative research practice (pp. 420–433). Sage.

Hamel, J., Dufour, S., & Fortin, D. (1993). Case study methods . Sage.

Book Google Scholar

Healy, M. E. (1947). Le Play’s contribution to sociology: His method. The American Catholic Sociological Review, 8 (2), 97–110.

Johansson, R. (2003). Case study methodology. [Keynote speech]. In International Conference “Methodologies in Housing Research.” Royal Institute of Technology, Stockholm, September 2003 (pp. 1–14).

Klonoski, R. (2013). The case for case studies: Deriving theory from evidence. Journal of Business Case Studies, 9 (31), 261–266.

McDonough, J., & McDonough, S. (1997). Research methods for English language teachers . Routledge.

Merriam, S. B. (1998). Qualitative research and case study applications in education . Jossey-Bass.

Miles, M. B. (1979). Qualitative data as an attractive nuisance: The problem of analysis. Administrative Science Quarterly, 24 (4), 590–601.

Miles, M. B., & Huberman, A. M. (1994). Qualitative data analysis: An expanded sourcebook (2nd ed.). Sage.

Mills, A. J., Durepos, G. & E. Wiebe (Eds.) (2010). What is a case study? Encyclopedia of case study research, Volumes I and II. Sage.

National Film Board of Canada. (2012, April). Here at home: In search of the real cost of homelessness . [Web documentary]. Retrieved February 9, 2020, from http://athome.nfb.ca/#/athome/home

Popper, K. (2002). Conjectures and refutations: The growth of scientific knowledge . Routledge.

Ridder, H.-G. (2017). The theory contribution of case study research designs. Business Research, 10 (2), 281–305.

Rolls, G. (2005). Classic case studies in psychology . Hodder Education.

Seawright, J., & Gerring, J. (2008). Case-Selection techniques in case study research: A menu of qualitative and quantitative options. Political Research Quarterly, 61 , 294–308.

Stake, R. E. (1995). The art of case study research . Sage.

Stake, R. E. (2005). Multiple case study analysis . Guilford Press.

Swanborn, P. G. (2010). Case study research: What, why and how? Sage.

Thomas, W. I., & Znaniecki, F. (1996). The Polish peasant in Europe and America: A classic work in immigration history . University of Illinois Press.

Yin, R. K. (1981). The case study crisis: Some answers. Administrative Science Quarterly, 26 (1), 58–65.

Yin, R. K. (1991). Advancing rigorous methodologies : A Review of “Towards Rigor in Reviews of Multivocal Literatures….”. Review of Educational Research, 61 (3), 299–305.

Yin, R. K. (1999). Enhancing the quality of case studies in health services research. Health Services Research, 34 (5) Part II, 1209–1224.

Yin, R. K. (2012). Applications of case study research (3rd ed.). Sage.

Yin, R. K. (2014). Case study research: Design and methods (5th ed.). Sage.

Zaretsky, E. (1996). Introduction. In W. I. Thomas & F. Znaniecki (Eds.), The Polish peasant in Europe and America: A classic work in immigration history (pp. vii–xvii). University of Illinois Press.

Download references

Author information

Authors and affiliations.

Faculty of Education, St. Francis Xavier University, Antigonish, NS, Canada

Robert E. White

OISE, University of Toronto, Toronto, ON, Canada

Karyn Cooper

You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Robert E. White .

A Case in Case Study Methodology

Christine Benedichte Meyer

Norwegian School of Economics and Business Administration

Meyer, C. B. (2001). A Case in Case Study Methodology. Field Methods 13 (4), 329-352.

The purpose of this article is to provide a comprehensive view of the case study process from the researcher’s perspective, emphasizing methodological considerations. As opposed to other qualitative or quantitative research strategies, such as grounded theory or surveys, there are virtually no specific requirements guiding case research. This is both the strength and the weakness of this approach. It is a strength because it allows tailoring the design and data collection procedures to the research questions. On the other hand, this approach has resulted in many poor case studies, leaving it open to criticism, especially from the quantitative field of research. This article argues that there is a particular need in case studies to be explicit about the methodological choices one makes. This implies discussing the wide range of decisions concerned with design requirements, data collection procedures, data analysis, and validity and reliability. The approach here is to illustrate these decisions through a particular case study of two mergers in the financial industry in Norway.

In the past few years, a number of books have been published that give useful guidance in conducting qualitative studies (Gummesson 1988; Cassell & Symon 1994; Miles & Huberman 1994; Creswell 1998; Flick 1998; Rossman & Rallis 1998; Bryman & Burgess 1999; Marshall & Rossman 1999; Denzin & Lincoln 2000). One approach often mentioned is the case study (Yin 1989). Case studies are widely used in organizational studies in the social science disciplines of sociology, industrial relations, and anthropology (Hartley 1994). Such a study consists of detailed investigation of one or more organizations, or groups within organizations, with a view to providing an analysis of the context and processes involved in the phenomenon under study.

As opposed to other qualitative or quantitative research strategies, such as grounded theory (Glaser and Strauss 1967) or surveys (Nachmias & Nachmias 1981), there are virtually no specific requirements guiding case research. Yin (1989) and Eisenhardt (1989) give useful insights into the case study as a research strategy, but leave most of the design decisions on the table. This is both the strength and the weakness of this approach. It is a strength because it allows tailoring the design and data collection procedures to the research questions. On the other hand, this approach has resulted in many poor case studies, leaving it open to criticism, especially from the quantitative field of research (Cook and Campbell 1979). The fact that the case study is a rather loose design implies that there are a number of choices that need to be addressed in a principled way.

Although case studies have become a common research strategy, the scope of methodology sections in articles published in journals is far too limited to give the readers a detailed and comprehensive view of the decisions taken in the particular studies, and, given the format of methodology sections, will remain so. The few books (Yin 1989, 1993; Hamel, Dufour, & Fortin 1993; Stake 1995) and book chapters on case studies (Hartley 1994; Silverman 2000) are, on the other hand, mainly normative and span a broad range of different kinds of case studies. One exception is Pettigrew (1990, 1992), who places the case study in the context of a research tradition (the Warwick process research).

Given the contextual nature of the case study and its strength in addressing contemporary phenomena in real-life contexts, I believe that there is a need for articles that provide a comprehensive overview of the case study process from the researcher’s perspective, emphasizing methodological considerations. This implies addressing the whole range of choices concerning specific design requirements, data collection procedures, data analysis, and validity and reliability.

WHY A CASE STUDY?

Case studies are tailor-made for exploring new processes or behaviors or ones that are little understood (Hartley 1994). Hence, the approach is particularly useful for responding to how and why questions about a contemporary set of events (Leonard-Barton 1990). Moreover, researchers have argued that certain kinds of information can be difficult or even impossible to tackle by means other than qualitative approaches such as the case study (Sykes 1990). Gummesson (1988:76) argues that an important advantage of case study research is the opportunity for a holistic view of the process: “The detailed observations entailed in the case study method enable us to study many different aspects, examine them in relation to each other, view the process within its total environment and also use the researchers’ capacity for ‘verstehen.’ ”

The contextual nature of the case study is illustrated in Yin’s (1993:59) definition of a case study as an empirical inquiry that “investigates a contemporary phenomenon within its real-life context and addresses a situation in which the boundaries between phenomenon and context are not clearly evident.”

The key difference between the case study and other qualitative designs such as grounded theory and ethnography (Glaser & Strauss 1967; Strauss & Corbin 1990; Gioia & Chittipeddi 1991) is that the case study is open to the use of theory or conceptual categories that guide the research and analysis of data. In contrast, grounded theory or ethnography presupposes that theoretical perspectives are grounded in and emerge from firsthand data. Hartley (1994) argues that without a theoretical framework, the researcher is in severe danger of providing description without meaning. Gummesson (1988) says that a lack of preunderstanding will cause the researcher to spend considerable time gathering basic information. This preunderstanding may arise from general knowledge such as theories, models, and concepts or from specific knowledge of institutional conditions and social patterns. According to Gummesson, the key is not to require researchers to have split but dual personalities: “Those who are able to balance on a razor’s edge using their pre-understanding without being its slave” (p. 58).

DESCRIPTION OF THE ILLUSTRATIVE STUDY

The study that will be used for illustrative purposes is a comparative and longitudinal case study of organizational integration in mergers and acquisitions taking place in Norway. The study had two purposes: (1) to identify contextual factors and features of integration that facilitated or impeded organizational integration, and (2) to study how the three dimensions of organizational integration (integration of tasks, unification of power, and integration of cultures and identities) interrelated and evolved over time. Examples of contextual factors were relative power, degree of friendliness, and economic climate. Integration features included factors such as participation, communication, and allocation of positions and functions.

Mergers and acquisitions are inherently complex. Researchers in the field have suggested that managers continuously underestimate the task of integrating the merging organizations in the postintegration process (Haspeslaph & Jemison 1991). The process of organizational integration can lead to sharp interorganizational conflict as the different top management styles, organizational and work unit cultures, systems, and other aspects of organizational life come into contact (Blake & Mounton 1985; Schweiger & Walsh 1990; Cartwright & Cooper 1993). Furthermore, cultural change in mergers and acquisitions is compounded by additional uncertainties, ambiguities, and stress inherent in the combination process (Buono & Bowditch 1989).

I focused on two combinations: one merger and one acquisition. The first case was a merger between two major Norwegian banks, Bergen Bank and DnC (to be named DnB), that started in the late 1980s. The second case was a study of a major acquisition in the insurance industry (i.e., Gjensidige’s acquisition of Forenede), that started in the early 1990s. Both combinations aimed to realize operational synergies though merging the two organizations into one entity. This implied disruption of organizational boundaries and threat to the existing power distribution and organizational cultures.

The study of integration processes in mergers and acquisitions illustrates the need to find a design that opens for exploration of sensitive issues such as power struggles between the two merging organizations. Furthermore, the inherent complexity in the integration process, involving integration of tasks, unification of power, and cultural integration stressed the need for in-depth study of the phenomenon over time. To understand the cultural integration process, the design also had to be linked to the past history of the two organizations.

DESIGN DECISIONS

In the introduction, I stressed that a case is a rather loose design that requires that a number of design choices be made. In this section, I go through the most important choices I faced in the study of organizational integration in mergers and acquisitions. These include: (1) selection of cases; (2) sampling time; (3) choosing business areas, divisions, and sites; and (4) selection of and choices regarding data collection procedures, interviews, documents, and observation.

Selection of Cases

There are several choices involved in selecting cases. First, there is the question of how many cases to include. Second, one must sample cases and decide on a unit of analysis. I will explore these issues subsequently.

Single or Multiple Cases

Case studies can involve single or multiple cases. The problem of single cases is limitations in generalizability and several information-processing biases (Eisenhardt 1989).

One way to respond to these biases is by applying a multi-case approach (Leonard-Barton 1990). Multiple cases augment external validity and help guard against observer biases. Moreover, multi-case sampling adds confidence to findings. By looking at a range of similar and contrasting cases, we can understand a single-case finding, grounding it by specifying how and where and, if possible, why it behaves as it does. (Miles & Huberman 1994)

Given these limitations of the single case study, it is desirable to include more than one case study in the study. However, the desire for depth and a pluralist perspective and tracking the cases over time implies that the number of cases must be fairly few. I chose two cases, which clearly does not support generalizability any more than does one case, but allows for comparison and contrast between the cases as well as a deeper and richer look at each case.

Originally, I planned to include a third case in the study. Due to changes in management during the initial integration process, my access to the case was limited and I left this case entirely. However, a positive side effect was that it allowed a deeper investigation of the two original cases and in hindsight turned out to be a good decision.

Sampling Cases

The logic of sampling cases is fundamentally different from statistical sampling. The logic in case studies involves theoretical sampling, in which the goal is to choose cases that are likely to replicate or extend the emergent theory or to fill theoretical categories and provide examples for polar types (Eisenhardt 1989). Hence, whereas quantitative sampling concerns itself with representativeness, qualitative sampling seeks information richness and selects the cases purposefully rather than randomly (Crabtree and Miller 1992).

The choice of cases was guided by George (1979) and Pettigrew’s (1990) recommendations. The aim was to find cases that matched the three dimensions in the dependent variable and provided variation in the contextual factors, thus representing polar cases.

To match the choice of outcome variable, organizational integration, I chose cases in which the purpose was to fully consolidate the merging parties’ operations. A full consolidation would imply considerable disruption in the organizational boundaries and would be expected to affect the task-related, political, and cultural features of the organizations. As for the contextual factors, the two cases varied in contextual factors such as relative power, friendliness, and economic climate. The DnB merger was a friendly combination between two equal partners in an unfriendly economic climate. Gjensidige’s acquisition of Forenede was, in contrast, an unfriendly and unbalanced acquisition in a friendly economic climate.

Unit of Analysis

Another way to respond to researchers’ and respondents’ biases is to have more than one unit of analysis in each case (Yin 1993). This implies that, in addition to developing contrasts between the cases, researchers can focus on contrasts within the cases (Hartley 1994). In case studies, there is a choice of a holistic or embedded design (Yin 1989). A holistic design examines the global nature of the phenomenon, whereas an embedded design also pays attention to subunit(s).

