qualitative data case study

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

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

Research question

• Conceptual framework
• Conceptual vs. theoretical framework

Data collection

• Qualitative research methods
• Focus groups
• Observational research

What is a case study?

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

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

Case studies

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

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

Definition of a case study

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

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

Characteristics of case studies

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

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

The role of case studies in research

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

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

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

What is the purpose of a case study?

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

Why use case studies in qualitative research?

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

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

The explanatory, exploratory, and descriptive roles of case studies

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

The impact of case studies on knowledge development

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

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

Types of case studies

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

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

Exploratory case studies

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

Descriptive case studies

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

Explanatory case studies

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

Intrinsic, instrumental, and collective case studies

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

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

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

Critical information systems research

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

Health research

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

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

Asthma research studies

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

Other fields

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

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

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

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

Propositions

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

Units of analysis

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

Argumentation

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

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

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

Defining the research question

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

Selecting and defining the case

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

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

Developing a detailed case study protocol

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

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

Collecting data

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

Analyzing and interpreting data

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

Writing the case study report

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

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

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

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

Observations

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

Documents and artifacts

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

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

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

Ensuring the quality of data collection

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

Data analysis

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

Organizing the data

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

Categorizing and coding the data

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

Identifying patterns and themes

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

Interpreting the data

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

Verification of the data

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

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

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

Benefits include the following:

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

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

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

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

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Home » Case Study – Methods, Examples and Guide

Case Study – Methods, Examples and Guide

Table of Contents

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

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

Types of Case Study

Types and Methods of Case Study are as follows:

Single-Case Study

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

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

Multiple-Case Study

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

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

Exploratory Case Study

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

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

Descriptive Case Study

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

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

Instrumental Case Study

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

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

Case Study Data Collection Methods

Here are some common data collection methods for case studies:

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

Observations

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

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

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

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

How to conduct Case Study Research

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

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

Examples of Case Study

Here are some examples of case study research:

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

Application of Case Study

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

Business and Management

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

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

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

Social Sciences

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

Law and Ethics

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

Purpose of Case Study

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

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

Case studies can also serve other purposes, including:

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

Advantages of Case Study Research

There are several advantages of case study research, including:

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

Limitations of Case Study Research

There are several limitations of case study research, including:

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

About the author

Muhammad Hassan

Researcher, Academic Writer, Web developer

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Qualitative case study data analysis: an example from practice

Affiliation.

• 1 School of Nursing and Midwifery, National University of Ireland, Galway, Republic of Ireland.
• PMID: 25976531
• DOI: 10.7748/nr.22.5.8.e1307

Aim: To illustrate an approach to data analysis in qualitative case study methodology.

Background: There is often little detail in case study research about how data were analysed. However, it is important that comprehensive analysis procedures are used because there are often large sets of data from multiple sources of evidence. Furthermore, the ability to describe in detail how the analysis was conducted ensures rigour in reporting qualitative research.

Data sources: The research example used is a multiple case study that explored the role of the clinical skills laboratory in preparing students for the real world of practice. Data analysis was conducted using a framework guided by the four stages of analysis outlined by Morse ( 1994 ): comprehending, synthesising, theorising and recontextualising. The specific strategies for analysis in these stages centred on the work of Miles and Huberman ( 1994 ), which has been successfully used in case study research. The data were managed using NVivo software.

Review methods: Literature examining qualitative data analysis was reviewed and strategies illustrated by the case study example provided. Discussion Each stage of the analysis framework is described with illustration from the research example for the purpose of highlighting the benefits of a systematic approach to handling large data sets from multiple sources.

Conclusion: By providing an example of how each stage of the analysis was conducted, it is hoped that researchers will be able to consider the benefits of such an approach to their own case study analysis.

Implications for research/practice: This paper illustrates specific strategies that can be employed when conducting data analysis in case study research and other qualitative research designs.

Keywords: Case study data analysis; case study research methodology; clinical skills research; qualitative case study methodology; qualitative data analysis; qualitative research.

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• Data Interpretation, Statistical*
• Nursing Research / methods*
• Qualitative Research*
• Research Design

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22 Case Study Research: In-Depth Understanding in Context

Helen Simons, School of Education, University of Southampton

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

Introduction

This chapter explores case study as a major approach to research and evaluation using primarily qualitative methods, as well as documentary sources, contemporaneous or historical. However, this is not the only way in which case study can be conceived. No one has a monopoly on the term. While sharing a focus on the singular in a particular context, case study has a wide variety of uses, not all associated with research. A case study, in common parlance, documents a particular situation or event in detail in a specific sociopolitical context. The particular can be a person, a classroom, an institution, a program, or a policy. Below I identify different ways in which case study is used before focusing on qualitative case study research in particular. However, first I wish to indicate how I came to advocate and practice this form of research. Origins, context, and opportunity often shape the research processes we endorse. It is helpful for the reader, I think, to know how I came to the perspective I hold.

The Beginnings

I first came to appreciate and enjoy the virtues of case study research when I entered the field of curriculum evaluation and research in the 1970s. The dominant research paradigm for educational research at that time was experimental or quasi- experimental, cost-benefit, or systems analysis, and the dominant curriculum model was aims and objectives ( House, 1993 ). The field was dominated, in effect, by a psychometric view of research in which quantitative methods were preeminent. But the innovative projects we were asked to evaluate (predominantly, but not exclusively, in the humanities) were not amenable to such methodologies. The projects were challenging to the status quo of institutions, involved people interpreting the policy and programs, were implemented differently in different contexts and regions, and had many unexpected effects.

We had no choice but to seek other ways to evaluate these complex programs, and case study was the methodology we found ourselves exploring, in order to understand how the projects were being implemented, why they had positive effects in some regions of the country and not others, and what the outcomes meant in different sociopolitical and cultural contexts. What better way to do this than to talk with people to see how they interpreted the “new” curriculum; to watch how teachers and students put it into practice; to document transactions, outcomes, and unexpected consequences; and to interpret all in the specific context of the case ( Simons, 1971 , 1987 , pp. 55–89). From this point on and in further studies, case study in educational research and evaluation came to be a major methodology for understanding complex educational and social programs. It also extended to other practice professions, such as nursing, health, and social care ( Zucker, 2001 ; Greenhalgh & Worrall, 1997 ; Shaw & Gould, 2001 ). For further details of the evolution of the case study approach and qualitative methodologies in evaluation, see House, 1993 , pp. 2–3; Greene, 2000 ; Simons, 2009 , pp. 14–18; Simons & McCormack, 2007 , pp. 292–311).

This was not exactly the beginning of case study, of course. It has a long history in many disciplines ( Simons, 1980; Ragin, 1992; Gomm, Hammersley, & Foster, 2004 ; Platt, 2007 ), many aspects of which form part of case study practice to this day. But its evolution in the context just described was a major move in the contemporary evolution of the logic of evaluative inquiry ( House, 1980 ). It also coincided with movement toward the qualitative in other disciplines, such as sociology and psychology. This was all part of what Denzin & Lincoln (1994) termed “a quiet methodological revolution” (p. ix) in qualitative inquiry that had been evolving over the course of forty years.

There is a further reason why I continue to advocate and practice case study research and evaluation to this day and that is my personal predilection for trying to understand and represent complexity, for puzzling through the ambiguities that exist in many contexts and programs and for presenting and negotiating different values and interests in fair and just ways.

Put more simply, I like interacting with people, listening to their stories, trials and tribulations—giving them a voice in understanding the contexts and projects with which they are involved, and finding ways to share these with a range of audiences. In other words, the move toward case study methodology described here suited my preference for how I learn.

Concepts and Purposes of Case Study

Before exploring case study as it has come to be established in educational research and evaluation over the past forty years, I wish to acknowledge other uses of case study. More often than not, these relate to purpose, and appropriately so in their different contexts, but many do not have a research intention. For a study to count as research, it would need to be a systematic investigation generating evidence that leads to “new” knowledge that is made public and open to scrutiny. There are many ways to conduct research stemming from different traditions and disciplines, but they all, in different ways, involve these characteristics.

Everyday Usage: Stories We Tell

The most common of these uses of case study is the everyday reference to a person, an anecdote or story illustrative of a particular incident, event, or experience of that person. It is often a short, reported account commonly seen in journalism but also in books exploring a phenomenon, such as recovery from serious accidents or tragedies, where the author chooses to illustrate the story or argument with a “lived” example. This is sometimes written by the author and sometimes by the person whose tale it is. “Let me share with you a story,” is a phrase frequently heard

The spirit behind this common usage and its power to connect can be seen in a report by Tim Adams of the London Olympics opening ceremony’s dramatization by Danny Boyle.

It was the point when we suddenly collectively wised up to the idea that what we are about to receive over the next two weeks was not only about “legacy collateral” and “targeted deliverables,” not about G4S failings and traffic lanes and branding opportunities, but about the second-by-second possibilities of human endeavour and spirit and communality, enacted in multiple places and all at the same time. Stories in other words. ( Adams, 2012 )

This was a collective story, of course, not an individual one, but it does convey some of the major characteristics of case study—that richness of detail, time, place, multiple happenings and experiences—that are also manifest in case study research, although carefully evidenced in the latter instance. We can see from this common usage how people have come to associate case study with story. I return to this thread in the reporting section.

Professions Individual Cases

In professional settings, in health and social care, case studies, often called case histories , are used to accurately record a person’s health or social care history and his or her current symptoms, experience, and treatment. These case histories include facts but also judgments and observations about the person’s reaction to situations or medication. Usually these are confidential. Not dissimilar is the detailed documentation of a case in law, often termed a case precedent when referred to in a court case to support an argument being made. However in law there is a difference in that such case precedents are publicly documented.

Case Studies in Teaching

Exemplars of practice.

In education, but also in health and social care training contexts, case studies have long been used as exemplars of practice. These are brief descriptions with some detail of a person or project’s experience in an area of practice. Though frequently reported accounts, they are based on a person’s experience and sometimes on previous research.

Case scenarios

Management studies are a further context in which case studies are often used. Here, the case is more like a scenario outlining a particular problem situation for the management student to resolve. These scenarios may be based on research but frequently are hypothetical situations used to raise issues for discussion and resolution. What distinguishes these case scenarios and the case exemplars in education from case study research is the intention to use them for teaching purposes.

Country Case Studies

Then there are case studies of programs, projects, and even countries, as in international development, where a whole-country study might be termed a case study or, in the context of the Organization for Economic Co-operation and Development (OECD), where an exploration is conducted of the state of the art of a subject, such as education or environmental science in one or several countries. This may be a contemporaneous study and/or what transpired in a program over a period of time. Such studies often do have a research base but frequently are reported accounts that do not detail the design, methodology, and analysis of the case, as a research case study would do, or report in ways that give readers a vicarious experience of what it was like to be there. Such case studies tend to be more knowledge and information-focused than experiential.

Case Study as History

Closer to a research context is case study as history—what transpired at a certain time in a certain place. This is likely to be supported by documentary evidence but not primary data gathering unless it is an oral history. In education, in the late 1970s, Stenhouse (1978) experimented with a case study archive. Using contemporaneous data gathering, primarily through interviewing, he envisaged this database, which he termed a “case record,” forming an archive from which different individuals,, at some later date, could write a “case study.” This approach uses case study as a documentary source to begin to generate a history of education, as the subtitle of Stenhouse’s 1978 paper indicates “Towards a contemporary history of education.”

Case Study Research

From here on, my focus is on case study research per se, adopting for this purpose the following definition:

Case study is an in-depth exploration from multiple perspectives of the complexity and uniqueness of a particular project, policy, institution or system in a “real-life” context. It is research based, inclusive of different methods and is evidence-led. ( Simons, 2009 , p. 21).

For further related definitions of case study, see Stake (1995) , Merriam (1998), and Chadderton & Torrance (2011) . And for definitions from a slightly different perspective, see Yin (2004) and Thomas (2011a) .

Not Defined by Method or Perspective

The inclusion of different methods in the definition quoted above definition signals that case study research is not defined by methodology or method. What defines case study is its singularity and the concept and boundary of the case. It is theoretically possible to conduct a case study using primarily quantitative data if this is the best way of providing evidence to inform the issues the case is exploring. It is equally possible to conduct case study that is mainly qualitative, to engage people with the experience of the case or to provide a rich portrayal of an event, project, or program.

Or one can design the case using mixed methods. This increases the options for learning from different ways of knowing and is sometimes preferred by stakeholders who believe it provides a firmer basis for informing policy. This is not necessarily the case but is beyond the scope of this chapter to explore. For further discussion of the complexities of mixing methods and the virtue of using qualitative methods and case study in a mixed method design, see Greene (2007) .

Case study research may also be conducted from different standpoints—realist, interpretivist, or constructivist, for example. My perspective falls within a constructivist, interpretivist framework. What interests me is how I and those in the case perceive and interpret what we find and how we construct or co-construct understandings of the case. This not only suits my predilection for how I see the world, but also my preferred phenomenological approach to interviewing and curiosity about people and how they act in social and professional life.

Qualitative Case Study Research

Qualitative case study research shares many characteristics with other forms of qualitative research, such as narrative, oral history, life history, ethnography, in-depth interview, and observational studies that utilize qualitative methods. However, its focus, purpose, and origins, in educational research at least, are a little different.

The focus is clearly the study of the singular. The purpose is to portray an in-depth view of the quality and complexity of social/educational programs or policies as they are implemented in specific sociopolitical contexts. What makes it qualitative is its emphasis on subjective ways of knowing, particularly the experiential, practical, and presentational rather than the propositional ( Heron, 1992 , 1999 ) to comprehend and communicate what transpired in the case.

Characteristic Features and Advantages

Case study research is not method dependent, as noted earlier, nor is it constrained by resources or time. Although it can be conducted over several years, which provides an opportunity to explore the process of change and explain how and why things happened, it can equally be carried out contemporaneously in a few days, weeks, or months. This flexibility is extremely useful in many contexts, particularly when a change in policy or unforeseen issues in the field require modifying the design.

Flexibility extends to reporting. The case can be written up in different lengths and forms to meet different audience needs and to maximize use (see the section on Reporting). Using the natural language of participants and familiar methods (like interview, observation, oral history) also enables participants to engage in the research process, thereby contributing significantly to the generation of knowledge of the case. As I have indicated elsewhere ( Simons, 2009 ), “This is both a political and epistemological point. It signals a potential shift in the power base of who controls knowledge and recognizes the importance of co-constructing perceived reality through the relationships and joint understandings we create in the field” (p. 23).

Possible Disadvantages

If one is an advocate, identifying advantages of a research approach is easier than pointing out its disadvantages, something detractors are quite keen to do anyway! But no approach is perfect, and here are some of the issues that often trouble people about case study research. The “sample of one” is an obvious issue that worries those convinced that only large samples can constitute valid research and especially if this is to inform policy. Understanding complexity in depth may not be a sufficient counterargument, and I suspect there is little point in trying to persuade otherwise For frequently, this perception is one of epistemological and methodological, if not ideological, preference.

However, there are some genuine concerns that many case researchers face: the difficulty of processing a mass of data; of “telling the truth” in contexts where people may be identifiable; personal involvement, when the researcher is the main instrument of data gathering; and writing reports that are data-based, yet readable in style and length. But one issue that concerns advocates and nonadvocates alike is how inferences are drawn from the single case.

Answers to some of these issues are covered in the sections that follow. Whether they convince may again be a question of preference. However, it is worth noting here that I do not think we should seek to justify these concerns in terms identified by other methodologies. Many of them are intrinsic to the nature and strength of qualitative case study research.

Subjectivity, for instance, both of participants and researcher is inevitable, as it is in many other qualitative methodologies. This is often the basis on which we act. Rather than see this as bias or something to counter, it is an intelligence that is essential to understanding and interpreting the experience of participants and stakeholders. Such subjectivity needs to be disciplined, of course, through procedures that examine both the validity of individuals’ representations of “their truth”, and demonstrate how the researcher took a reflexive approach to monitoring how his or her own values and predilections may have unduly influenced the data.

Types of Case Study

There are numerous types of case study, too many to categorize, I think, as there are overlaps between them. However, attempts have been made to do this and, for those who value typologies, I refer them to Bassey (1999) and, for a more extended typology, to Thomas (2011b) . A slightly different approach is taken by Gomm, Hammersley, and Foster (2004) in annotating the different emphases in major texts on case study. What I prefer to do here is to highlight a few familiar types to focus the discussion that follows on the practice of case study research.

Stake (1995) offers a threefold distinction that is helpful when it comes to practice, he says, because it influences the methods we choose to gather data (p. 4). He distinguishes between an intrinsic case study , one that is studied to learn about the particular case itself and an instrumental case study , in which we choose a case to gain insight into a particular issue (i.e., the case is instrumental to understanding something else; p. 3). The collective case study is what its name suggests: an extension of the instrumental to several cases.

Theory-led or theory-generated case study is similarly self-explanatory, the first starting from a specific theory that is tested through the case; the second constructing a theory through interpretation of data generated in the case. In other words, one ends rather than begins with a theory. In qualitative case study research, this is the more familiar route. The theory of the case becomes the argument or story you will tell.