I used an embedded design to analyze the cases (i.e., within each case, I also gave attention to subunits and subprocesses). In both cases, I compared the combination processes in the various divisions and local networks. Moreover, I compared three distinct change processes in DnB: before the merger, during the initial combination, and two years after the merger. The overall and most important unit of analysis in the two cases was, however, the integration process.

Sampling Time

According to Pettigrew (1990), time sets a reference for what changes can be seen and how those changes are explained. When conducting a case study, there are several important issues to decide when sampling time. The first regards how many times data should be collected, while the second concerns when to enter the organizations. There is also a need to decide whether to collect data on a continuous basis or in distinct periods.

Number of data collections. I studied the process by collecting real time and retrospective data at two points in time, with one-and-a-half- and two-year intervals in the two cases. Collecting data twice had some interesting implications for the interpretations of the data. During the first data collection in the DnB study, for example, I collected retrospective data about the premerger and initial combination phase and real-time data about the second step in the combination process.

Although I gained a picture of how the employees experienced the second stage of the combination process, it was too early to assess the effects of this process at that stage. I entered the organization two years later and found interesting effects that I had not anticipated the first time. Moreover, it was interesting to observe how people’s attitudes toward the merger processes changed over time to be more positive and less emotional.

When to enter the organizations. It would be desirable to have had the opportunity to collect data in the precombination processes. However, researchers are rarely given access in this period due to secrecy. The emphasis in this study was to focus on the postcombination process. As such, the precombination events were classified as contextual factors. This implied that it was most important to collect real-time data after the parties had been given government approval to merge or acquire. What would have been desirable was to gain access earlier in the postcombination process. This was not possible because access had to be negotiated. Due to the change of CEO in the middle of the merger process and the need for renegotiating access, this took longer than expected.

Regarding the second case, I was restricted by the time frame of the study. In essence, I had to choose between entering the combination process as soon as governmental approval was given, or entering the organization at a later stage. In light of the previous studies in the field that have failed to go beyond the initial two years, and given the need to collect data about the cultural integration process, I chose the latter strategy. And I decided to enter the organizations at two distinct periods of time rather than on a continuous basis.

There were several reasons for this approach, some methodological and some practical. First, data collection on a continuous basis would have required use of extensive observation that I didn’t have access to, and getting access to two data collections in DnB was difficult in itself. Second, I had a stay abroad between the first and second data collection in Gjensidige. Collecting data on a continuous basis would probably have allowed for better mapping of the ongoing integration process, but the contrasts between the two different stages in the integration process that I wanted to elaborate would probably be more difficult to detect. In Table 1 I have listed the periods of time in which I collected data in the two combinations.

Sampling Business Areas, Divisions, and Sites

Even when the cases for a study have been chosen, it is often necessary to make further choices within each case to make the cases researchable. The most important criteria that set the boundaries for the study are importance or criticality, relevance, and representativeness. At the time of the data collection, my criteria for making these decisions were not as conscious as they may appear here. Rather, being restricted by time and my own capacity as a researcher, I had to limit the sites and act instinctively. In both cases, I decided to concentrate on the core businesses (criticality criterion) and left out the business units that were only mildly affected by the integration process (relevance criterion). In the choice of regional offices, I used the representativeness criterion as the number of offices widely exceeded the number of sites possible to study. In making these choices, I relied on key informants in the organizations.

SELECTION OF DATA COLLECTION PROCEDURES

The choice of data collection procedures should be guided by the research question and the choice of design. The case study approach typically combines data collection methods such as archives, interviews, questionnaires, and observations (Yin 1989). This triangulated methodology provides stronger substantiation of constructs and hypotheses. However, the choice of data collection methods is also subject to constraints in time, financial resources, and access.

I chose a combination of interviews, archives, and observation, with main emphasis on the first two. Conducting a survey was inappropriate due to the lack of established concepts and indicators. The reason for limited observation, on the other hand, was due to problems in obtaining access early in the study and time and resource constraints. In addition to choosing among several different data collection methods, there are a number of choices to be made for each individual method.

When relying on interviews as the primary data collection method, the issue of building trust between the researcher and the interviewees becomes very important. I addressed this issue by several means. First, I established a procedure of how to approach the interviewees. In most cases, I called them first, then sent out a letter explaining the key features of the project and outlining the broad issues to be addressed in the interview. In this letter, the support from the institution’s top management was also communicated. In most cases, the top management’s support of the project was an important prerequisite for the respondent’s input. Some interviewees did, however, fear that their input would be open to the top management without disguising the information source. Hence, it became important to communicate how I intended to use and store the information.

To establish trust, I also actively used my preunderstanding of the context in the first case and the phenomenon in the second case. As I built up an understanding of the cases, I used this information to gain confidence. The active use of my preunderstanding did, however, pose important challenges in not revealing too much of the research hypotheses and in balancing between asking open-ended questions and appearing knowledgeable.

There are two choices involved in conducting interviews. The first concerns the sampling of interviewees. The second is that you must decide on issues such as the structure of the interviews, use of tape recorder, and involvement of other researchers.

Sampling Interviewees

Following the desire for detailed knowledge of each case and for grasping different participant’s views the aim was, in line with Pettigrew (1990), to apply a pluralist view by describing and analyzing competing versions of reality as seen by actors in the combination processes.

I used four criteria for sampling informants. First, I drew informants from populations representing multiple perspectives. The first data collection in DnB was primarily focused on the top management level. Moreover, most middle managers in the first data collection were employed at the head offices, either in Bergen or Oslo. In the second data collection, I compensated for this skew by including eight local middle managers in the sample. The difference between the number of employees interviewed in DnB and Gjensidige was primarily due to the fact that Gjensidige has three unions, whereas DnB only has one. The distribution of interviewees is outlined in Table 2 .

The second criterion was to use multiple informants. According to Glick et al. (1990), an important advantage of using multiple informants is that the validity of information provided by one informant can be checked against that provided by other informants. Moreover, the validity of the data used by the researcher can be enhanced by resolving the discrepancies among different informants’ reports. Hence, I selected multiple respondents from each perspective.

Third, I focused on key informants who were expected to be knowledgeable about the combination process. These people included top management members, managers, and employees involved in the integration project. To validate the information from these informants, I also used a fourth criterion by selecting managers and employees who had been affected by the process but who were not involved in the project groups.

Structured versus unstructured. In line with the explorative nature of the study, the goal of the interviews was to see the research topic from the perspective of the interviewee, and to understand why he or she came to have this particular perspective. To meet this goal, King (1994:15) recommends that one have “a low degree of structure imposed on the interviewer, a preponderance of open questions, a focus on specific situations and action sequences in the world of the interviewee rather than abstractions and general opinions.” In line with these recommendations, the collection of primary data in this study consists of unstructured interviews.

Using tape recorders and involving other researchers. The majority of the interviews were tape-recorded, and I could thus concentrate fully on asking questions and responding to the interviewees’ answers. In the few interviews that were not tape-recorded, most of which were conducted in the first phase of the DnB-study, two researchers were present. This was useful as we were both able to discuss the interviews later and had feedback on the role of an interviewer.

In hindsight, however, I wish that these interviews had been tape-recorded to maintain the level of accuracy and richness of data. Hence, in the next phases of data collection, I tape-recorded all interviews, with two exceptions (people who strongly opposed the use of this device). All interviews that were tape-recorded were transcribed by me in full, which gave me closeness and a good grasp of the data.

When organizations merge or make acquisitions, there are often a vast number of documents to choose from to build up an understanding of what has happened and to use in the analyses. Furthermore, when firms make acquisitions or merge, they often hire external consultants, each of whom produces more documents. Due to time constraints, it is seldom possible to collect and analyze all these documents, and thus the researcher has to make a selection.

The choice of documentation was guided by my previous experience with merger and acquisition processes and the research question. Hence, obtaining information on the postintegration process was more important than gaining access to the due-diligence analysis. As I learned about the process, I obtained more documents on specific issues. I did not, however, gain access to all the documents I asked for, and, in some cases, documents had been lost or shredded.

The documents were helpful in a number of ways. First, and most important, they were used as inputs to the interview guide and saved me time, because I did not have to ask for facts in the interviews. They were also useful for tracing the history of the organizations and statements made by key people in the organizations. Third, the documents were helpful in counteracting the biases of the interviews. A list of the documents used in writing the cases is shown in Table 3 .

Observation

The major strength of direct observation is that it is unobtrusive and does not require direct interaction with participants (Adler and Adler 1994). Observation produces rigor when it is combined with other methods. When the researcher has access to group processes, direct observation can illuminate the discrepancies between what people said in the interviews and casual conversations and what they actually do (Pettigrew 1990).

As with interviews, there are a number of choices involved in conducting observations. Although I did some observations in the study, I used interviews as the key data collection source. Discussion in this article about observations will thus be somewhat limited. Nevertheless, I faced a number of choices in conducting observations, including type of observation, when to enter, how much observation to conduct, and which groups to observe.

The are four ways in which an observer may gather data: (1) the complete participant who operates covertly, concealing any intention to observe the setting; (2) the participant-as-observer, who forms relationships and participates in activities, but makes no secret of his or her intentions to observe events; (3) the observer-as-participant, who maintains only superficial contact with the people being studied; and (4) the complete observer, who merely stands back and eavesdrops on the proceedings (Waddington 1994).

In this study, I used the second and third ways of observing. The use of the participant-as-observer mode, on which much ethnographic research is based, was rather limited in the study. There were two reasons for this. First, I had limited time available for collecting data, and in my view interviews made more effective use of this limited time than extensive participant observation. Second, people were rather reluctant to let me observe these political and sensitive processes until they knew me better and felt I could be trusted. Indeed, I was dependent on starting the data collection before having built sufficient trust to observe key groups in the integration process. Nevertheless, Gjensidige allowed me to study two employee seminars to acquaint me with the organization. Here I admitted my role as an observer but participated fully in the activities. To achieve variation, I chose two seminars representing polar groups of employees.

As observer-as-participant, I attended a top management meeting at the end of the first data collection in Gjensidige and observed the respondents during interviews and in more informal meetings, such as lunches. All these observations gave me an opportunity to validate the data from the interviews. Observing the top management group was by far the most interesting and rewarding in terms of input.

Both DnB and Gjensidige started to open up for more extensive observation when I was about to finish the data collection. By then, I had built up the trust needed to undertake this approach. Unfortunately, this came a little late for me to take advantage of it.

DATA ANALYSIS

Published studies generally describe research sites and data-collection methods, but give little space to discuss the analysis (Eisenhardt 1989). Thus, one cannot follow how a researcher arrives at the final conclusions from a large volume of field notes (Miles and Huberman 1994).

In this study, I went through the stages by which the data were reduced and analyzed. This involved establishing the chronology, coding, writing up the data according to phases and themes, introducing organizational integration into the analysis, comparing the cases, and applying the theory. I will discuss these phases accordingly.

The first step in the analysis was to establish the chronology of the cases. To do this, I used internal and external documents. I wrote the chronologies up and included appendices in the final report.

The next step was to code the data into phases and themes reflecting the contextual factors and features of integration. For the interviews, this implied marking the text with a specific phase and a theme, and grouping the paragraphs on the same theme and phase together. I followed the same procedure in organizing the documents.

I then wrote up the cases using phases and themes to structure them. Before starting to write up the cases, I scanned the information on each theme, built up the facts and filled in with perceptions and reactions that were illustrative and representative of the data.

The documents were primarily useful in establishing the facts, but they also provided me with some perceptions and reactions that were validated in the interviews. The documents used included internal letters and newsletters as well as articles from the press. The interviews were less factual, as intended, and gave me input to assess perceptions and reactions. The limited observation was useful to validate the data from the interviews. The result of this step was two descriptive cases.

To make each case more analytical, I introduced the three dimensions of organizational integration—integration of tasks, unification of power, and cultural integration—into the analysis. This helped to focus the case and to develop a framework that could be used to compare the cases. The cases were thus structured according to phases, organizational integration, and themes reflecting the factors and features in the study.

I took all these steps to become more familiar with each case as an individual entity. According to Eisenhardt (1989:540), this is a process that “allows the unique patterns of each case to emerge before the investigators push to generalise patterns across cases. In addition it gives investigators a rich familiarity with each case which, in turn, accelerates cross-case comparison.”

The comparison between the cases constituted the next step in the analysis. Here, I used the categories from the case chapters, filled in the features and factors, and compared and contrasted the findings. The idea behind cross-case searching tactics is to force investigators to go beyond initial impressions, especially through the use of structural and diverse lenses on the data. These tactics improve the likelihood of accurate and reliable theory, that is, theory with a close fit to the data (Eisenhardt 1989).

As a result, I had a number of overall themes, concepts, and relationships that had emerged from the within-case analysis and cross-case comparisons. The next step was to compare these emergent findings with theory from the organizational field of mergers and acquisitions, as well as other relevant perspectives.

This method of generalization is known as analytical generalization. In this approach, a previously developed theory is used as a template with which to compare the empirical results of the case study (Yin 1989). This comparison of emergent concepts, theory, or hypotheses with the extant literature involves asking what it is similar to, what it contradicts, and why. The key to this process is to consider a broad range of theory (Eisenhardt 1989). On the whole, linking emergent theory to existent literature enhances the internal validity, generalizability, and theoretical level of theory-building from case research.

According to Eisenhardt (1989), examining literature that conflicts with the emergent literature is important for two reasons. First, the chance of neglecting conflicting findings is reduced. Second, “conflicting results forces researchers into a more creative, frame-breaking mode of thinking than they might otherwise be able to achieve” (p. 544). Similarly, Eisenhardt (1989) claims that literature discussing similar findings is important because it ties together underlying similarities in phenomena not normally associated with each other. The result is often a theory with a stronger internal validity, wider generalizability, and a higher conceptual level.

The analytical generalization in the study included exploring and developing the concepts and examining the relationships between the constructs. In carrying out this analytical generalization, I acted on Eisenhardt’s (1989) recommendation to use a broad range of theory. First, I compared and contrasted the findings with the organizational stream on mergers and acquisition literature. Then I discussed other relevant literatures, including strategic change, power and politics, social justice, and social identity theory to explore how these perspectives could contribute to the understanding of the findings. Finally, I discussed the findings that could not be explained either by the merger and acquisition literature or the four theoretical perspectives.

In every scientific study, questions are raised about whether the study is valid and reliable. The issues of validity and reliability in case studies are just as important as for more deductive designs, but the application is fundamentally different.

VALIDITY AND RELIABILITY

The problems of validity in qualitative studies are related to the fact that most qualitative researchers work alone in the field, they focus on the findings rather than describe how the results were reached, and they are limited in processing information (Miles and Huberman 1994).

Researchers writing about qualitative methods have questioned whether the same criteria can be used for qualitative and quantitative studies (Kirk & Miller 1986; Sykes 1990; Maxwell 1992). The problem with the validity criteria suggested in qualitative research is that there is little consistency across the articles as each author suggests a new set of criteria.

One approach in examining validity and reliability is to apply the criteria used in quantitative research. Hence, the criteria to be examined here are objectivity/intersubjectivity, construct validity, internal validity, external validity, and reliability.

Objectivity/Intersubjectivity

The basic issue of objectivity can be framed as one of relative neutrality and reasonable freedom from unacknowledged research biases (Miles & Huberman 1994). In a real-time longitudinal study, the researcher is in danger of losing objectivity and of becoming too involved with the organization, the people, and the process. Hence, Leonard-Barton (1990) claims that one may be perceived as, and may even become, an advocate rather than an observer.

According to King (1994), however, qualitative research, in seeking to describe and make sense of the world, does not require researchers to strive for objectivity and distance themselves from research participants. Indeed, to do so would make good qualitative research impossible, as the interviewer’s sensitivity to subjective aspects of his or her relationship with the interviewee is an essential part of the research process (King 1994:31).

This does not imply, however, that the issue of possible research bias can be ignored. It is just as important as in a structured quantitative interview that the findings are not simply the product of the researcher’s prejudices and prior experience. One way to guard against this bias is for the researcher to explicitly recognize his or her presuppositions and to make a conscious effort to set these aside in the analysis (Gummesson 1988). Furthermore, rival conclusions should be considered (Miles & Huberman 1994).

My experience from the first phase of the DnB study was that it was difficult to focus the questions and the analysis of the data when the research questions were too vague and broad. As such, developing a framework before collecting the data for the study was useful in guiding the collection and analysis of data. Nevertheless, it was important to be open-minded and receptive to new and surprising data. In the DnB study, for example, the positive effect of the reorganization process on the integration of cultures came as a complete surprise to me and thus needed further elaboration.

I also consciously searched for negative evidence and problems by interviewing outliers (Miles & Huberman 1994) and asking problem-oriented questions. In Gjensidige, the first interviews with the top management revealed a much more positive perception of the cultural integration process than I had expected. To explore whether this was a result of overreliance on elite informants, I continued posing problem-oriented questions to outliers and people at lower levels in the organization. Moreover, I told them about the DnB study to be explicit about my presuppositions.

Another important issue when assessing objectivity is whether other researchers can trace the interpretations made in the case studies, or what is called intersubjectivity. To deal with this issue, Miles & Huberman (1994) suggest that: (1) the study’s general methods and procedures should be described in detail, (2) one should be able to follow the process of analysis, (3) conclusions should be explicitly linked with exhibits of displayed data, and (4) the data from the study should be made available for reanalysis by others.

In response to these requirements, I described the study’s data collection procedures and processing in detail. Then, the primary data were displayed in the written report in the form of quotations and extracts from documents to support and illustrate the interpretations of the data. Because the study was written up in English, I included the Norwegian text in a separate appendix. Finally, all the primary data from the study were accessible for a small group of distinguished researchers.

Construct Validity

Construct validity refers to whether there is substantial evidence that the theoretical paradigm correctly corresponds to observation (Kirk & Miller 1986). In this form of validity, the issue is the legitimacy of the application of a given concept or theory to established facts.

The strength of qualitative research lies in the flexible and responsive interaction between the interviewer and the respondents (Sykes 1990). Thus, meaning can be probed, topics covered easily from a number of angles, and questions made clear for respondents. This is an advantage for exploring the concepts (construct or theoretical validity) and the relationships between them (internal validity). Similarly, Hakim (1987) says the great strength of qualitative research is the validity of data obtained because individuals are interviewed in sufficient detail for the results to be taken as true, correct, and believable reports of their views and experiences.

Construct validity can be strengthened by applying a longitudinal multicase approach, triangulation, and use of feedback loops. The advantage of applying a longitudinal approach is that one gets the opportunity to test sensitivity of construct measures to the passage of time. Leonard-Barton (1990), for example, found that one of her main constructs, communicability, varied across time and relative to different groups of users. Thus, the longitudinal study aided in defining the construct more precisely. By using more than one case study, one can validate stability of construct across situations (Leonard-Barton 1990). Since my study only consists of two case studies, the opportunity to test stability of constructs across cases is somewhat limited. However, the use of more than one unit of analysis helps to overcome this limitation.

Construct validity is strengthened by the use of multiple sources of evidence to build construct measures, which define the construct and distinguish it from other constructs. These multiple sources of evidence can include multiple viewpoints within and across the data sources. My study responds to these requirements in its sampling of interviewees and uses of multiple data sources.

Use of feedback loops implies returning to interviewees with interpretations and developing theory and actively seeking contradictions in data (Crabtree & Miller 1992; King 1994). In DnB, the written report had to be approved by the bank’s top management after the first data collection. Apart from one minor correction, the bank had no objections to the established facts. In their comments on my analysis, some of the top managers expressed the view that the political process had been overemphasized, and that the CEO’s role in initiating a strategic process was undervalued. Hence, an important objective in the second data collection was to explore these comments further. Moreover, the report was not as positive as the management had hoped for, and negotiations had to be conducted to publish the report. The result of these negotiations was that publication of the report was postponed one-and-a-half years.

The experiences from the first data collection in the DnB had some consequences. I was more cautious and brought up the problems of confidentiality and the need to publish at the outset of the Gjensidige study. Also, I had to struggle to get access to the DnB case for the second data collection and some of the information I asked for was not released. At Gjensidige, I sent a preliminary draft of the case chapter to the corporation’s top management for comments, in addition to having second interviews with a small number of people. Beside testing out the factual description, these sessions gave me the opportunity to test out the theoretical categories established as a result of the within-case analysis.

Internal Validity

Internal validity concerns the validity of the postulated relationships among the concepts. The main problem of internal validity as a criterion in qualitative research is that it is often not open to scrutiny. According to Sykes (1990), the researcher can always provide a plausible account and, with careful editing, may ensure its coherence. Recognition of this problem has led to calls for better documentation of the processes of data collection, the data itself, and the interpretative contribution of the researcher. The discussion of how I met these requirements was outlined in the section on objectivity/subjectivity above.

However, there are some advantages in using qualitative methods, too. First, the flexible and responsive methods of data collection allow cross-checking and amplification of information from individual units as it is generated. Respondents’ opinions and understandings can be thoroughly explored. The internal validity results from strategies that eliminate ambiguity and contradiction, filling in detail and establishing strong connections in data.

Second, the longitudinal study enables one to track cause and effect. Moreover, it can make one aware of intervening variables (Leonard-Barton 1990). Eisenhardt (1989:542) states, “Just as hypothesis testing research an apparent relationship may simply be a spurious correlation or may reflect the impact of some third variable on each of the other two. Therefore, it is important to discover the underlying reasons for why the relationship exists.”

Generalizability

According to Mitchell (1983), case studies are not based on statistical inference. Quite the contrary, the inferring process turns exclusively on the theoretically necessary links among the features in the case study. The validity of the extrapolation depends not on the typicality or representativeness of the case but on the cogency of the theoretical reasoning. Hartley (1994:225) claims, “The detailed knowledge of the organization and especially the knowledge about the processes underlying the behaviour and its context can help to specify the conditions under which behaviour can be expected to occur. In other words, the generalisation is about theoretical propositions not about populations.”

Generalizability is normally based on the assumption that this theory may be useful in making sense of similar persons or situations (Maxwell 1992). One way to increase the generalizability is to apply a multicase approach (Leonard-Barton 1990). The advantage of this approach is that one can replicate the findings from one case study to another. This replication logic is similar to that used on multiple experiments (Yin 1993).

Given the choice of two case studies, the generalizability criterion is not supported in this study. Through the discussion of my choices, I have tried to show that I had to strike a balance between the need for depth and mapping changes over time and the number of cases. In doing so, I deliberately chose to provide a deeper and richer look at each case, allowing the reader to make judgments about the applicability rather than making a case for generalizability.

Reliability

Reliability focuses on whether the process of the study is consistent and reasonably stable over time and across researchers and methods (Miles & Huberman 1994). In the context of qualitative research, reliability is concerned with two questions (Sykes 1990): Could the same study carried out by two researchers produce the same findings? and Could a study be repeated using the same researcher and respondents to yield the same findings?

The problem of reliability in qualitative research is that differences between replicated studies using different researchers are to be expected. However, while it may not be surprising that different researchers generate different findings and reach different conclusions, controlling for reliability may still be relevant. Kirk and Miller’s (1986:311) definition takes into account the particular relationship between the researcher’s orientation, the generation of data, and its interpretation:

For reliability to be calculated, it is incumbent on the scientific investigator to document his or her procedure. This must be accomplished at such a level of abstraction that the loci of decisions internal to the project are made apparent. The curious public deserves to know how the qualitative researcher prepares him or herself for the endeavour, and how the data is collected and analysed.

The study addresses these requirements by discussing my point of departure regarding experience and framework, the sampling and data collection procedures, and data analysis.

Case studies often lack academic rigor and are, as such, regarded as inferior to more rigorous methods where there are more specific guidelines for collecting and analyzing data. These criticisms stress that there is a need to be very explicit about the choices one makes and the need to justify them.

One reason why case studies are criticized may be that researchers disagree about the definition and the purpose of carrying out case studies. Case studies have been regarded as a design (Cook and Campbell 1979), as a qualitative methodology (Cassell and Symon 1994), as a particular data collection procedure (Andersen 1997), and as a research strategy (Yin 1989). Furthermore, the purpose for carrying out case studies is unclear. Some regard case studies as supplements to more rigorous qualitative studies to be carried out in the early stage of the research process; others claim that it can be used for multiple purposes and as a research strategy in its own right (Gummesson 1988; Yin 1989). Given this unclear status, researchers need to be very clear about their interpretation of the case study and the purpose of carrying out the study.

This article has taken Yin’s (1989) definition of the case study as a research strategy as a starting point and argued that the choice of the case study should be guided by the research question(s). In the illustrative study, I used a case study strategy because of a need to explore sensitive, ill-defined concepts in depth, over time, taking into account the context and history of the mergers and the existing knowledge about the phenomenon. However, the choice of a case study strategy extended rather than limited the number of decisions to be made. In Schramm’s (1971, cited in Yin 1989:22–23) words, “The essence of a case study, the central tendency among all types of case study, is that it tries to illuminate a decision or set of decisions, why they were taken, how they were implemented, and with what result.”

Hence, the purpose of this article has been to illustrate the wide range of decisions that need to be made in the context of a particular case study and to discuss the methodological considerations linked to these decisions. I argue that there is a particular need in case studies to be explicit about the methodological choices one makes and that these choices can be best illustrated through a case study of the case study strategy.

As in all case studies, however, there are limitations to the generalizability of using one particular case study for illustrative purposes. As such, the strength of linking the methodological considerations to a specific context and phenomenon also becomes a weakness. However, I would argue that the questions raised in this article are applicable to many case studies, but that the answers are very likely to vary. The design choices are shown in Table 4 . Hence, researchers choosing a longitudinal, comparative case study need to address the same set of questions with regard to design, data collection procedures, and analysis, but they are likely to come up with other conclusions, given their different research questions.

Adler, P. A., and P. Adler. 1994. Observational techniques. In Handbook of qualitative research, edited by N. K. Denzin and Y. S. Lincoln, 377–92. London: Sage.

Andersen, S. S. 1997. Case-studier og generalisering: Forskningsstrategi og design (Case studies and generalization: Research strategy and design). Bergen, Norway: Fagbokforlaget.

Blake, R. R., and J. S. Mounton. 1985. How to achieve integration on the human side of the merger. Organizational Dynamics 13 (3): 41–56.

Bryman, A., and R. G. Burgess. 1999. Qualitative research. London: Sage.

Buono, A. F., and J. L. Bowditch. 1989. The human side of mergers and acquisitions. San Francisco: Jossey-Bass.