Evaluation case study requires a slightly longer description as this is my context of practice, one which has influenced the way I conduct case study and what I choose to emphasize in this chapter. An evaluation case study has three essential features: to determine the value of the case, to include and balance different interests and values, and to report findings to a range of stakeholders in ways that they can use. The reasons for this may be found in the interlude that follows, which offers a brief characterization of the social and ethical practice of evaluation and why qualitative methods are so important in this practice.

Interlude: Social and Ethical Practice of Evaluation

Evaluation is a social practice that documents, portrays, and seeks to understand the value of a particular project, program, or policy. This can be determined by different evaluation methodologies, of course. But the value of qualitative case study is that it is possible to discern this value without decontextualizing the data. While the focus of the case is usually a project, program, policy, or some unit within, studies of key individuals, what I term case profiles , may be embedded within the overall case. In some instances, these profiles, or even shorter cameos of individuals, may be quite prominent. For it is through the perceptions, interpretations, and interactions of people that we learn how policies and programs are enacted ( Kushner, 2000 , p. 12). The program is still the main focus of analysis, but, in exploring how individuals play out their different roles in the program, we get closer to the actual experience and meaning of the program in practice.

Case study evaluation is often commissioned from an external source (government department or other agency) keen to know the worth of publicly funded programs and policies to inform future decision making. It needs to be responsive to issues or questions identified by stakeholders, who often have different values and interests in the expected outcomes and appreciate different perspectives of the program in action. The context also is often highly politicized, and interests can conflict. The task of the evaluator in such situations becomes one of including and balancing all interests and values in the program fairly and justly.

This is an inherently political process and requires an ethical practice that offers participants some protection over the personal data they give as part of the research and agreed audiences access to the findings, presented in ways they can understand. Negotiating what information becomes public can be quite difficult in singular settings where people are identifiable and intricate or problematic transactions have been documented. The consequences that ensue from making knowledge public that hitherto was private may be considerable for those in the case. It may also be difficult to portray some of the contextual detail that would enhance understanding for readers.

The ethical stance that underpins the case study research and evaluation I conduct stems from a theory of ethics that emphasizes the centrality of relationships in the specific context and the consequences for individuals, while remaining aware of the research imperative to publicly report. It is essentially an independent democratic process based on the concepts of fairness and justice, in which confidentiality, negotiation, and accessibility are key principles ( MacDonald, 1976 ; Simons, 2009 , pp. 96–111; and Simons 2010 ). The principles are translated into specific procedures to guide the collection, validation, and dissemination of data in the field. These include:

engaging participants and stakeholders in identifying issues to explore and sometimes also in interpreting the data;

documenting how different people interpret and value the program;

negotiating what data becomes public respecting both the individual’s “right to privacy” and the public’s “right to know”;

offering participants opportunities to check how their data are used in the context of reporting;

reporting in language and forms accessible to a wide range of audiences;

disseminating to audiences within and beyond the case.

For further discussion of the ethics of democratic case study evaluation and examples of their use in practice, see Simons (2000 , 2006 , 2009 , chapter 6, 2010 ).

Designing Case Study Research

Design issues in case study sometimes take second place to those of data gathering, the more exciting task perhaps in starting research. However, it is critical to consider the design at the outset, even if changes are required in practice due to the reality of what is encountered in the field. In this sense, the design of case study is emergent, rather than preordinate, shaped and reshaped as understanding of the significance of foreshadowed issues emerges and more are discovered.

Before entering the field, there are a myriad of planning issues to think about related to stakeholders, participants, and audiences. These include whose values matter, whether to engage them in data gathering and interpretation, the style of reporting appropriate for each, and the ethical guidelines that will underpin data collection and reporting. However, here I emphasize only three: the broad focus of the study, what the case is a case of, and framing questions/issues. These are steps often ignored in an enthusiasm to gather data, resulting in a case study that claims to be research but lacks the basic principles required for generation of valid, public knowledge.

Conceptualize the Topic

First, it is important that the topic of the research is conceptualized in a way that it can be researched (i.e., it is not too wide). This seems an obvious point to make, but failure to think through precisely what it is about your research topic you wish to investigate will have a knock-on effect on the framing of the case, data gathering, and interpretation and may lead, in some instances, to not gathering or analyzing data that actually informs the topic. Further conceptualization or reconceptualization may be necessary as the study proceeds, but it is critical to have a clear focus at the outset.

What Constitutes the Case

Second, I think it is important to decide what would constitute the case (i.e., what it is a case of) and where the boundaries of this lie. This often proves more difficult than first appears. And sometimes, partly because of the semifluid nature of the way the case evolves, it is only possible to finally establish what the case is a case of at the end. Nevertheless, it is useful to identify what the case and its boundaries are at the outset to help focus data collection while maintaining an awareness that these may shift. This is emergent design in action.

In deciding the boundary of the case, there are several factors to bear in mind. Is it bounded by an institution or a unit within an institution, by people within an institution, by region, or by project, program or policy,? If we take a school as an example, the case could be comprised of the principal, teachers, and students, or the boundary could be extended to the cleaners, the caretaker, the receptionist, people who often know a great deal about the subnorms and culture of the institution.

If the case is a policy or particular parameter of a policy, the considerations may be slightly different. People will still be paramount—those who generated the policy and those who implemented it—but there is likely also to be a political culture surrounding the policy that had an influence on the way the policy evolved. Would this be part of the case?

Whatever boundary is chosen, this may change in the course of conducting the study when issues arise that can only be understood by going to another level. What transpires in a classroom, for example, if this is the case, is often partly dependent on the support of the school leadership and culture of the institution and this, in turn, to some extent is dependent on what resources are allocated from the local education administration. Much like a series of Russian dolls, one context inside the other.

Unit of analysis

Thinking about what would constitute the unit of analysis— a classroom, an institution, a program, a region—may help in setting the boundaries of the case, and it will certainly help when it comes to analysis. But this is a slightly different issue from deciding what the case is a case of. Taking a health example, the case may be palliative care support, but the unit of analysis the palliative care ward or wards. If you took the palliative care ward as the unit of analysis this would be as much about how palliative care was exercised in this or that ward than issues about palliative care support in general. In other words, you would need to have specific information and context about how this ward was structured and managed to understand how palliative care was conducted in this particular ward. Here, as in the school example above, you would need to consider which of the many people who populate the ward form part of the case—nurses, interns, or doctors only, or does it extend to patients, cleaners, nurse aides, and medical students?

Framing Questions and Issues

The third most important consideration is how to frame the study, and you are likely to do this once you have selected the site or sites for study. There are at least four approaches. You could start with precise questions, foreshadowed issues ( Smith & Pohland, 1974 ), theories, or a program logic. To some extent, your choice will be dictated by the type of case you have chosen, but also by your personal preference for how to conduct it—in either a structured or open way.

Initial questions give structure; foreshadowed issues more freedom to explore. In qualitative case study, foreshadowed issues are more common, allowing scope for issues to change as the study evolves, guided by participants’ perspectives and events in the field. With this perspective, it is more likely that you will generate a theory of the case toward the end, through your interpretation and analysis.

If you are conducting an instrumental case study, staying close to the questions or foreshadowed issues is necessary to be sure you gain data that will illuminate the central focus of the study. This is critical if you are exploring issues across several cases, although it is possible to do a cross-case analysis from cases that have each followed a different route to discovering significant issues.

Opting to start with a theoretical framework provides a basis for formulating questions and issues, but it can also constrain the study to only those questions/issues that fit the framework. The same is true with using program logic to frame the case. This is an approach frequently adopted in evaluation case study where the evaluator, individually or with stakeholders, examines how the aims and objectives of the program relate to the activities designed to promote it and the outcomes and impacts expected. It provides direction, although it can lead to simply confirming what was anticipated, rather than documenting what transpired in the case.

Whichever approach you choose to frame the case, it is useful to think about the rationale or theory for each question and what methods would best enable you to gain an understanding of them. This will not only start a reflexive process of examining your choices—an important aspect of the process of data gathering and interpretation—it will also aid analysis and interpretation further down the track.

Methodology and Methods

Qualitative case study research, as already noted, appeals to subjective ways of knowing and to a primarily qualitative methodology, that captures experiential understanding ( Stake, 2010 , pp. 56–70). It follows that the main methods of data gathering to access this way of knowing will be qualitative. Interviewing, observation, and document analysis are the primary three, often supported by critical incidents, focus groups, cameos, vignettes, diaries/journals, and photographs. Before gathering any primary data, however, it is useful to search relevant existing sources (written or visual) to learn about the antecedents and context of a project, program, or policy as a backdrop to the case. This can sharpen framing questions, avoid unnecessary data gathering, and shorten the time needed in the field.

Given that there are excellent texts on qualitative methods (see, for example, Denzin & Lincoln, 1994 ; Seale, 1999 ; Silverman, 2000 , 2004 ), I will not discuss all potential relevant methods here, but simply focus on the qualities of the primary methods that are particularly appropriate for case study research.

Primary Qualitative Data Gathering Methods

Interviewing.

The most effective style of interviewing in qualitative case study research to gain in-depth data, document multiple perspectives and experiences and explore contested issues is the unstructured interview, active listening and open questioning are paramount, whatever prequestions or foreshadowed issues have been identified. This can include photographs—a useful starting point with certain cultural groups and the less articulate, to encourage them to tell their story through connecting or identifying with something in the image.

The flexibility of unstructured interviewing has three further advantages for understanding participants’ experiences. First, through questioning, probing, listening, and, above all, paying attention to the silences and what they mean, you can get closer to the meaning of participants’ experiences. It is not always what they say.

Second, unstructured interviewing is useful for engaging participants in the process of research. Instead of starting with questions and issues, invite participants to tell their stories or reflect on specific issues, to conduct their own self-evaluative interview, in fact. Not only will they contribute their particular perspective to the case, they will also learn about themselves, thereby making the process of research educative for them as well as for the audiences of the research.

Third, the open-endedness of this style of interviewing has the potential for creating a dialogue between participants and the researcher and between the researcher and the public, if enough of the dialogue is retained in the publication ( Bellah, Madsen, Sullivan, Swidler, & Tipton, 1985 ).

Observations

Observations in case study research are likely to be close-up descriptions of events, activities, and incidents that detail what happens in a particular context. They will record time, place, specific incidents, transactions, and dialogue, and note characteristics of the setting and of people in it without preconceived categories or judgment. No description is devoid of some judgment in selection, of course, but, on the whole, the intent is to describe the scene or event “as it is,” providing a rich, textured description to give readers a sense of what it was like to be there or provide a basis for later interpretation.

Take the following excerpt from a study of the West Bromwich Operatic Society. It is the first night of a new production, The Producers , by this amateur operatic society. This brief excerpt is from a much longer observation of the overture to the first evening’s performance, detailing exactly what the production is, where it is, and why there is such a tremendous sense of atmosphere and expectation surrounding the event. Space prevents including the whole observation, but I hope you can get a glimmer of the passion and excitement that precedes the performance:

Birmingham, late November, 2011, early evening.... Bars and restaurants spruce up for the evening’s trade. There is a chill in the air but the party season is just starting....

A few hundred yards away, past streaming traffic on Suffolk Street, Queensway, an audience is gathering at the New Alexandra Theatre. The foyer windows shine in the orange sodium night. Above each one is the rubric: WORLD CLASS THEATRE.

Inside the preparatory rituals are being observed; sweets chosen, interval drinks ordered and programmes bought. People swap news and titbits about the production.... The bubble of anticipation grows as the 5-minute warning sounds. People make their way to the auditorium. There have been so many nights like this in the past 110 years since a man named William Coutts invested £10,000 to build this palace of dreams.... So many fantasies have been played under this arch: melodramas and pantomimes, musicals and variety.... So many audiences, settling down in their tip-up seats, wanting to be transported away from work, from ordinariness and private troubles.... The dimming lights act like a mother’s hush. You could touch the silence. Boinnng! A spongy thump on a bass drum, and the horns pipe up that catchy, irrepressible, tasteless tune and already you’re singing under your breath, ‘Springtime for Hitler and Germany....’ The orchestra is out of sight in the pit. There’s just the velvet curtain to watch as your fingers tap along. What’s waiting behind? Then it starts it to move. Opening night.... It’s opening night! ( Matarasso, 2012 , pp. 1–2)

For another and different example—a narrative observation of an everyday but unique incident that details date, time, place, and experience—see Simons (2009 , p. 60).

Such naturalistic observations are also useful in contexts where we cannot understand what is going on through interviewing alone—in cultures with which we are less familiar or where key actors may not share our language or have difficulty expressing it. Careful description in these situations can help identify key issues, discover the norms and values that exist in the culture, and, if sufficiently detailed, allow others to cross corroborate what significance we draw from these observations. This last point is very important to avoid the danger in observation of ascribing motivations to people and meanings to transactions.

Finally, naturalistic observations are very important in highly politicized environments, often the case in commissioned evaluation case study, where individuals in interview may try to elude the “truth” or press on you that their view is the “right” view of the situation. In these contexts, naturalistic observations not only enable you to document interactions as you perceive them, but they also provide a cross-check on the veracity of information obtained in interviews.

Document analysis

Analysis of documents, as already intimated, is useful for establishing what historical antecedents might exist to provide a springboard for contemporaneous data gathering. In most cases, existing documents are also extremely pertinent for understanding the policy context.

In a national policy case study I conducted on a major curriculum change, the importance of preexisting documentation was brought home to me sharply when certain documentation initially proved elusive to obtain. It was difficult to believe that it did not exist, as the evolution of the innovation involved several parties who had not worked together before. There was bound, I thought, to be minuted meetings sharing progress and documentation of the “new” curriculum. In the absence of some crucial documents, I began to piece together the story through interviewing. Only there were gaps, and certain issues did not make sense.

It was only when I presented two versions of what I discerned had transpired in the development of this initiative in an interim report eighteen months into the study that things started to change. Subsequent to the meeting at which the report was presented, the “missing” documents started to appear. Suddenly found. What lay behind the “missing documents,” something I suspected from what certain individuals did and did not say in interview, was a major difference of view about how the innovation evolved, who was key in the process, and whose voice was more important in the context. Political differences, in other words, that some stakeholders were trying to keep from me. The emergence of the documents enabled me to finally produce an accurate and fair account.

This is an example of the importance of having access to all relevant documents relating to a program or policy in order to study it fairly. The other major way in which document analysis is useful in case study is for understanding the values, explicit and hidden, in policy and program documents and in the organization where the program or policy is implemented. Not to be ignored as documents are photographs, and these, too, can form the basis of a cultural and value analysis of an organization ( Prosser, 2000 ).

Creative artistic approaches

Increasingly, some case study researchers are employing creative approaches associated with the arts as a means of data gathering and analysis. Artistic approaches have often been used in representing findings, but less frequently in data gathering and interpretation ( Simons & McCormack, 2007 ). A major exception is the work of Richardson (1994) , who sees the very process of writing as an interpretative act, and of Cancienne and Snowber (2003) , who argue for movement as method.

The most familiar of these creative and artistic forms are written—narratives and short stories ( Clandinin & Connelly, 2000 ; Richardson, 1994 ; Sparkes, 2002 ), poems or poetic form ( Butler-Kisber, 2010 ; Duke, 2007 ; Richardson, 1997 ; Sparkes & Douglas, 2007 ), cameos of people, or vignettes of situations. These can be written by participants or by the researcher or developed in partnership. They can also be shared with participants to further interpret the data. But photographs also have a long history in qualitative research for presenting and constructing understanding ( Butler-Kisber, 2010 ; Collier, 1967 ; Prosser, 2000 ; Rugang, 2006 ; Walker, 1993 ).

Less common are other visual forms of gathering data, such as “draw and write” ( Sewell, 2011 ), artefacts, drawings, sketches, paintings, and collages, although all forms are now on the increase. For examples of the use of collage in data gathering, see Duke (2007) and Butler-Kisber (2010) , and for charcoal drawing, Elliott (2008) .

In qualitative inquiry broadly, these creative approaches are now quite common. And in the context of arts and health in particular (see, for example, Frank, 1997 ; Liamputtong & Rumbold, 2008 ; Spouse, 2000 ), we can see how artistic approaches illuminate in-depth understanding. However, in case study research to date, I think narrative forms have tended to be most prominent.

Finally, for capturing the quality and essence of peoples’ experience, nothing could be more revealing than a recording of their voices. Video diaries—self-evaluative portrayals by individuals of their perspectives, feelings, or experience of an event or situation—are a most potent way both of gaining understanding and communicating that to others. It is rather more difficult to gain access for observational videos, but they are useful for documentation and have the potential to engage participants and stakeholders in the interpretation.

Getting It All Together

Case study is so often associated with story or with a report of some event or program that it is easy to forget that much analysis and interpretation has gone on before we reach this point. In many case study reports, this process is hidden, leaving the reader with little evidence on which to assess the validity of the findings and having to trust the one who wrote the tale.

This section briefly outlines possibilities, first, for analyzing and interpreting data, and second, for how to communicate the findings to others. However it is useful to think of these together and indeed, at the start, because decisions about how you report may influence how you choose to make sense of the data. Your choice may also vary according to the context of the study—what is expected or acceptable—and your personal predilections, whether you prefer a more rational than intuitive mode of analysis, for example, or a formal or informal style of writing up that includes images, metaphor, narratives, or poetic forms.

Analyzing and Interpreting Data

When it comes to making sense of data, I make a distinction between analysis—a formal inductive process that seeks to explain—and interpretation, a more intuitive process that gains understanding and insight from a holistic grasp of data, although these may interact and overlap at different stages.