Cartwright, S., and C. L. Cooper. 1993. The psychological impact of mergers and acquisitions on the individual: A study of building society managers. Human Relations 46 (3): 327–47.

Cassell, C., and G. Symon, eds. 1994. Qualitative methods in organizational research: A practical guide. London: Sage.

Cook, T. D., and D. T. Campbell. 1979. Quasi experimentation: Design & analysis issues for field settings. Boston: Houghton Mifflin.

Crabtree, B. F., and W. L. Miller. 1992. Primary care research: A multimethod typology and qualitative road map. In Doing qualitative research: Methods for primary care, edited by B. F. Crabtree and W. L. Miller, 3–28. Vol. 3. Thousand Oaks, CA: Sage.

Creswell, J. W. 1998. Qualitative inquiry and research design: Choosing among five traditions. Thousand Oaks, CA: Sage.

Denzin, N. K., and L. S. Lincoln. 2000. Handbook of qualitative research. London: Sage.

Eisenhardt, K. M. 1989. Building theories from case study research. Academy of Management Review 14 (4): 532–50.

Flick, U. 1998. An introduction to qualitative research. London: Sage.

George, A. L. 1979. Case studies and theory development: The method of structured, focused comparison. In Diplomacy: New approaches in history, theory, and policy, edited by P. G. Lauren, 43–68. New York: Free Press.

Gioia, D. A., and K. Chittipeddi. 1991. Sensemaking and sensegiving in strategic change initiation. Strategic Management Journal 12:433–48.

Glaser, B. G., and A. L. Strauss. 1967. The discovery of grounded theory: Strategies for qualitative research. Chicago: Aldine.

Glick, W. H, G. P. Huber, C. C. Miller, D. H. Doty, and K. M. Sutcliffe. 1990. Studying changes in organizational design and effectiveness: Retrospective event histories and periodic assessments. Organization Science 1 (3): 293–312.

Gummesson, E. 1988. Qualitative methods in management research. Lund, Norway: Studentlitteratur, Chartwell-Bratt.

Hakim, C. 1987. Research design. Strategies and choices in the design of social research. Boston: Unwin Hyman.

Hamel, J., S. Dufour, and D. Fortin. 1993. Case study methods. London: Sage.

Hartley, J. F. 1994. Case studies in organizational research. In Qualitative methods in organizational research: A practical guide, edited by C. Cassell and G. Symon, 209–29. London: Sage.

Haspeslaph, P., and D. B. Jemison. 1991. The challenge of renewal through acquisitions. Planning Review 19 (2): 27–32.

King, N. 1994. The qualitative research interview. In Qualitative methods in organizational research: A practical guide, edited by C. Cassell and G. Symon, 14–36. London: Sage.

Kirk, J., and M. L. Miller. 1986. Reliability and validity in qualitative research. Qualitative Research Methods Series 1. London: Sage.

Leonard-Barton, D. 1990.Adual methodology for case studies: Synergistic use of a longitudinal single site with replicated multiple sites. Organization Science 1 (3): 248–66.

Marshall, C., and G. B. Rossman. 1999. Designing qualitative research. London: Sage.

Maxwell, J. A. 1992. Understanding and validity in qualitative research. Harvard Educational Review 62 (3): 279–99.

Miles, M. B., and A. M. Huberman. 1994. Qualitative data analysis. 2d ed. London: Sage.

Mitchell, J. C. 1983. Case and situation analysis. Sociology Review 51 (2): 187–211.

Nachmias, C., and D. Nachmias. 1981. Research methods in the social sciences. London: Edward Arnhold.

Pettigrew, A. M. 1990. Longitudinal field research on change: Theory and practice. Organization Science 1 (3): 267–92.

___. (1992). The character and significance of strategic process research. Strategic Management Journal 13:5–16.

Rossman, G. B., and S. F. Rallis. 1998. Learning in the field: An introduction to qualitative research. Thousand Oaks, CA: Sage.

Schramm, W. 1971. Notes on case studies for instructional media projects. Working paper for Academy of Educational Development, Washington DC.

Schweiger, D. M., and J. P. Walsh. 1990. Mergers and acquisitions: An interdisciplinary view. In Research in personnel and human resource management, edited by G. R. Ferris and K. M. Rowland, 41–107. Greenwich, CT: JAI.

Silverman, D. 2000. Doing qualitative research: A practical handbook. London: Sage.

Stake, R. E. 1995. The art of case study research. London: Sage.

Strauss, A. L., and J. Corbin. 1990. Basics of qualitative research: Grounded theory procedures and techniques. Newbury Park, CA: Sage.

Sykes, W. 1990. Validity and reliability in qualitative market research: A review of the literature. Journal of the Market Research Society 32 (3): 289–328.

Waddington, D. 1994. Participant observation. In Qualitative methods in organizational research, edited by C. Cassell and G. Symon, 107–22. London: Sage.

Yin, R. K. 1989. Case study research: Design and methods. Applied Social Research Series, Vol. 5. London: Sage.

___. 1993. Applications of case study research. Applied Social Research Series, Vol. 34. London: Sage.

Christine Benedichte Meyer is an associate professor in the Department of Strategy and Management in the Norwegian School of Economics and Business Administration, Bergen-Sandviken, Norway. Her research interests are mergers and acquisitions, strategic change, and qualitative research. Recent publications include: “Allocation Processes in Mergers and Acquisitions: An Organisational Justice Perspective” (British Journal of Management 2001) and “Motives for Acquisitions in the Norwegian Financial Industry” (CEMS Business Review 1997).

Rights and permissions

Reprints and permissions

Copyright information

About this chapter

White, R.E., Cooper, K. (2022). Case Study Research. In: Qualitative Research in the Post-Modern Era. Springer, Cham. https://doi.org/10.1007/978-3-030-85124-8_7

Download citation

DOI : https://doi.org/10.1007/978-3-030-85124-8_7

Published : 29 September 2022

Publisher Name : Springer, Cham

Print ISBN : 978-3-030-85126-2

Online ISBN : 978-3-030-85124-8

eBook Packages : Education Education (R0)

Share this chapter

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

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

Provided by the Springer Nature SharedIt content-sharing initiative

Publish with us

Policies and ethics

Find a journal
Track your research

Open access
Published: 02 April 2024

Towards universal health coverage in Vietnam: a mixed-method case study of enrolling people with tuberculosis into social health insurance

Rachel Forse ORCID: orcid.org/0000-0002-0716-3342 1 , 2 ,
Clara Akie Yoshino 2 ,
Thanh Thi Nguyen 1 ,
Thi Hoang Yen Phan 3 ,
Luan N. Q. Vo 1 , 2 ,
Andrew J. Codlin 1 , 2 ,
Lan Nguyen 4 ,
Chi Hoang 4 ,
Lopa Basu 5 ,
Minh Pham 5 ,
Hoa Binh Nguyen 6 ,
Luong Van Dinh 6 ,
Maxine Caws 7 , 8 ,
Tom Wingfield 2 , 7 ,
Knut Lönnroth 2 &
Kristi Sidney-Annerstedt 2

Health Research Policy and Systems volume 22 , Article number: 40 ( 2024 ) Cite this article

93 Accesses

4 Altmetric

Metrics details

Vietnam’s primary mechanism of achieving sustainable funding for universal health coverage (UHC) and financial protection has been through its social health insurance (SHI) scheme. Steady progress towards access has been made and by 2020, over 90% of the population were enrolled in SHI. In 2022, as part of a larger transition towards the increased domestic financing of healthcare, tuberculosis (TB) services were integrated into SHI. This change required people with TB to use SHI for treatment at district-level facilities or to pay out of pocket for services. This study was conducted in preparation for this transition. It aimed to understand more about uninsured people with TB, assess the feasibility of enrolling them into SHI, and identify the barriers they faced in this process.

A mixed-method case study was conducted using a convergent parallel design between November 2018 and January 2022 in ten districts of Hanoi and Ho Chi Minh City, Vietnam. Quantitative data were collected through a pilot intervention that aimed to facilitate SHI enrollment for uninsured individuals with TB. Descriptive statistics were calculated. Qualitative interviews were conducted with 34 participants, who were purposively sampled for maximum variation. Qualitative data were analyzed through an inductive approach and themes were identified through framework analysis. Quantitative and qualitative data sources were triangulated.

We attempted to enroll 115 uninsured people with TB into SHI; 76.5% were able to enroll. On average, it took 34.5 days to obtain a SHI card and it cost USD 66 per household. The themes indicated that a lack of knowledge, high costs for annual premiums, and the household-based registration requirement were barriers to SHI enrollment. Participants indicated that alternative enrolment mechanisms and greater procedural flexibility, particularly for undocumented people, is required to achieve full population coverage with SHI in urban centers.

Conclusions

Significant addressable barriers to SHI enrolment for people affected by TB were identified. A quarter of individuals remained unable to enroll after receiving enhanced support due to lack of required documentation. The experience gained during this health financing transition is relevant for other middle-income countries as they address the provision of financial protection for the treatment of infectious diseases.

Peer Review reports

Contributing to universal health coverage (UHC) by improving access to fair and sustainable health financing, of which one mechanism is health insurance, has become a priority among low- and middle-income countries [ 1 , 2 ]. Many countries in the Asia Pacific region have made steady progress towards UHC coverage through sustained political commitments and fiscal policy aligned with their commitment [ 3 ]. By 2020, 27 countries had implemented a social health insurance (SHI) financing mechanism, which typically includes open enrollment for the full population along with partial or full subsidization of healthcare costs for vulnerable groups [ 4 ].

Vietnam’s first SHI scheme was piloted in 1989 and grew through successive pilots and expansions. In 2009 the national-level Health Insurance Law (HIL) went into effect, uniting the existing health insurance programs and schemes for the poor [ 5 ]. Amendments to the HIL effective in 2015 made SHI compulsory for all and pooled risk by re-structuring registration around the household unit [ 4 ]. A household in Vietnam is defined by inclusion in the ‘family book ’, the national system of family and address registration [ 6 ].

Access to SHI in Vietnam increased rapidly, principally through subsidization of premiums. Specific groups were enrolled automatically with full subsidy, including vulnerable populations (e.g., households classified as ‘poor’, children aged < 6, people aged > 80), pensioners and meritorious groups (e.g., veterans). Partial premium subsidization was also available for students, households classified as ‘near-poor’ and some farmers [ 7 ]. More than half of SHI members are entitled to 80% coverage with a 20% co-payment for services [ 8 ]. However, co-payments are reduced to 5% or are eliminated for subsidized groups (e.g., households classified as ‘poor’ and ‘near-poor’, children < 6) [ 4 ].

By 2020, Vietnam recorded a 91% national SHI coverage rate [ 7 ]. Those remaining uninsured mainly consisted of informally employed individuals [ 7 ]. Enrollment rates were highest among low- and high-income groups, leaving the so-called “missing middle” of uninsured [ 5 ].

Vietnam continues to transition to domestic financing of healthcare from donor financing by expanding the breadth of the national SHI. The Ministry of Health and Vietnam Social Security (VSS) have begun to close service gaps and integrate vertical health programs (e.g., those with stand-alone budget allocations and/or direct donor financing) into SHI financing [ 7 ]. The costs for antiretroviral therapy (ART) were transitioned from donor funding to SHI in 2019 [ 9 ], COVID-19 treatments were covered by SHI in 2020, and financing for tuberculosis (TB) care was fully transitioned to SHI in 2022 [ 7 ].

Until this financing transition, anti-TB medications and consultations were provided free of charge in the public sector, funded by a mixture of domestic and international funding [ 10 ]. While first-line TB medications were included in the SHI-reimbursable list of essential medicines, the government network of District TB Units (DTUs) were ineligible for registration with VSS, or reimbursement for services provided. Since July 2022, TB health facilities that met certain conditions could register with VSS and receive reimbursements for TB consultations, diagnostics and anti-TB medications [ 11 ]. The financing for drug-resistant (DR-)TB tests and medications remains largely unchanged, co-financed by the Global Fund and domestic budgets [ 12 ].

This transition of the TB financing model in Vietnam is a large undertaking as the country has the world’s 10th highest TB burden and the SHI benefits package is already considered to be generous, and the sustainability of the SHI fund is a concern [ 4 , 13 ] An estimated 169,000 individuals developed TB in 2021, and the disease killed approximately 14,200 [ 14 ]. A national costing survey of TB-affected households showed that 63% experienced catastrophic costs, spending ≥ 20% of their annual income on TB [ 10 ]. Many face food insecurity and cope with TB-related costs by taking loans, dissavings and informally borrowing money [ 10 , 15 , 16 ].

As Vietnam continues to expand SHI financing for the TB program, it is now vital for people with TB to have SHI. Those without SHI coverage will need to finance their care out of pocket (OOP) or purchase SHI and make co-payments for their care to be subsidized. For these reasons, it is important to understand why certain people with TB are uninsured, the feasibility of enrolling them in insurance when they begin treatment, and the challenges they may face with enrolling in SHI.