The process, whichever emphasis you choose, is one of reducing or transforming a large amount of data to themes that can encapsulate the overarching meaning in the data. This involves sorting, refining, and refocusing data until they make sense. It starts at the beginning with preliminary hunches, sometimes called “interpretative asides” or “working hypotheses,” later moving to themes, analytic propositions, or a theory of the case.

There are many ways to conduct this process. Two strategies often employed are concept mapping —a means of representing data visually to explore links between related concepts—and progressive focusing ( Parlett & Hamilton, 1976 ), the gradual reframing of initially identified issues into themes that are then further interpreted to generate findings. Each of these strategies tends to have three stages: initial sense making, identification of themes, and examination of patterns and relationships between them.

If taking a formal analytic approach to the task, the data would likely be broken down into segments or datasets (coded and categorized) and then reordered and explored for themes, patterns, and possible propositions. If adopting a more intuitive process, you might focus on identifying insights through metaphors and images, lateral thinking, or puzzling over paradoxes and ambiguities in the data, after first immersing yourself in the total dataset, reading and re-reading interview scripts, observations and field notes to get a sense of the whole. Trying out different forms of making sense through poetry, vignettes, cameos, narratives, collages, and drawing are further creative ways to interpret data, as are photographs taken in the case arranged to explain or tell the story of the case.

Reporting Case Study Research

Narrative structure and story.

As indicated in the introduction, telling a story is often associated with case study and some think this is what a case study is. In one sense, it is and, given that story is the natural way in which we learn ( Okri, 1997 ), it is a useful framework both for gathering data and for communicating case study findings. Not any story will do however. To count as research, it must be authentic, grounded in data, interpreted and analyzed to convey the meaning of the case.

There are several senses in which story is appropriate in qualitative case study: in capturing stories participants tell, in generating a narrative structure that makes sense of the case (i.e., the story you will tell), and in deciding how you communicate this narrative (i.e., in story form). If you choose a written story form (and advice here can be sought from Harrington (2003) and Caulley (2008) ), it needs to be clearly structured, well written, and contain only the detail that is necessary to give readers the vicarious experience of what it was like in the case. If the story is to be communicated in other ways, through, for example, audio or videotape, or computer or personal interaction, the same applies, substituting visual and interpersonal skill for written.

Matching forms of reporting to audience

The art of reporting is strongly connected to usability, so forms of reporting need to connect to the audiences we hope to inform: how they learn, what kind of evidence they value, and what kind of reporting maximizes the chances they will use the findings to promote policies and programs in the interests of beneficiaries. As Okri (1997) further reminds us, the writer only does half the work; the reader does the other (p. 41).

There may be other considerations as well: how open are commissioners to receiving stories of difficulties, as well as success stories? What might they need to hear beyond what is sought in the technical brief? And through what style of reporting would you try and persuade them? If conducting noncommissioned case study research, the scope for different forms of reporting is wider. In academia, for instance, many institutions these days accept creative and artistic forms of reporting when supported by supervisors and appreciated by examiners.

Styles of Reporting

The most obvious form of reporting is linear, often starting with a short executive summary and a brief description of focus and context, followed by methodology, the case study or thematic analysis, findings, and conclusions or implications. Conclusion-led reporting is similar in terms of its formality, but simply starts the other way around. From the conclusions drawn from the analyzed data, it works backward to tell the story through narrative, verbatim, and observational data of how these conclusions were reached. Both have a strong story line. The intent is analytic and explanatory.

Quite a different approach is to engage the reader in the experience and veracity of the case. Rather like constructing a portrait or editing a documentary film, this involves the sifting, constructing, re-ordering of frames, events and episodes to tell a coherent story primarily through interview excerpts, observations, vignettes, and critical incidents that depict what transpired in the case. Interpretation is indirect through the weaving of the data. The story can start at any point provided the underlying narrative structure is maintained to establish coherence ( House, 1980 , p. 116).

Different again, and from the other end of a continuum, is a highly interpretative account that may use similar ways of presenting data but weaves a story from the outset that is highly interpretative. Engaging metaphor, images, short stories, contradictions, paradoxes, and puzzles, it is invariably interesting to read and can be most persuasive. However, the evidence is less visible and therefore less open to alternative interpretations.

Even more persuasive is a case study that uses artistic forms to communicate the story of the case. Paintings, poetic form, drawings, photography, collage, and movement can all be adopted to report findings, whether the data was acquired using these forms or by other means. The arts-based inquiry movement ( Mullen & Finley, 2003 ) has contributed hugely to the validation and legitimation of artistic and creative ways of representing qualitative research findings. The journal Qualitative Inquiry contains many good examples, but see also Liamputtong & Rumbold (2008) . Such artistic forms of representation may not be for everyone or appropriate in some contexts, but they do have the power to engage an audience and the potential to facilitate use.

Generalization in Case Study Research

One of the potential limitations of case study often proposed is that it is impossible to generalize. This is not so. However, the way in which one generalizes from a case is different from that adopted in traditional forms of social science research that utilize large samples (randomly selected) and statistical procedures and which assume regularities in the social world that allow cause and effect to be determined. In this form of research inferences from data are stated as formal propositions that apply to all in the target population. See Donmoyer (1990) for an argument on the restricted nature of this form of generalization when considering single-case studies.

Making inferences from cases with a qualitative data set arises more from a process of interpretation in context, appealing to tacit and situated understanding for acceptance of their validity. Such inferences are possible where the context and experience of the case is richly described so the reader can recognize and connect with the events and experiences portrayed. There are two ways to examine how to reach these generalized understandings. One is to generalize from the case to other cases of a similar or dissimilar nature. The other is to see what we learn in-depth from the uniqueness of the single case itself.

Generalizing from the Single Case

A common approach to generalization and one most akin to a propositional form is cross-case generalization. In a collective or multi-site case study, each case is explored to see if issues that arise in one case also exist in other cases and what interconnecting themes there are between them. This kind of generalization has a degree of abstraction and potential for theorizing and is often welcomed by commissioners of research concerned that findings from the single case do not provide an adequate or “safe” basis for policy determination.

However, there are four additional ways to generalize from the single case, all of which draw more on tacit knowledge and recognition of context, although in different ways. In naturalistic generalization , first proposed by Stake (1978) , generalization is reached on the basis of recognition of similarities and differences to cases with which we are familiar. To enable such recognition, the case needs to feature rich description; people’s voices; and enough detail of time, place, and context to provide a vicarious experience to help readers discern what is similar and dissimilar to their own context ( Stake, 1978 ).

Situated generalization ( Simons, Kushner, Jones, & James, 2003 ) is close to the concept of naturalistic generalization in relying for its generality on retaining a connectedness with the context in which it first evolved. However, it has an extra dimension in a practice context. This notion of generalization was identified in an evaluation of a research project that engaged teachers in and with research. Here, in addition to the usual validity criteria to establish the warrant for the findings, the generalization was seen as dependable if trust existed between those who conducted the research (teachers, in this example) and those thinking about using it (other teachers). In other words, beyond the technical validity of the research, teachers considered using the findings in their own practice because they had confidence in those who generated them. This is a useful way to think about generalization if we wish research findings to improve professional practice.

The next two concepts of generalization— concept and process generalization —relate more to what you discover in making sense of the case. As you interpret and analyze, you begin to generate a theory of the case that makes sense of the whole. Concepts may be identified that make sense in the one case but have equal significance in other cases of a similar kind, even if the contexts are different.

It is the concept that generalizes, not the specific content or context. This may be similar to the process Donmoyer (2008) identifies of “intellectual generalization” (quoted by Butler-Kisber, 2010 , p. 15) to indicate the cognitive understanding one can gain from qualitative accounts even if settings are quite different.

The same is true for generalization of a process. It is possible to identify a significant process in one case (or several cases) that is transferable to other contexts, irrespective of the precise content and contexts of those other cases. An example here is the collaborative model for sustainable school self-evaluation I identified in researching school self-evaluation in a number of schools and countries ( Simons, 2002 ). Schools that successfully sustained school self-evaluation had an infrastructure that was collaborative at all stages of the evaluation process from design to conduct of the study, to analyzing the results and to reporting the findings. This ensured that the whole school was involved and that results were discussed and built into the ongoing development of school policies and practice. In other cases, different processes may be discovered that have applicability in a range of contexts. As with concept generalization, it is the process that generalizes not the substantive content or specific context.

Particularization

The forms of generalization discussed above are useful when we have to justify case study in a research or policy context. But the overarching justification for how we learn from case study is particularization —a rich portrayal of insights and understandings interpreted in the particular context. Several authors have made this point ( Stake, 1995 ; Flyvberg, 2006 ; Simons 2009 ). Stake puts it most sharply when he observes that “The real business of case study is particularization, not generalization” (p. 8), referring here to the main reason for studying the singular, which is to understand the uniqueness of the case itself.

My perspective (explored further in Simons, 1996 ; Simons, 2009 , p. 239; Simons & McCormack, 2007 ) is similar in that I believe the “real” strength of case study lies in the insights we gain from in-depth study of the particular. But I also argue for the universality of such insights—if we get it “right.” By which I mean that if we are able to capture and report the uniqueness, the essence, of the case in all its particularity and present this in a way we can all recognize, we will discover something of universal significance. This is something of a paradox. The more you learn in depth about the particularity of one person, situation, or context, the more likely you are to discover something universal. This process of reaching understanding has support both from the way in which many discoveries are made in science and in how we learn from artists, poets, and novelists, who reach us by communicating a recognizable truth about individuals, human relationships, and/or social contexts.

This concept of particularization is far from new, as the quotation from a preface to a book written in 1908 attests. Stephen Reynolds, the author of A Poor Man’s House , notes that the substance of the book was first recorded in a journal, kept for purposes of fiction, and in letters to one of his friends, but fiction proved an inappropriate medium. He felt that the life and the people were so much better than anything he could invent. The book therefore consists of the journal and letters drawn together to present a picture of a typical poor man’s house and life, much as we might draw together a range of data to present a case study. It is not the substance of the book that concerns us here but the methodological relevance to case study research. Reynolds notes that the conclusions expressed are tentative and possibly go beyond this man’s life, so he thought some explanation of the way he arrived at them was needed:

Educated people usually deal with the poor man’s life deductively; they reason from the general to the particular; and, starting with a theory, religious, philanthropic, political, or what not, they seek, and too easily find, among the millions of poor, specimens—very frequently abnormal—to illustrate their theories. With anything but human beings, that is an excellent method. Human beings, unfortunately, have individualities. They do what, theoretically, they ought not to do, and leave undone those things they ought to do. They are even said to possess souls—untrustworthy things beyond the reach of sociologists. The inductive method—reasoning from the particular to the general... should at least help to counterbalance the psychological superficiality of the deductive method. ( Reynolds, 1908 : preface) 1

Slightly overstated perhaps, but the point is well made. In our search for general laws, we not only lose sight of the uniqueness and humanity of individuals, but reduce them in the process, failing to present their experience in any “real” sense. What is astonishing about the quotation is that it was written over a century ago and yet many still argue today that you cannot generalize from the particular.

Going even further back, in 1798, Blake proclaimed that “To Generalize is to be an Idiot. To Particularize is the Alone Distinction of Merit.” In research, we may not wish to make such a strong distinction: these processes both have their uses in different kinds of research. But there is a major point here for the study of the particular that Wilson (2008) notes in commenting on Blake’s perception when he says: “Favouring the abstract over the concrete, one ‘sees all things only thro’ the narrow chinks of his cavern”’ (referring here to Blake’s The Marriage of Heaven and Hell [1793]; in Wilson, 2008 , p. 62). The danger Wilson is pointing to here is that abstraction relies heavily on what we know from our past understanding of things, and this may prevent us experiencing a concrete event directly or “apprehend[ing] a particular moment” ( Wilson, 2008 , p. 63).

Blake had a different mission, of course, than case researchers, and he was not himself free from abstractions, as Wilson points out, although he fought hard “to break through mental barriers to something unique and living” ( Wilson, 2008 , p. 65). It is this search for the “unique and living” and experiencing the “isness” of the particular that we should take from the Blake example to remind ourselves of the possibility of discovering something “new,” beyond our current understanding of the way things are.

Focusing on particularization does not diminish the usefulness of case study research for policy makers or practitioners. Grounded in recognizable experience, the potential is there to reach a range of audiences and to facilitate use of the findings. It may be more difficult for those who seek formal generalizations that seem to offer a safe basis for policy making to accept case study reports. However, particular stories often hold the key to why policies have or have not worked well in the past. It is not necessary to present long cases—a criticism frequently levelled—to demonstrate the story of the case. Such case stories can be most insightful for policy makers who, like many of us in everyday life, often draw inferences from a single instance or case, whatever the formal evidence presented. “I am reminded of the story of....”

The case for studying the particular to inform practice in professional contexts needs less persuasion because practitioners can recognize the content and context quite readily and make the inference to their own particular context ( Simons et al., 2003 ). In both sets of circumstances—policy and practice—it is more a question of whether the readers of our case research accept the validity of findings determined in this way, how they choose to learn, and our skill in telling the case study story.

Conclusion and Future Directions

In this chapter, I have presented an argument for case study research, making the case, in particular, for using qualitative methods to highlight what it is that qualitative case study research can bring to the study of social and educational programs. I outlined the various ways in which case study is commonly used before focusing directly on case study as a major mode of research inquiry, noting characteristics it shares with other qualitative methodologies, as well as itsdifference and the difficulties it is sometimes perceived to have. The chapter emphasizes the importance of thinking through what the case is, to be sure that the issues explored and the data generated do illuminate this case and not any other.

But there is still more to be done. In particular, I think we need to be more adventurous in how we craft and report the case. I suspect we may have been too cautious in the past in how we justified case study research, borrowing concepts from other disciplines and forms of educational research. More than 40 years on, it is time to take a greater risk—in demonstrating the intrinsic nature of case study and what it can offer to our understanding of human and social situations.

I have already drawn attention to the need to design the case, although this could be developed further to accentuate the uniqueness of the particular case. One way to do this is to feature individuals more in the design itself, not only to explore programs and policies through perspectives of key actors or groups and transactions between them, which to some extent happens already, but also to get them to characterize what makes the context unique. This is the reversal of many a design framework that starts with the logic of a program and takes forward the argument for personal evaluation ( Kushner, 2000 ), noted in the interlude on evaluation. Apart from this attention to design, there are three other issues I think we need to explore further: the warrant for creative methods in case study, more imaginative reporting; and how we learn from a study of the singular.

Warrant for More Creative Methods in Case Study Research

The promise that creative methods have for eliciting in-depth understanding and capturing the unusual, the idiosyncratic, the uniqueness of the case, was mentioned in the methods section. Yet, in case study research, particularly in program and policy contexts, we have few good examples of the use of artistic approaches for eliciting and interpreting data, although more, as acknowledged later, for presenting it. This may be because case study research is often conducted in academic or policy environments, where propositional ways of knowing are more valued.

Using creative and artistic forms in generating and interpreting case study data offers a form of evidence that acknowledges experiential understanding in illuminating the uniqueness of the case. The question is how to establish the warrant for this way of knowing and persuade others of its virtue. The answer is simple. By demonstrating the use of these methods in action, by arguing for a different form of validity that matches the intrinsic nature of the method, and, above all, by good examples.

Representing Findings to Engage Audiences in Learning

In evaluative and research policy contexts, where case study is often the main mode of inquiry or part of a broader study, case study reports often take a formal structure or sometimes, where the context is receptive, a portrayal or interpretative form. But, too often, the qualitative is an add-on to a story told by other means or reduced to issues in which the people who gave rise to the data are no longer seen. However, there are many ways to put them center stage.

Tell good stories and tell them well. Or, let key actors tell their own stories. Explore the different ways technology can help. Make video clips that demonstrate events in context, illustrate interactions between people, give voice to participants—show the reality of the program, in other words. Use graphics to summarize key issues and interactive, cartoon technology, as seen on some TED presentations, to summarize and visually show the complexity of the case. Video diaries were mentioned in the methods section: seeing individuals tell their tales directly is a powerful way of communicating, unhindered by “our” sense making. Tell photo stories. Let the photos convey the narrative, but make sure the structure of the narrative is evident to ensure coherence. These are just the beginnings. Those skilled in information technology could no doubt stretch our imagination further.

One problem and a further question concerns our audiences. Will they accept these modes of communication? Maybe not, in some contexts. However, there are three points I wish to leave you with. First, do not presume that they won’t. If people are fully present in the story and the complexity is not diminished, those reading, watching, or hearing about the case will get the message. If you are worried about how commissioners might respond, remember that they are no different from any other stakeholder or participant when it comes to how they learn from human experience. Witness the reference to Okri (1997) earlier about how we learn.

Second, when you detect that the context requires a more formal presentation of findings, respond according to expectation but also include elements of other forms of presentation. Nudge a little in the direction of creativity. Third, simply take a chance, that risk I spoke about earlier. Challenge the status quo. Find situations and contexts where you can fully represent the qualitative nature of the experience in the cases you study with creative forms of interpretation and representation. And let the audience decide.