We conducted a convergent parallel mixed-method case study [ 17 ]. A case study was selected because it is well-suited to describe a complex issue in a real-life setting [ 18 ]. We used a naturalistic design with theoretical sampling of uninsured persons with TB using an interpretivist approach [ 19 ]. Mixed methods were selected to facilitate comparisons between quantitative and qualitative data and interpretation of the findings. An intervention, assisting TB-affected households to enroll in SHI, was conducted between November 2019 and January 2022, prior to the integration of the TB program into the SHI financing scheme. Quantitative data collection sought to answer questions regarding enrollment success rate, time to enrollment and cost of SHI enrollment for uninsured TB-affected households upon TB treatment initiation. The qualitative data explored barriers to SHI enrollment to explain and contextualize the quantitative findings. The quantitative and qualitative data were weighted equally [ 17 ].

Intervention description

A pilot intervention was conducted to facilitate SHI enrollment for people with TB in ten districts of Ha Noi and Ho Chi Minh City (HCMC). The standard process for first-time enrollment into SHI was mapped and costed from a household’s perspective (Additional file 1 ). Uninsured individuals were identified from the TB treatment register when they were enrolled in drug-susceptible (DS-)TB treatment at DTUs [ 20 ]. Study staff then attempted to facilitate enrollment of the person with TB and up to three household members into SHI.

SHI enrollment support included home visits by study staff to provide detailed information and counseling about the process of SHI enrollment, assistance with SHI application preparation including obtaining photocopies of all required documents, follow-up to obtain missing documentation within the household, accompaniment to the SHI office for application submission, and direct payment of the annual SHI premium for the household. For people who did not have the paperwork certifying temporary residence in Hanoi or Ho Chi Minh City, staff visited the local government office to obtain the information about the process for individual cases to obtain residency certificates and support participants with navigation of the bureaucracy. TB-affected people and their household members were also provided with a hotline number to call and receive support during working hours from the social workers who were employed by the study. Study staff attempted to facilitate the SHI enrollment process throughout the entire 6-month duration of DS-TB treatment. After a TB treatment outcome was recorded by the DTU, study staff stopped assisting with SHI enrollment and participants were recorded as ‘not enrolled in SHI’ in the study’s evaluation.

Quantitative methods

Case-level TB treatment notification data and SHI status were exported from VITIMES, the government-implemented electronic TB register for Vietnam, for all individuals who started TB treatment during the intervention period. The pilot intervention recruited participants from two TB treatment support projects (Project 1, n = 59 and Project 2, n = 56) [ 21 , 22 ] and tracked study forms housed in ONA.io. The sample size was determined by the availability of funding provided by the donor for treatment support service delivery, rather than to measure a specific end point of SHI enrollment. Descriptive statistics summarizing the enrollment cascade and turnaround time of enrollment were calculated using Stata v17 (Stata17 Corp, College Station, USA). To obtain the mean costs for household SHI enrollment, total direct costs for purchasing SHI were summed and divided by the total number of participants. Costs were captured in Vietnamese Dong (VND) and converted to United States Dollars (USD) using the exchange rate from the mid-point of the pilot intervention (1 June 2020) from OANDA.com.

Qualitative methods

Individuals were purposively sampled for maximum variation to ensure representation of all implementation areas and provide gender balance [ 23 ].The concept of information power guided the sample size [ 24 ]. Given the well-defined study aim, high quality in-depth responses from the participants and the authors’ expertise in the subject area, the sample size of 19 individual interviews and three focus group discussions was deemed appropriate. These were conducted in Ha Noi and HCMC. A total of 34 individuals participated in the interviews (Table 1 ).

They included 14 people enrolled in the pilot intervention, five community members who were non-beneficiaries of the treatment support intervention, 13 TB program staff from the national-, provincial- and district-levels and two study staff. Interviews were conducted at two time points: June 2019 and 2020. SHI enrollment barriers were collected as part of a qualitative study on the acceptability of providing cash transfers and SHI enrollment to adults with TB [ 25 ]. During the second round of interviews in 2020, study staff were included due to their in-depth knowledge of the challenges faced by TB-affected households when attempting to enroll in SHI and their ability to suggest programmatic-level solutions to these challenges. These interviews were conducted one-on-one, after the other interviews and focus groups had been conducted to reduce bias. The interviews were conducted at the National Lung Hospital, HCMC Provincial Lung Hospital, study office or DTUs. All interviews were conducted and transcribed in Vietnamese, translated into English, checked and finalized by a lead translator.

The interviews were analyzed through an inductive approach and themes were drawn through a framework analysis [ 26 ] to identify barriers to enrolling in SHI using Dedoose Version 7.0.23 (SocioCultural Research Consultants, Los Angeles, USA).

Data triangulation

Quantitative and qualitative data were collected in parallel. Triangulation of quantitative and qualitative data was conducted to synthesize findings and assess the level of agreement, convergence, and divergence from the findings generated by the different methods [ 17 ].

During the study, 5887 individuals were treated for DS-TB across the 10 intervention districts (Table 2 ). TB registers indicated that 2846 (48.3%) individuals were uninsured upon treatment initiation, or their SHI enrollment status was not recorded. Among 115 uninsured study participants, 88 (76.5%) were successfully enrolled in SHI before the end of their TB treatment. Among those, the household had an average of two members, resulting in a total of 206 individuals living in TB-affected households receiving SHI coverage through the pilot intervention.

The median time between DS-TB treatment initiation and SHI card issuance was 34.5 days (IQR 24–68): 11 days (IQR 5–23) between treatment initiation and pilot enrollment, 7 days (IQR 1–19.5) for SHI application preparation and submission, and 12 days (IQR 9–20) for application processing and SHI card provision.

The qualitative data showed that participants across all participant groups broadly understood that SHI is a system designed to prevent catastrophic OOP medical expenditure. As shown in Table 3 , National and provincial-level TB staff described SHI as a human right and spoke about achieving UHC as a nation; no other participant groups discussed SHI in this way. However, district-level doctors and intervention beneficiaries spoke in greater details about coverage and service gaps, and the practicalities of utilizing SHI. These participant groups expressed that when individuals purchase SHI only after a negative health event, such as a TB diagnosis, then the social safety net is unavailable to provide support until SHI coverage begins. Drawn from these views, the first theme indicated that the optimal time to purchase SHI is prior to a TB diagnosis.

One DTU staff member described how the standard processing time, or delays in processing SHI applications led to periods of high OOP expenditure:

“Unfortunately, claims are not immediately paid upon [SHI registration] submission. They may be handled in about 2 or 3 weeks, or even one month. That is why the insurance is not available at the time that they want to go for an examination and treat their condition using insurance.” (Female, District-level TB staff)

A complementary theme was that perceived lack of knowledge about SHI enrollment procedures prevents or delays enrollment. District-level TB doctors and program staff identified a lack of understanding and knowledge of the SHI enrollment process as a main contributor to lack of insurance or delays in obtaining coverage.

“Actually, for some people [with TB] who do not clearly understand the [enrollment] procedures… it will take a lot of time [to obtain SHI]. It also depends on the staff who handle the files at the commune; some staff are very enthusiastic and they help patients complete forms. There are cases [...] where they [people with TB] are required to fill in all information and write specific codes of each insurance card [from other family members] on a form. Meanwhile some people in their family work far from home and cannot send their insurance cards home in a timely manner.” (Female, program staff)

Participants tended to believe that individuals who lacked information about SHI made up the small minority of uninsured people in Vietnamese society. The above quote illustrated that the complicated administrative process prohibits enrollment; however, a factor potentially facilitating SHI enrollment may be the helpfulness of the person processing the SHI application.

The average cost per household to obtain SHI enrollment for one year (Table 2 ) was VND 1,503,313 (USD 65.52). (For detailed information on the costs of SHI enrollment, see Additional file 1 ). A third theme contextualized this finding and showed that SHI enrollment costs were perceived as prohibitively high for some. Cost was a greater challenge for lower income families, who did not meet the government’s criterion of households classified as ‘poor’ or ‘near-poor’, and were therefore ineligible for premium subsidies and SHI registration with lower co-payment rates. One DTU doctor reported that:

“We think that it is simple to buy health insurance cards, but that is only true for those who have sustainable income - when our income is much higher than the fee for buying health insurance. For some people, buying health insurance is a luxury.” (Male, District-level TB staff)

Twenty-seven people with TB (23.5%) were unable to obtain SHI coverage. The primary reason (70.4%) was missing documentation. In four instances (14.8%) a household member other than the person with TB refused to enroll in SHI. One individual (3.7%) died during the enrollment process. Three individuals (11.1%) did not enroll for other reasons.

SHI refusal by household members was not identified as a barrier to SHI enrollment in the qualitative data. However, a fourth theme confirmed the primary reason for non-enrollment by showing that some individuals do not possess the required documentation to obtain SHI, such as their identity card or ‘family book.’ [See Supplementary File] Even with six months of support from study staff, some TB-affected households were unable to gather the required documents for enrollment. The following quotation by an undocumented, elderly woman with TB illustrates the prolonged challenges she faced with obtaining formal employment, access to government services and SHI:

“I have had problems with my personal papers for a few decades and I cannot adjust my papers because I don’t have the money. […] I searched for my Identity Card and found out that I had lost it. Then I came back there [my hometown] to get the family book, to reissue my ID and to get my CV certified so I could join a company. I was very young at that time, just a little bit more than thirty years old, and I learned that I was cut from the family book.” (Female, pilot beneficiary)

To address challenges with documentation, one DTU officer in HCMC suggested that individuals who had never been insured required a change to the SHI registration requirements to ensure that everyone in Vietnam can access SHI:

“I think we should be flexible with these cases or we can find another way. Normally, the people who really need the support and the insurance or cash support, they are the people who have less information. […] We cannot have the same requirements for these people as for other people. Actually, for those who have [met] all conditions, they already have health insurance cards.” (Male, District-level TB staff)

Participants expressed that the uninsured had often not purchased SHI for a reason, and alternative registration procedures were needed to make SHI accessible for all. A fifth theme was identified indicating that current SHI enrollment procedures may prevent full population coverage.

Beyond the undocumented, some participants reported the enrollment mandate for the entire household (made under the Amendment to the HIL) for first-time enrollees was viewed as prohibitive of SHI coverage.

“Because in the old days, health insurance was sold individually for each person, but now it is sold to households, and many households do not have as good economic [situation]… so they can only afford to buy it for 50% or 60% of the household. Unskilled labor or low-income labor cannot afford to buy it for the whole family. That is to say, it is easier to buy it for each individual and it is difficult to buy for the whole family.” (Male, community member)

Though individual registration would make SHI more accessible to individuals with TB due to lower annual costs, household members with high vulnerability to TB would not be covered if policy promoted individual enrollment solely for TB.

This mixed-methods case study showed that by providing full subsidy and registration assistance, most uninsured people with TB could access SHI. However, the median time to insurance coverage meant that approximately 20% of a person’s DS-TB treatment duration remained uncovered by SHI despite successful enrollment. A substantial number of participants were unable to enroll in SHI and are likely to be perpetually locked out of SHI due to lack of personal documentation. Additional barriers to SHI enrollment were found to be lack of knowledge, the cost of obtaining coverage, and the household-based registration requirement.

The pilot intervention had dedicated staff who facilitated SHI application development and submission, yet it still took a median of 34.5 days for SHI coverage to take effect. In a context where this level of support is not available to all people with TB, it is likely that the turnaround time for SHI coverage is longer due to the complicated bureaucracy involved. This poses a major challenge, as TB-affected households incur the highest cost during the first two months of treatment [ 15 ]. One cost avoidance/mitigation strategy that people with a TB diagnosis may employ following the health financing transition is delaying TB treatment initiation until SHI coverage commences. This will likely lead to worse outcomes and sustained community transmission. The time between diagnosis and treatment should be rigorously monitored to ensure that this coping strategy is not employed, and alternative support should be made available to ensure that people diagnosed with TB are able to receive immediate treatment.

With the TB health financing transition, the uninsured will be asked to pay OOP for TB treatment and most insured individuals must co-pay for TB services which were previously provided free of cost. A national patient cost survey in 2018 found that 63% of TB-affected households experienced catastrophic costs under the previous health financing model [ 10 ]. There is a risk that the proportion of TB-affected households experiencing catastrophic costs could increase with the introduction of fees. This was not found to be the case for people living with HIV (PLHIV) when the costs of ART transitioned to SHI in Vietnam, but a new nationally representative TB costing survey is needed to assess this risk [ 9 ]. Several domestic solutions could ameliorate these challenges. As suggested for the Indian context, domestic revenues allocated by the Ministry of Finance to VSS could be increased to better support TB care [ 27 ]. VSS could also reclassify the category of TB disease and thus ensure that SHI paid for all diagnostics and drugs associated with TB treatment, without the need for a co-payment. A mid-term review of the Global Fund program in Vietnam has also called for a SHI package specifically designed to cover the OOP medical costs of TB care [ 28 ]. There are several potential mechanisms to prevent costs from falling on TB-affected households. A deeper investigation is needed to understand the fiscal space available within the Vietnamese government to cover such costs.

This case study showed that 23.5% of the uninsured people with TB were never able to enroll for the duration of their treatment, primarily due to lack of documentation. Specific provisions need to be made for the undocumented to receive free TB diagnosis, consultations, and medications through routine practice of the TB program. Multi- and bi-lateral funding mechanisms can also play a role in filling gaps by paying for TB tests for the uninsured, purchasing SHI for those diagnosed with TB, subsidizing or reimbursing OOP expenditure in the period before SHI coverage takes effect, and fully financing TB care for the undocumented. Furthermore, longer-term health system strengthening initiatives, such as creating a legal mechanism for the undocumented to obtain SHI, are likely needed to address the challenges faced by the 9% of the general population that remain uninsured. The ILO has called for “determining new strategies, which may include extension of state budget-funded subsidies to further support the participation of workers in the informal economy [ 7 ].” These forms of inclusive initiatives would solve the TB-specific challenges identified in this study and have a large positive impact on society.

We found that addressing the cost of SHI premiums and knowledge gaps in the enrollment procedures may improve SHI coverage. These findings mirror those following the transition of HIV financing to SHI in 2017. A study among PLHIV identified burdensome processes, lack of information about SHI registration procedures, and high SHI premium costs for a household as key barriers to SHI coverage [ 29 ]. However, a cluster randomized control trial which provided education, a 25% premium subsidy, or both to uninsured households found that these interventions had limited effects on SHI enrollment. Yet, “less healthy” individuals had higher SHI enrollment rates [ 30 ]. This suggests that people who have just received a TB diagnosis could be more receptive to interventions promoting SHI enrollment through premium subsidization and education. Vietnam’s National TB Program (NTP) has established a fund to subsidize SHI enrollment costs for TB-affected individuals. The size of the fund could be increased with additional support while access to the fund and the procedures for receiving support could be optimized [ 31 ]. Given the SHI transition, the NTP should also consider providing educational materials about the SHI enrollment process through the DTU network to uninsured persons with TB.

TB registers indicated that 52% of people starting TB treatment in the urban intervention districts had recorded SHI coverage. This rate is lower than other recent SHI coverage reports. A 2018–2022 DS-TB costing survey reported a SHI coverage of 70% [ 32 ], while in a DR-TB costing survey (2020–2022) it was 85% [ 16 ]. All available data sources indicate that SHI coverage among people with TB is lower than the general population, which is indicative of their socioeconomic vulnerability [ 33 ]. However, this large SHI coverage rate discrepancy may be explained by people with TB not revealing they had SHI coverage, or DTU staff could have also inconsistently recorded an individual’s SHI status in the paper TB registers since these data did not have much clinical relevance for TB treatment at the time. Now that DTUs receive financial reimbursements for the TB services from VSS, SHI coverage rates in treatment registers are likely to increase. Further research should be conducted to understand the national SHI coverage rate for people receiving TB treatment, along with the risk factors associated with being uninsured.

Limitations

This case study was conducted in the two largest cities of Vietnam and findings may not be representative of the entire country. Quantitative data were collected in a programmatic setting, and SHI coverage data for all individuals initiating TB treatment in the intervention areas appear to be underreported for reasons described above. Lastly, we were unable to collect SHI enrollment data from a control population, either prospectively during the pilot intervention or retrospectively during the pilot evaluation. As a result, we do not have information on the enrollment status or time to obtain SHI coverage among a population that did not receive assistance from the pilot intervention. However, given the substantial additional support provided by study staff for the enrollment process, we believe it is safe to assume that if left alone, TB-affected households would be slower in the enrollment process and likely enroll in lower rates.

Vietnam is viewed as a leader among Southeast Asian nations in its commitment and progress towards UHC. This mixed-methods case study illustrated the progress that Vietnam has made in its path to greater domestic financing of healthcare through SHI. This study is one of the first to examine the integration of TB services into SHI in Vietnam and define the challenges that people with TB face while attempting to gain access to financial protection after receiving a TB diagnosis. In order to make strides towards UHC in Vietnam and to close population coverage gaps, initiatives are required to specifically address the barriers faced by the uninsured. This study found that the majority of the uninsured were able to gain access to SHI through full subsidization of premiums, enrollment assistance and education. However, initiating TB care and SHI enrollment concomitantly left a significant portion of the 6-month TB treatment duration without financial protection. Additionally, a quarter of the uninsured with TB were unable to gain access to SHI during treatment, primarily due to a lack of documentation. There is great need for official mechanisms to be in place that enable those without sufficient state documents to access the TB program and to address the time-sensitive nature of providing effective financial protection during treatment of an infectious disease. These findings are relevant for other high TB burden, middle-income countries who are on a similar pathway for transitioning away from donor-financed TB programs to ones supported with a higher proportion of domestic resources.

Availability of data and materials

The quantitative dataset used and analyzed during the current study are available from the corresponding author on reasonable request. Seven anonymized transcripts of interviews with the people enrolled in the pilot intervention and non-beneficiaries have been uploaded to the following URL: https://doi.org/ https://doi.org/10.5281/zenodo.7736220 .

Abbreviations

Anti antiretroviral therapy

Drug resistant tuberculosis

Drug susceptible tuberculosis

District TB Unit

Ho Chi Minh City

Health Insurance Law

Human immunodeficiency virus

International Labour Organization

Interquartile range

National Tuberculosis Program

Out of pocket

People Living with HIV

Social Health Insurance

Tuberculosis

Universal Health Coverage

United States Dollar

Vietnamese Dong

Vietnam Social Security

World health statistics 2023: monitoring health for the SDGs, sustainable development goals. https://www.who.int/publications-detail-redirect/9789240074323 . Accessed 31 May 2023.

SDG Target 3.8 | Achieve universal health coverage, including financial risk protection, access to quality essential health-care services and access to safe, effective, quality and affordable essential medicines and vaccines for all. https://www.who.int/data/gho/data/themes/topics/indicator-groups/indicator-group-details/GHO/sdg-target-3.8-achieve-universal-health-coverage-(uhc)-including-financial-risk-protection . Accessed 29 May 2023.

Hondo D, Kim Y. Achieving universal health coverage in developing Asia and the Pacific. Asian Development Bank Institute; 2023. Report No.: 2023-15 (November). https://doi.org/10.56506/VUWA5043 . Accessed 1 Feb 2024.

Le QN, Blizzard L, Si L, Giang LT, Neil AL. The evolution of social health insurance in Vietnam and its role towards achieving universal health coverage. Health Policy OPEN. 2020;100011. http://www.sciencedirect.com/science/article/pii/S2590229620300095 . Accessed 10 Sep 2023.

Somanathan A, Tandon A, Dao HL, Hurt KL, Fuenzalida-Puelma HL. Moving toward universal coverage of social health insurance in Vietnam: assessments and options. Washington, DC: World Bank; 2014, p. 177. (Directions in Development). https://doi.org/10.1596/978-1-4648-0261-4

Hardy A. Rules and resources: negotiating the household registration system in Vietnam under reform. Sojourn J Soc Issues Southeast Asia. 2001;16(2):187–212.

Article CAS Google Scholar

Bales S, Phe Goursat M, Phuong NK. Extending social health protection in Viet Nam: accelerating progress towards universal health coverage. International Labour Organization; 2021, p. 1–14. (Social Protection in action: building social protection floors for all.). https://www.social-protection.org/gimi/gess/ShowRessource.action;jsessionid=iFmxgS-hSrmJjf_1uG90JAnijskVEc8XJD9-4lubAqbFD4-JPYOm!341651707?id=57668 . Accessed 26 Aug 2022.

Bao Hiem Xa Hoi [Vietnam Social Security]. 2019. Phát triển bền vững BHYT toàn dân [Sustainable development of universal health insurance]. https://baohiemxahoi.gov.vn/congkhai/Pages/so-lieu-thong-ke-nganh.aspx?CateID=130&ItemID=12916 . Accessed 26 Aug 2022.

Vu LTH, Johns B, Bui QTT, Duong Thuy A, Nguyen Thi D, Nguyen Thi H, et al. Moving to social health insurance financing and payment for HIV/AIDS treatment in Vietnam. Health Serves Insights. 2021;14:1178632920988843. https://doi.org/10.1177/1178632920988843 .

Article Google Scholar

Nhung NV, Hoa NB, Anh NT, Anh LTN, Siroka A, Lonnroth K, et al. Measuring catastrophic costs due to tuberculosis in Viet Nam. Int J Tuberc Lung Dis. 2018;22(9):983–90.

Article CAS PubMed Google Scholar

Tran VT. Circular No. 36/2021/TT-BYT dated December 31, 2021 on Medical examination and treatment, and payment for medical examination and treatment costs covered by health insurance relating to tuberculosis examination and treatment. 36/2021/TT-BYT Dec 31, 2021. https://hethongphapluat.com/circular-no-36-2021-tt-byt-dated-december-31-2021-on-medical-examination-and-treatment-and-payment-for-medical-examination-and-treatment-costs-covered-by-health-insurance-relating-to-tuberculosis-examination-and-treatment.html .

The Global Fund. Country Profiles Tuberculosis- 2022- Viet Nam. The Global Fund; 2023. https://data.theglobalfund.org/location/VNM/documents . Accessed 30 May 2023.

Nguyen Thi Thu Cúc. Socialist Republic of Viet Nam: strengthening the policy and institutional framework of social health insurance. Hanoi, Vietnam: Asian Development Bank; 2021, p. 1–27. Report No.: 50139–002. https://www.adb.org/projects/documents/vie-50139-002-tacr-4 . Accessed 26 Aug 2022.

Global tuberculosis report 2022. Geneva: World Health Organization; 2022. Licence: CC BY-NC-SA 3.0 IGO. https://www.who.int/publications-detail-redirect/9789240061729 .

Vo LNQ, Forse RJ, Codlin AJ, Dang HM, Van Truong V, Nguyen LH, et al. Socio-protective effects of active case finding on catastrophic costs from tuberculosis in Ho Chi Minh City, Viet Nam: a longitudinal patient cost survey. BMC Health Serv Res. 2021;21(1):1051. https://doi.org/10.1186/s12913-021-06984-2 .

Article PubMed PubMed Central Google Scholar

Pham TAM, Forse R, Codlin AJ, Phan THY, Nguyen TT, Nguyen N, et al. Determinants of catastrophic costs among households affected by multi-drug resistant tuberculosis in Ho Chi Minh City, Viet Nam: a prospective cohort study. BMC Public Health. 2023;23(1):2372. https://doi.org/10.1186/s12889-023-17078-5 .

Creswell JW, Clark Plano VL. Designing and conducting mixed methods research. 3rd ed. Thousand Oaks, California: SAGE Publications; 2017. p. 520.

Google Scholar

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

Crowe S, Cresswell K, Robertson A, Huby G, Avery A, Sheikh A. The case study approach. BMC Med Res Methodol. 2011;11(1):100. https://doi.org/10.1186/1471-2288-11-100 .

Thai LH, Nhat LM, Shah N, Lyss S, Ackers M. Sensitivity, completeness and agreement of the tuberculosis electronic system in Ho Chi Minh City. Viet Nam Public Health Act. 2017;7(4):294–8.

IMPACT TB Overview | IMPACT TB. https://impacttbproject.org/impact-tb-overview/ . Accessed 2 Jun 2023.

Fact Sheet: USAID Erase TB Project 2020. 2020. https://www.usaid.gov/vietnam/documents/fact-sheet-erase-tb-project . Accessed 24 Sep 2024.

Palinkas LA, Horwitz SM, Green CA, Wisdom JP, Duan N, Hoagwood K. Purposeful sampling for qualitative data collection and analysis in mixed method implementation research. Adm Policy Ment Health. 2015;42(5):533–44. https://doi.org/10.1007/s10488-013-0528-y .

Malterud K, Siersma VD, Guassora AD. Sample size in qualitative interview studies: guided by information power. Qual Health Res. 2016;26(13):1753–60. https://doi.org/10.1177/1049732315617444 .

Article PubMed Google Scholar

Forse R, Nguyen TT, Dam T, Vo LNQ, Codlin AJ, Caws M, et al. A qualitative assessment on the acceptability of providing cash transfers and social health insurance for tuberculosis-affected families in Ho Chi Minh City, Vietnam. PLOS Glob Public Health. 2023;3(12): e0002439.

Ritchie J, Lewis J, Nicholls CM, Ormston R. Qualitative research practice: a guide for social science students and researchers. Second edn. SAGE Publications Ltd; 2013. p. 456.

Behera DK, Dash U, Sahu SK. Exploring the possible sources of fiscal space for health in India: insights from political regimes. Health Res Policy Syst. 2022;20(1):32. https://doi.org/10.1186/s12961-022-00831-4 .

Draft Report: Key Messages from the TB National Strategic Plan Mid Term Review (MTR) for Vietnam, between 8th to 18th January 2023. Hanoi, Vietnam: Vietnam’s National TB Program; 2023 Jan p. 1.

Matsumoto S, Nguyen HDT, Nguyen DT, Van Tran G, Tanuma J, Mizushima D, et al. The patient voice: a survey of worries and anxieties during health system transition in HIV services in Vietnam. BMC Int Health Hum Rights. 2020;20:1.

Wagstaff A, Nguyen HTH, Dao H, Bales S. Encouraging health insurance for the informal sector: a cluster randomized experiment in Vietnam. Health Econ. 2016;25(6):663–74. https://doi.org/10.1002/hec.3293 .

Hoa NB, Nhung NV. National tuberculosis patients cost survey: research findings lead to change in policy and practice. Viet Nam Public Health Act. 2019;9(2):50–2.