Learning from a Study of the Singular

Finally, to return to the issue of “generalization” in case study that worries some audiences. I pointed out in the generalization section several ways in which it is possible to generalize from case study research, not in a formal propositional sense or from a case to a population, but by retaining a connection with the context in which the generalization first arose—that is, to realize in-depth understanding in context in different circumstances and situations. However, I also emphasized that, in many instances, it is particularization from which we learn. That is the point of the singular case study, and it is an art to perceive and craft the case in ways that we can.

Acknowledgments

Parts of this chapter build on ideas first explored in Simons, 2009 .

I am grateful to Bob Williams for pointing out the relevance of this quotation from Reynolds to remind us that “there is nothing new under the sun” and that we sometimes continue to engage endlessly in debates that have been well rehearsed before.

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Chapter 8: Case study

Darshini Ayton

Learning outcomes

Upon completion of this chapter, you should be able to:

• Identify the key terms and concepts used in qualitative case study research.
• Discuss the advantages and disadvantages of qualitative case study research.

What is a case study?

The key concept in a case study is context .

In qualitative research, case studies provide in-depth accounts of events, relationships, experiences or processes. Stemming from the fields of evaluation, political science and law, the aim of a qualitative case study is to explore a phenomenon within the context of the case 1 and to answer how and why research questions. 2 The contextual conditions are relevant to the phenomenon under study and the contextual factors tend to lie with the case. 1 From the outset it is important (a) to determine who or what is your case – this can be a person, program, organisation or group, or a process – and (b) to articulate the phenomenon of interest.

An example of why context is important in understanding the phenomenon of interest is a study of health promotion action by local churches in Victoria, Australia. 3 The phenomenon under study was health promotion action, with 10 churches comprising the cases, which were mapped across the framework of health promotion approaches. 4 The contextual factors included church denomination (Baptist, Church of Christ, Uniting, Anglican, Catholic and Salvation Army), size (small, medium and large), location (rural and metropolitan), partnerships with external organisations (government, local schools and social welfare organisations) and theological orientation (traditional, modern or postmodern), to understand the phenomenon of health promotion action. Data collection took 12 months and involved interviews with 37 church leaders, 10 focus groups with volunteers, 17 instances of participant observation of church activities, including church services, youth events, food banks and community meals, and 12 documentary analyses of church websites, newsletters and annual reports. The case studies identified and illustrated how and why three different expressions of church – traditional, new modern and emerging – led to different levels and types of health promotion activities.

Three prominent qualitative case study methodologists, Robert Stake, Robert Yin and Sharan Merriams, have articulated different approaches to case studies and their underpinning philosophical and paradigmatic assumptions. Table 8 outlines these approaches, based on work by Yazan, 5 whose expanded table covers characteristics of case studies, data collection and analysis.

Table 8.1. Comparison of case study terms used by three key methodologists

Table 8.1 is derived from ‘Three Approaches to Case Study Methods in Education: Yin, Merriam, and Stake ‘  by Bedrettin Yazan,  licensed under CC BY-NC-SA 4.0. 5

There are several forms of qualitative case studies. 1,2

Discovery-led case studies, which:

• describe what is happening in the setting
• explore the key issues affecting people within the setting
• compare settings, to learn from the similarities and differences between them.

Theory-led case studies, which:

• explain the causes of events, processes or relationships within a setting
• illustrate how a particular theory applies to a real-life setting
• experiment with changes in the setting to test specific factors or variables.

Single and collective case studies, where: 2, 9

• the researcher wants to understand a unique phenomenon in detail– known as an intrinsic case study
• the researcher is seeking insight and understanding of a particular situation or phenomenon, known as an illustrative case study or instrumental case study.

In both intrinsic, instrumental and illustrative case studies, the exploration might take place within a single case. In contrast, a collective case study includes multiple individual cases, and the exploration occurs both within and between cases. Collective case studies may include comparative cases, whereby cases are sampled to provide points of comparison for either context or the phenomenon. Embedded case studies are increasingly common within multi-site, randomised controlled trials, where each of the study sites is considered a case.

Multiple forms of data collection and methods of analysis (e.g. thematic, content, framework and constant comparative analyses) can be employed, since case studies are characterised by the depth of knowledge they provide and their nuanced approaches to understanding phenomena within context. 2,5 This approach enables triangulation between data sources (interviews, focus groups, participant observations), researchers and theory. Refer to Chapter 19 for information about triangulation.

Advantages and disadvantages of qualitative case studies

Advantages of using a case study approach include the ability to explore the subtleties and intricacies of complex social situations, and the use of multiple data collection methods and data from multiple sources within the case, which enables rigour through triangulation. Collective case studies enable comparison and contrasting within and across cases.

However, it can be challenging to define the boundaries of the case and to gain appropriate access to the case for the ‘deep dive’ form of analysis. Participant observation, which is a common form of data collection, can lead to observer bias. Data collection can take a long time and may require lengthy times, resources and funding to conduct the study. 9

Table 8.2 provides an example of a single case study and of a collective case study.

Table 8.2. Examples of qualitative case studies

Qualitative case studies provide a study design with diverse methods to examine the contextual factors relevant to understanding the why and how of a phenomenon within a case. The design incorporates single case studies and collective cases, which can also be embedded within randomised controlled trials as a form of process evaluation.

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• Nayback-Beebe AM, Yoder LH. The lived experiences of a male survivor of intimate partner violence: a qualitative case study. Medsurg Nurs . 2012;21(2):89-95; quiz 96.
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Qualitative Research – a practical guide for health and social care researchers and practitioners Copyright © 2023 by Darshini Ayton is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License , except where otherwise noted.

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• Can J Hosp Pharm
• v.68(3); May-Jun 2015

Qualitative Research: Data Collection, Analysis, and Management

Introduction.

In an earlier paper, 1 we presented an introduction to using qualitative research methods in pharmacy practice. In this article, we review some principles of the collection, analysis, and management of qualitative data to help pharmacists interested in doing research in their practice to continue their learning in this area. Qualitative research can help researchers to access the thoughts and feelings of research participants, which can enable development of an understanding of the meaning that people ascribe to their experiences. Whereas quantitative research methods can be used to determine how many people undertake particular behaviours, qualitative methods can help researchers to understand how and why such behaviours take place. Within the context of pharmacy practice research, qualitative approaches have been used to examine a diverse array of topics, including the perceptions of key stakeholders regarding prescribing by pharmacists and the postgraduation employment experiences of young pharmacists (see “Further Reading” section at the end of this article).

In the previous paper, 1 we outlined 3 commonly used methodologies: ethnography 2 , grounded theory 3 , and phenomenology. 4 Briefly, ethnography involves researchers using direct observation to study participants in their “real life” environment, sometimes over extended periods. Grounded theory and its later modified versions (e.g., Strauss and Corbin 5 ) use face-to-face interviews and interactions such as focus groups to explore a particular research phenomenon and may help in clarifying a less-well-understood problem, situation, or context. Phenomenology shares some features with grounded theory (such as an exploration of participants’ behaviour) and uses similar techniques to collect data, but it focuses on understanding how human beings experience their world. It gives researchers the opportunity to put themselves in another person’s shoes and to understand the subjective experiences of participants. 6 Some researchers use qualitative methodologies but adopt a different standpoint, and an example of this appears in the work of Thurston and others, 7 discussed later in this paper.

Qualitative work requires reflection on the part of researchers, both before and during the research process, as a way of providing context and understanding for readers. When being reflexive, researchers should not try to simply ignore or avoid their own biases (as this would likely be impossible); instead, reflexivity requires researchers to reflect upon and clearly articulate their position and subjectivities (world view, perspectives, biases), so that readers can better understand the filters through which questions were asked, data were gathered and analyzed, and findings were reported. From this perspective, bias and subjectivity are not inherently negative but they are unavoidable; as a result, it is best that they be articulated up-front in a manner that is clear and coherent for readers.

THE PARTICIPANT’S VIEWPOINT

What qualitative study seeks to convey is why people have thoughts and feelings that might affect the way they behave. Such study may occur in any number of contexts, but here, we focus on pharmacy practice and the way people behave with regard to medicines use (e.g., to understand patients’ reasons for nonadherence with medication therapy or to explore physicians’ resistance to pharmacists’ clinical suggestions). As we suggested in our earlier article, 1 an important point about qualitative research is that there is no attempt to generalize the findings to a wider population. Qualitative research is used to gain insights into people’s feelings and thoughts, which may provide the basis for a future stand-alone qualitative study or may help researchers to map out survey instruments for use in a quantitative study. It is also possible to use different types of research in the same study, an approach known as “mixed methods” research, and further reading on this topic may be found at the end of this paper.