Wiemers A, Sidney-Annerstedt K, Forse R, Phan THY, Codlin A, Vo LNQ, et al. EP-13-729 COVID-19 lockdowns resulting in household income decline for people with TB in Ho Chi Minh City: interrupted time series analysis of household income changes. In: Proceedings of the union world conference on lung health 2022. Virtual event, 8–11 November 2022: the international journal of tuberculosis and lung disease (IJTLD); 2022. p. 191.

Lönnroth K, Jaramillo E, Williams BG, Dye C, Raviglione M. Drivers of tuberculosis epidemics: the role of risk factors and social determinants. Soc Sci Med. 2009;68(12):2240–6.

Download references

Acknowledgements

The authors would like to acknowledge the contributions of Hoang Thi My Linh, Chu Thi Hoang Anh, Nguyen Khac Cuong, Nham Thi Yen Ngoc and Tran Thai Hiep for conducting qualitative interviews and assisting with SHI enrollment activities. Special thanks to Dr. Kerri Viney for providing insightful comments on an early draft of this manuscript; they greatly strengthened the final version. This work was graciously supported by the staff of Vietnam’s National TB Program, the Hanoi Lung Hospital, Pham Ngoc Thach Provincial TB Hospital and 10 District TB Units. Lastly, we would like to thank the interview participants who shared their time and insights.

Open access funding provided by Karolinska Institute. The European Commission's Horizon 2020 program supported the provision of SHI and all data collection in 2019 through the IMPACT-TB study under grant agreement number 733174. For the period of 2020–2022, support to implement the pilot and conduct the evaluation was made possible by the generous support of the American people through the USAID under award number 72044020FA00001. TW was supported by grants from: the Wellcome Trust, UK ( Seed Award, grant number 209075/Z/17/Z); the Department of Health and Social Care (DHSC), the Foreign, Commonwealth & Development Office (FCDO), the Medical Research Council (MRC) and Wellcome, UK (Joint Global Health Trials, MR/V004832/1); the Medical Research Council (Public Health Intervention Development Award “PHIND”, APP2293); and the Medical Research Foundation (Dorothy Temple Cross International Collaboration Research Grant, MRF-131–0006-RG-KHOS-C0942). KSA was supported by the ASPECT Trial funded the Swedish Research Council (2022-00727). The contents of this study are the responsibility of the listed authors, and do not necessarily reflect the views of USAID or the United States Government.

Author information

Authors and affiliations.

Friends for International TB Relief, Hanoi, Vietnam

Rachel Forse, Thanh Thi Nguyen, Luan N. Q. Vo & Andrew J. Codlin

Department of Global Public Health, WHO Collaboration Centre on Tuberculosis and Social Medicine, Karolinska Institutet, Stockholm, Sweden

Rachel Forse, Clara Akie Yoshino, Luan N. Q. Vo, Andrew J. Codlin, Tom Wingfield, Knut Lönnroth & Kristi Sidney-Annerstedt

Centre for Development of Community Health Initiatives, Hanoi, Vietnam

Thi Hoang Yen Phan

IRD VN, Ho Chi Minh City, Vietnam

Lan Nguyen & Chi Hoang

USAID Vietnam, Hanoi, Vietnam

Lopa Basu & Minh Pham

National Lung Hospital, Hanoi, Vietnam

Hoa Binh Nguyen & Luong Van Dinh

Centre for TB Research, Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK

Maxine Caws & Tom Wingfield

Birat Nepal Medical Trust, Kathmandu, Nepal

Maxine Caws

You can also search for this author in PubMed Google Scholar

Contributions

This study was conceived of by RF, KSA, TTN, THYP, CAY, AJC, LNQV. The study was administered by RF, YP, TTN, AJC. Support from Vietnam’s National TB program was provided by HBN and LVD. The methodology was developed by RJ, CAY, KV, KL, KSA. The analysis was carried out by RF, CAY, TTN, and THYP. LNQV, AJC, TW, LN, CH, LB, MP, HBN, LVD, MC, KV, KL, and KSA supported the interpretation of findings. The first manuscript was written by RF. All co-authors reviewed and commented on the initial manuscript. The final manuscript was approved and reviewed by all authors.

Corresponding author

Correspondence to Rachel Forse .

Ethics declarations

Ethics approval and consent to participate.

All study procedures were conducted in strict adherence to the Declaration of Helsinki. Ethical approvals were granted by the National Lung Hospital Institutional Review Board (114/19/CT-HĐKH-ĐĐ), the Pham Ngoc Thach Hospital Institutional Review Board (1225/PNT-HĐĐĐ) and Ha Noi University of Public Health Institutional Review Board (300/2020/YTCC-HD3). All participants provided written informed consent and individual-level data were pseudonymized prior to analysis.

Consent for publication

Informed written consent was obtained for all individuals who the study attempted to enroll in SHI, as part of the pilot intervention. It was also obtained for all individuals who participated in the qualitative interviews.

Competing interests

Ten of the authors received salary support from one of the funding agencies to implement the pilot interventions and their evaluation. Two of the authors were employed by United States Agency for International Development (USAID), which funded one of the two pilot interventions. They played no role in the design or implementation of the pilot interventions or their evaluation, but during the development of the manuscript, they provided their insights about the context of the results and Vietnam’s health financing transition as experts in the field.

Additional information

Publisher's note.

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

Supplementary Information

Additional file 1..

Mapping of procedures and costs for first-time enrollment into Vietnam's social health insurance scheme.

Rights and permissions

Reprints and permissions

About this article

Cite this article.

Forse, R., Yoshino, C.A., Nguyen, T.T. et al. Towards universal health coverage in Vietnam: a mixed-method case study of enrolling people with tuberculosis into social health insurance. Health Res Policy Sys 22 , 40 (2024). https://doi.org/10.1186/s12961-024-01132-8

Download citation

Received : 11 August 2023

Accepted : 13 March 2024

Published : 02 April 2024

DOI : https://doi.org/10.1186/s12961-024-01132-8

Share this article

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

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

Provided by the Springer Nature SharedIt content-sharing initiative

Social health insurance
Universal health coverage
Health financing transition
Financial protection

Health Research Policy and Systems

ISSN: 1478-4505

Submission enquiries: Access here and click Contact Us
General enquiries: [email protected]

SUGGESTED TOPICS
The Magazine
Newsletters
Managing Yourself
Managing Teams
Work-life Balance
The Big Idea
Data & Visuals
Reading Lists
Case Selections
HBR Learning
Topic Feeds
Account Settings
Email Preferences

Creating a Corporate Social Responsibility Program with Real Impact

Emilio Marti,
David Risi,
Eva Schlindwein,
Andromachi Athanasopoulou

Lessons from multinational companies that adapted their CSR practices based on local feedback and knowledge.

Exploring the critical role of experimentation in Corporate Social Responsibility (CSR), research on four multinational companies reveals a stark difference in CSR effectiveness. Successful companies integrate an experimental approach, constantly adapting their CSR practices based on local feedback and knowledge. This strategy fosters genuine community engagement and responsive initiatives, as seen in a mining company’s impactful HIV/AIDS program. Conversely, companies that rely on standardized, inflexible CSR methods often fail to achieve their goals, demonstrated by a failed partnership due to local corruption in another mining company. The study recommends encouraging broad employee participation in CSR and fostering a culture that values CSR’s long-term business benefits. It also suggests that sustainable investors and ESG rating agencies should focus on assessing companies’ experimental approaches to CSR, going beyond current practices to examine the involvement of diverse employees in both developing and adapting CSR initiatives. Overall, embracing a dynamic, data-driven approach to CSR is essential for meaningful social and environmental impact.

By now, almost all large companies are engaged in corporate social responsibility (CSR): they have CSR policies, employ CSR staff, engage in activities that aim to have a positive impact on the environment and society, and write CSR reports. However, the evolution of CSR has brought forth new challenges. A stark contrast to two decades ago, when the primary concern was the sheer neglect of CSR, the current issue lies in the ineffective execution of these practices. Why do some companies implement CSR in ways that create a positive impact on the environment and society, while others fail to do so? Our research reveals that experimentation is critical for impactful CSR, which has implications for both companies that implement CSR and companies that externally monitor these CSR activities, such as sustainable investors and ESG rating agencies.

EM Emilio Marti is an associate professor at the Rotterdam School of Management, Erasmus University. His research focuses on corporate sustainability with a specific focus on sustainable investing.
DR David Risi is a professor at the Bern University of Applied Sciences and a habilitated lecturer at the University of St. Gallen. His research focuses on how companies organize CSR and sustainability.
ES Eva Schlindwein is a professor at the Bern University of Applied Sciences and a postdoctoral fellow at the University of Oxford. Her research focuses on how organizations navigate tensions between business and society.
AA Andromachi Athanasopoulou is an associate professor at Queen Mary University of London and an associate fellow at the University of Oxford. Her research focuses on how individuals manage their leadership careers and make ethically charged decisions.

Partner Center

Supported by

Use of Abortion Pills Has Risen Significantly Post Roe, Research Shows

By Pam Belluck

Pam Belluck has been reporting about reproductive health for over a decade.

Share full article

On the eve of oral arguments in a Supreme Court case that could affect future access to abortion pills, new research shows the fast-growing use of medication abortion nationally and the many ways women have obtained access to the method since Roe v. Wade was overturned in June 2022.

The Details

A person pours pills out of a bottle into a gloved hand.

A study, published on Monday in the medical journal JAMA , found that the number of abortions using pills obtained outside the formal health system soared in the six months after the national right to abortion was overturned. Another report, published last week by the Guttmacher Institute , a research organization that supports abortion rights, found that medication abortions now account for nearly two-thirds of all abortions provided by the country’s formal health system, which includes clinics and telemedicine abortion services.

The JAMA study evaluated data from overseas telemedicine organizations, online vendors and networks of community volunteers that generally obtain pills from outside the United States. Before Roe was overturned, these avenues provided abortion pills to about 1,400 women per month, but in the six months afterward, the average jumped to 5,900 per month, the study reported.

Overall, the study found that while abortions in the formal health care system declined by about 32,000 from July through December 2022, much of that decline was offset by about 26,000 medication abortions from pills provided by sources outside the formal health system.

“We see what we see elsewhere in the world in the U.S. — that when anti-abortion laws go into effect, oftentimes outside of the formal health care setting is where people look, and the locus of care gets shifted,” said Dr. Abigail Aiken, who is an associate professor at the University of Texas at Austin and the lead author of the JAMA study.

The co-authors were a statistics professor at the university; the founder of Aid Access, a Europe-based organization that helped pioneer telemedicine abortion in the United States; and a leader of Plan C, an organization that provides consumers with information about medication abortion. Before publication, the study went through the rigorous peer review process required by a major medical journal.

The telemedicine organizations in the study evaluated prospective patients using written medical questionnaires, issued prescriptions from doctors who were typically in Europe and had pills shipped from pharmacies in India, generally charging about $100. Community networks typically asked for some information about the pregnancy and either delivered or mailed pills with detailed instructions, often for free.

Online vendors, which supplied a small percentage of the pills in the study and charged between $39 and $470, generally did not ask for women’s medical history and shipped the pills with the least detailed instructions. Vendors in the study were vetted by Plan C and found to be providing genuine abortion pills, Dr. Aiken said.

The Guttmacher report, focusing on the formal health care system, included data from clinics and telemedicine abortion services within the United States that provided abortion to patients who lived in or traveled to states with legal abortion between January and December 2023.

It found that pills accounted for 63 percent of those abortions, up from 53 percent in 2020. The total number of abortions in the report was over a million for the first time in more than a decade.

Why This Matters

Overall, the new reports suggest how rapidly the provision of abortion has adjusted amid post-Roe abortion bans in 14 states and tight restrictions in others.

The numbers may be an undercount and do not reflect the most recent shift: shield laws in six states allowing abortion providers to prescribe and mail pills to tens of thousands of women in states with bans without requiring them to travel. Since last summer, for example, Aid Access has stopped shipping medication from overseas and operating outside the formal health system; it is instead mailing pills to states with bans from within the United States with the protection of shield laws.

What’s Next

In the case that will be argued before the Supreme Court on Tuesday, the plaintiffs, who oppose abortion, are suing the Food and Drug Administration, seeking to block or drastically limit the availability of mifepristone, the first pill in the two-drug medication abortion regimen.

The JAMA study suggests that such a ruling could prompt more women to use avenues outside the formal American health care system, such as pills from other countries.

“There’s so many unknowns about what will happen with the decision,” Dr. Aiken said.

She added: “It’s possible that a decision by the Supreme Court in favor of the plaintiffs could have a knock-on effect where more people are looking to access outside the formal health care setting, either because they’re worried that access is going away or they’re having more trouble accessing the medications.”

Pam Belluck is a health and science reporter, covering a range of subjects, including reproductive health, long Covid, brain science, neurological disorders, mental health and genetics. More about Pam Belluck

ORIGINAL RESEARCH article

Public perception of media social responsibility in developing countries: a case study of albania provisionally accepted.

1 Aleksandër Moisiu University, Albania

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

This study delves into public perceptions of media social responsibility within the contemporary Albanian media landscape. Through a comprehensive analysis of various factors, the study identifies the prevailing principles that the public deems crucial for the media's social responsibility and how these principles can enhance the media's contribution to society. A structured questionnaire was used to capture a wide range of public perceptions, with 1,321 questionnaires filled out. These questionnaires were distributed using a face-to-face method across five major urban centers in Albania, ensuring a comprehensive and representative sample of public viewpoints. The distribution method employed a stratified sampling approach to ensure diverse representation across different demographic groups. Additionally, employing a mixed-methods approach, the research includes qualitative interviews with 20 influential stakeholders, including media directors, professors, analysts, and media researchers. Purposive sampling was utilized to select stakeholders representing various sectors of the media landscape. Rigorous measures were taken to mitigate data pollution, including thorough interviewer training and constant monitoring of data quality. An overarching thematic analysis was conducted to identify common themes and patterns across the qualitative interviews, complementing the quantitative findings. To gain further insights, we purposefully selected and conducted a focus group with 28 journalists from various media platforms. The sampling method for the focus group involved purposive sampling to ensure representation from diverse media backgrounds and experiences. Data collected from the focus group underwent thematic analysis to identify common themes and patterns, contributing to an overarching qualitative analysis. The empirical findings reveal that the media's social responsibility in Albania does not fully adhere to the expected standards encompassing all relevant principles. Internal dynamics within media organizations and external forces from politics, economics, and society collectively influence this shortfall. The study highlights the importance of considering public perceptions and expectations in shaping media's social responsibility, emphasizing the need for substantial improvements. In conclusion, this research not only provides practical insights for media practitioners but also offers valuable perspectives for policymakers.

Keywords: media social responsibility, public perception, contemporary media landscape, transparency and accountability, Media ethics

Received: 14 Nov 2023; Accepted: 03 Apr 2024.

Copyright: © 2024 Skana and Gjerazi. 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. Blerina Gjerazi, Aleksandër Moisiu University, Durrës, 3001-3006, Albania

People also looked at

IMAGES

(PDF) The case study method in social inquiry
what is case study methodology
What is a Case Study? [+6 Types of Case Studies]
why use case study approach
Social inquiry model
PPT

VIDEO

Day-1 Case Study Method for better Teaching
case study Method And Interdisciplinary Research / Reasearch Methodology
Video assignment Approaches to Social Inquiry about my research belief
Day-2 Case Study Method for better Teaching
Day-2, Case Study Method for better Teaching
What is Case Study Method in Psychology Urdu I Hindi #Casestudymethod #casestudy

COMMENTS

The Case Study Method in Social Inquiry
MacDonald Barry and Walker Rob. Case study and the social philosophy of educational research. Cambridge Journal of Education 1975;5 No. 1. Ortony Andrew. Knowledge, language and thinking 1975 Urbana Univ. of III. College of Education (mimeo). Polanyi Michael. Personal knowledge 1958 New York Harper & Row. Popper Karl.
The Case Study Method in Social Inquiry
The Case Study Method in Social Inquiry, ROBERT E. STAKE. University of Illinois, Urbana-Champaign. It is widely believed that case studies. are useful in the study of human affairs. because they are down-to-earth and. attention-holding but that they are not a suitable basis for generalization. In this. paper, I claim that case studies will.
The Case Study Method in Social Inquiry
Abstract. It is widely believed that case studies are useful in the study of human affairs because they are down-to-earth and attention-holding but that they are not a suitable basis for generalization. In this paper, I claim that case studies will often be the preferred method of research because they may be epistemologically in harmony with ...
Case Study Methodology of Qualitative Research: Key Attributes and
A case study is one of the most commonly used methodologies of social research. This article attempts to look into the various dimensions of a case study research strategy, the different epistemological strands which determine the particular case study type and approach adopted in the field, discusses the factors which can enhance the effectiveness of a case study research, and the debate ...
Progress in Social and Educational Inquiry Through Case Study
The best case studies weave discussion and theorization with the presentation of the case account itself. The case study presents a view of inquiry that takes a pragmatic view of knowledge—one that elevates a view of life in its complexity. It's the realization that complexity in social affairs is often indivisible that has led to case ...
The Case Study in Social Research
The Case Study in Social Research proposes and develops an innovative, rigorous, and up to date methodological clarification of the case study approach in the social sciences to consistently and consciously apply it to different fields of social research. It aspires to provide the reader not with a set of prescriptive rules, but rather with a 'methodological awareness' of the complexity ...
The Case Study Method in Social Inquiry1
The Case Study Method in Social Inquiry1. R. Stake. Published 1 February 1978. Education. Educational Researcher. It is widely believed that case studies are useful in the study of human affairs because they are down-to-earth and attention-holding but that they are not a suitable basis for generalization.
Progress in Social and Educational Inquiry Through Case Study
While the case study has a relatively recent history in education, it has a longer pedigree in other disciplines. Garvin notes that it was a lawyer who had, in 1870, named case study method, with the use of the case study at that time in undergraduate teaching. The case had begun to be used, though, around the same time and a little before, in ...
Strategies for Social Inquiry
The Case for Case Studies - May 2022. Editors . Colin Elman, Maxwell School of Syracuse University John Gerring, Boston University James Mahoney, Northwestern University Editorial Board . Bear Braumoeller, David Collier, Francesco Guala, Peter Hedström, Theodore Hopf, Uskali Maki, Rose McDermott, Charles Ragin, Theda Skocpol, Peter Spiegler, David Waldner, Lisa Wedeen, Christopher WinshipThis ...
The Case Study Method in Social Inquiry
The Case Study Method in Social Inquiry. Robert E. Stake 1 • Institutions (1) 31 Jan 1978 - Educational Researcher (Springer, Dordrecht) - Vol. 7, Iss: 2, pp 5-8. TL;DR: This paper argued that case studies will often be the preferred method of research because they may be epistemologically in harmony with the reader's experience and thus to ...
Case Study Methodology of Qualitative Research: Key Attributes and
In a case study research, multiple methods of data collection are used, as it involves an in-depth study of a phenomenon. It ... (2009), a case study is not a method of data collection, rather is a research strategy or design to study a social unit. Creswell (2014, p. 241) makes a lucid and comprehensive definition of case study strategy.
Case study research in the social sciences
Case study methods are widely used in the social sciences and there exists a rich methodological literature, making the social sciences a natural place to start. In the following, we will first discuss the definition of case study research after which we point to various purposes that case study research may serve in the social sciences.
Case Study
The popularity and reliability of a case study as a research method in multidisciplinary areas is based on the advantages of the case study method. In the following part, an attempt has been done to examine the advantages of a case study and its applicability in social science research. Case study method is extensively used in educational settings.
Strategies for Social Inquiry
Case Study Research: Principles and Practices provides a general understanding of the case study method as well as specific tools for its successful implementation. These tools are applicable in a variety of fields including anthropology, business and management, communications, economics, education, medicine, political science, psychology ...
The Case Study in Social Research: History, Methods and Applications
The Case Study in Social Research The Case Study in So cial Research pr oposes and deve lops an innovat ive, rig- orous, and up to da te methodologi cal clari ﬁ ca tion of the case st udy approach
Redesigning Social Inquiry
Redesigning Social Inquiry provides a substantive critique of the standard approach to social research—namely, assessing the relative importance of causal variables drawn from competing theories. ... "Once upon a time, historically oriented social scientists had to choose between the empirical richness of the case study method and the ...
(PDF) The case study as a type of qualitative research
Abstract. This article presents the case study as a type of qualitative research. Its aim is to give a detailed description of a case study - its definition, some classifications, and several ...
Case Study Method: Key Issues, Key Texts
Case Study Method: Key Issues, Key Texts. Case Study Method. : Roger Gomm, Martyn Hammersley, Peter Foster. SAGE, Oct 17, 2000 - Social Science - 288 pages. This is the most comprehensive guide to the current uses and importance of case study methods in social research. The editors bring together key contributions from the field which reflect ...
The Case Method in Social Research on JSTOR
Katharine Jocher, The Case Method in Social Research, Social Forces, Vol. 7, No. 2 (Dec., 1928), pp. 203-211 ... "Round Table on the Case-Study Method of Sociological Research," Publications of the American Sociological Society, XXII, 226. 12. Queen, "Some Possible Sociological Uses of the Case-Work Method," Journal of Applied Sociology, XI ...
The Case Study Method in Social Inquiry (Robert Stake, 1978 ...
The Case Study Method in Social Inquiry (Robert Stake, 1978) - Free download as PDF File (.pdf), Text File (.txt) or read online for free. Estudo sobre o método de estudo de caso
A qualitative study of rural healthcare providers' views of social
Future research should examine acceptability- and appropriateness-related barriers to healthcare access in patient populations. Second, study participants were recruited through convenience sampling methods, so results may be biased towards healthcare providers who are more invested in addressing barriers to healthcare access.
Case Study and Narrative Inquiry as Merged Methodologies: A Critical
Case study was the main methodology of choice, best suited to address the research question, and so describing the social, political, economic, and historical contextual factors that influenced how this process happens for these occupational therapists was a fundamental starting point.
Effectiveness of problem-based learning methodology in undergraduate
Problem-based learning (PBL) is a pedagogical approach that shifts the role of the teacher to the student (student-centered) and is based on self-directed learning. Although PBL has been adopted in undergraduate and postgraduate medical education, the effectiveness of the method is still under discussion. The author's purpose was to appraise available international evidence concerning to the ...
Case Study Research
This method is useful for answering cause and effect questions (Davey, 1991 ). Case study research is personal, in-depth research. The concrete case, whether it is an individual, a group of individuals or a program, is bounded within social, political, cultural and historical contexts.
Towards universal health coverage in Vietnam: a mixed-method case study
A mixed-method case study was conducted using a convergent parallel design between November 2018 and January 2022 in ten districts of Hanoi and Ho Chi Minh City, Vietnam. ... Ritchie J, Lewis J, Nicholls CM, Ormston R. Qualitative research practice: a guide for social science students and researchers. Second edn. SAGE Publications Ltd; 2013. p ...
Creating a Corporate Social Responsibility Program with Real Impact
Summary. Exploring the critical role of experimentation in Corporate Social Responsibility (CSR), research on four multinational companies reveals a stark difference in CSR effectiveness ...
Use of Abortion Pills Has Risen Significantly Post Roe, Research Shows
Before Roe was overturned, these avenues provided abortion pills to about 1,400 women per month, but in the six months afterward, the average jumped to 5,900 per month, the study reported. Overall ...
Co-operative inquiry: Qualitative methodology transforming research
The following four case studies illustrate how experienced researchers, a PhD candidate, and people new to research, including students and practitioners, utilised the methodology. Each of the following case studies use co-operative inquiry differently, tailoring the methodology according to the research question and participants.
Frontiers
This study delves into public perceptions of media social responsibility within the contemporary Albanian media landscape. Through a comprehensive analysis of various factors, the study identifies the prevailing principles that the public deems crucial for the media's social responsibility and how these principles can enhance the media's contribution to society. A structured questionnaire was ...
A multi-source data fusion method for land cover production: a case
In summary, this research method is not only applicable to large-scale, high-resolution data studies and provides a viable solution for customized land cover data production in regional contexts. This method demonstrates broad prospects in the field of land cover classification through the fusion of multiple data sources and the application of ...

Progress in Social and Educational Inquiry Through Case Study: Generalization or Explanation?

Introduction

What is Case Study?

Methodological Issues for the Case Study in Education

Is It Science?

Some Examples of Case Study in Educational Science

Conclusions

The Case Study Method in Social Inquiry

Cites background from "The Case Study Method in Social Inq..."

Cites methods from "The Case Study Method in Social Inq..."

Related Papers (5)

A qualitative study of rural healthcare providers’ views of social, cultural, and programmatic barriers to healthcare access

Conclusions

Acceptability-related barriers to care

Appropriateness-related barriers to care

Participants

Recruitment and Data Collection

Definitions of Analytic Domains

Patient-provider communication

Provider-Provider Communication

Healthcare provider characteristics

Theme 1: A friction exists between aspects of patients’ rural identities and healthcare systems

Theme 2: Facilitating access to healthcare requires application of and respect for cultural differences

Theme 3: Communication between healthcare providers is systematically fragmented

Theme 4: Time and resource constraints disproportionately harm rural health systems

Theme 5: Profits are prioritized over addressing barriers to healthcare access in the US.

Implications for Practice

Implications for Policy

Implications for Future Research

Strengths and Limitations

Availability of data and materials

Acknowledgements

Author information

Contributions

Corresponding author

Ethics declarations

Additional information

Rights and permissions

About this article

Share this article

BMC Health Services Research

Effectiveness of problem-based learning methodology in undergraduate medical education: a scoping review

Stage 1: Identifying the research question

Stage 2: Identifying relevant studies

Stage 3: Study selection

Stage 4: Charting the data

Stage 5: Collating, summarizing and reporting the results

Main outcome: academic performance (learning and knowledge retention)

Secondary outcomes

Student satisfaction

Tutor satisfaction

Other skills (problem solving and self-learning)

Limitations

Conclusions

Abbreviations

References:

Acknowledgements

Author information

Contributions

Ethics declarations

Ethics approval and consent to participate

Consent for publication

Additional information

Supplementary Information

Rights and permissions

About this article

Share this article

BMC Medical Education

Case Study Research

Cite this chapter

Access this chapter

Author information

Corresponding author

A Case in Case Study Methodology

WHY A CASE STUDY?

DESCRIPTION OF THE ILLUSTRATIVE STUDY

DESIGN DECISIONS

Sampling Business Areas, Divisions, and Sites

SELECTION OF DATA COLLECTION PROCEDURES

DATA ANALYSIS