The role of the researcher in qualitative research is to attempt to access the thoughts and feelings of study participants. This is not an easy task, as it involves asking people to talk about things that may be very personal to them. Sometimes the experiences being explored are fresh in the participant’s mind, whereas on other occasions reliving past experiences may be difficult. However the data are being collected, a primary responsibility of the researcher is to safeguard participants and their data. Mechanisms for such safeguarding must be clearly articulated to participants and must be approved by a relevant research ethics review board before the research begins. Researchers and practitioners new to qualitative research should seek advice from an experienced qualitative researcher before embarking on their project.

DATA COLLECTION

Whatever philosophical standpoint the researcher is taking and whatever the data collection method (e.g., focus group, one-to-one interviews), the process will involve the generation of large amounts of data. In addition to the variety of study methodologies available, there are also different ways of making a record of what is said and done during an interview or focus group, such as taking handwritten notes or video-recording. If the researcher is audio- or video-recording data collection, then the recordings must be transcribed verbatim before data analysis can begin. As a rough guide, it can take an experienced researcher/transcriber 8 hours to transcribe one 45-minute audio-recorded interview, a process than will generate 20–30 pages of written dialogue.

Many researchers will also maintain a folder of “field notes” to complement audio-taped interviews. Field notes allow the researcher to maintain and comment upon impressions, environmental contexts, behaviours, and nonverbal cues that may not be adequately captured through the audio-recording; they are typically handwritten in a small notebook at the same time the interview takes place. Field notes can provide important context to the interpretation of audio-taped data and can help remind the researcher of situational factors that may be important during data analysis. Such notes need not be formal, but they should be maintained and secured in a similar manner to audio tapes and transcripts, as they contain sensitive information and are relevant to the research. For more information about collecting qualitative data, please see the “Further Reading” section at the end of this paper.

DATA ANALYSIS AND MANAGEMENT

If, as suggested earlier, doing qualitative research is about putting oneself in another person’s shoes and seeing the world from that person’s perspective, the most important part of data analysis and management is to be true to the participants. It is their voices that the researcher is trying to hear, so that they can be interpreted and reported on for others to read and learn from. To illustrate this point, consider the anonymized transcript excerpt presented in Appendix 1 , which is taken from a research interview conducted by one of the authors (J.S.). We refer to this excerpt throughout the remainder of this paper to illustrate how data can be managed, analyzed, and presented.

Interpretation of Data

Interpretation of the data will depend on the theoretical standpoint taken by researchers. For example, the title of the research report by Thurston and others, 7 “Discordant indigenous and provider frames explain challenges in improving access to arthritis care: a qualitative study using constructivist grounded theory,” indicates at least 2 theoretical standpoints. The first is the culture of the indigenous population of Canada and the place of this population in society, and the second is the social constructivist theory used in the constructivist grounded theory method. With regard to the first standpoint, it can be surmised that, to have decided to conduct the research, the researchers must have felt that there was anecdotal evidence of differences in access to arthritis care for patients from indigenous and non-indigenous backgrounds. With regard to the second standpoint, it can be surmised that the researchers used social constructivist theory because it assumes that behaviour is socially constructed; in other words, people do things because of the expectations of those in their personal world or in the wider society in which they live. (Please see the “Further Reading” section for resources providing more information about social constructivist theory and reflexivity.) Thus, these 2 standpoints (and there may have been others relevant to the research of Thurston and others 7 ) will have affected the way in which these researchers interpreted the experiences of the indigenous population participants and those providing their care. Another standpoint is feminist standpoint theory which, among other things, focuses on marginalized groups in society. Such theories are helpful to researchers, as they enable us to think about things from a different perspective. Being aware of the standpoints you are taking in your own research is one of the foundations of qualitative work. Without such awareness, it is easy to slip into interpreting other people’s narratives from your own viewpoint, rather than that of the participants.

To analyze the example in Appendix 1 , we will adopt a phenomenological approach because we want to understand how the participant experienced the illness and we want to try to see the experience from that person’s perspective. It is important for the researcher to reflect upon and articulate his or her starting point for such analysis; for example, in the example, the coder could reflect upon her own experience as a female of a majority ethnocultural group who has lived within middle class and upper middle class settings. This personal history therefore forms the filter through which the data will be examined. This filter does not diminish the quality or significance of the analysis, since every researcher has his or her own filters; however, by explicitly stating and acknowledging what these filters are, the researcher makes it easer for readers to contextualize the work.

Transcribing and Checking

For the purposes of this paper it is assumed that interviews or focus groups have been audio-recorded. As mentioned above, transcribing is an arduous process, even for the most experienced transcribers, but it must be done to convert the spoken word to the written word to facilitate analysis. For anyone new to conducting qualitative research, it is beneficial to transcribe at least one interview and one focus group. It is only by doing this that researchers realize how difficult the task is, and this realization affects their expectations when asking others to transcribe. If the research project has sufficient funding, then a professional transcriber can be hired to do the work. If this is the case, then it is a good idea to sit down with the transcriber, if possible, and talk through the research and what the participants were talking about. This background knowledge for the transcriber is especially important in research in which people are using jargon or medical terms (as in pharmacy practice). Involving your transcriber in this way makes the work both easier and more rewarding, as he or she will feel part of the team. Transcription editing software is also available, but it is expensive. For example, ELAN (more formally known as EUDICO Linguistic Annotator, developed at the Technical University of Berlin) 8 is a tool that can help keep data organized by linking media and data files (particularly valuable if, for example, video-taping of interviews is complemented by transcriptions). It can also be helpful in searching complex data sets. Products such as ELAN do not actually automatically transcribe interviews or complete analyses, and they do require some time and effort to learn; nonetheless, for some research applications, it may be a valuable to consider such software tools.

All audio recordings should be transcribed verbatim, regardless of how intelligible the transcript may be when it is read back. Lines of text should be numbered. Once the transcription is complete, the researcher should read it while listening to the recording and do the following: correct any spelling or other errors; anonymize the transcript so that the participant cannot be identified from anything that is said (e.g., names, places, significant events); insert notations for pauses, laughter, looks of discomfort; insert any punctuation, such as commas and full stops (periods) (see Appendix 1 for examples of inserted punctuation), and include any other contextual information that might have affected the participant (e.g., temperature or comfort of the room).

Dealing with the transcription of a focus group is slightly more difficult, as multiple voices are involved. One way of transcribing such data is to “tag” each voice (e.g., Voice A, Voice B). In addition, the focus group will usually have 2 facilitators, whose respective roles will help in making sense of the data. While one facilitator guides participants through the topic, the other can make notes about context and group dynamics. More information about group dynamics and focus groups can be found in resources listed in the “Further Reading” section.

Reading between the Lines

During the process outlined above, the researcher can begin to get a feel for the participant’s experience of the phenomenon in question and can start to think about things that could be pursued in subsequent interviews or focus groups (if appropriate). In this way, one participant’s narrative informs the next, and the researcher can continue to interview until nothing new is being heard or, as it says in the text books, “saturation is reached”. While continuing with the processes of coding and theming (described in the next 2 sections), it is important to consider not just what the person is saying but also what they are not saying. For example, is a lengthy pause an indication that the participant is finding the subject difficult, or is the person simply deciding what to say? The aim of the whole process from data collection to presentation is to tell the participants’ stories using exemplars from their own narratives, thus grounding the research findings in the participants’ lived experiences.

Smith 9 suggested a qualitative research method known as interpretative phenomenological analysis, which has 2 basic tenets: first, that it is rooted in phenomenology, attempting to understand the meaning that individuals ascribe to their lived experiences, and second, that the researcher must attempt to interpret this meaning in the context of the research. That the researcher has some knowledge and expertise in the subject of the research means that he or she can have considerable scope in interpreting the participant’s experiences. Larkin and others 10 discussed the importance of not just providing a description of what participants say. Rather, interpretative phenomenological analysis is about getting underneath what a person is saying to try to truly understand the world from his or her perspective.

Once all of the research interviews have been transcribed and checked, it is time to begin coding. Field notes compiled during an interview can be a useful complementary source of information to facilitate this process, as the gap in time between an interview, transcribing, and coding can result in memory bias regarding nonverbal or environmental context issues that may affect interpretation of data.

Coding refers to the identification of topics, issues, similarities, and differences that are revealed through the participants’ narratives and interpreted by the researcher. This process enables the researcher to begin to understand the world from each participant’s perspective. Coding can be done by hand on a hard copy of the transcript, by making notes in the margin or by highlighting and naming sections of text. More commonly, researchers use qualitative research software (e.g., NVivo, QSR International Pty Ltd; www.qsrinternational.com/products_nvivo.aspx ) to help manage their transcriptions. It is advised that researchers undertake a formal course in the use of such software or seek supervision from a researcher experienced in these tools.

Returning to Appendix 1 and reading from lines 8–11, a code for this section might be “diagnosis of mental health condition”, but this would just be a description of what the participant is talking about at that point. If we read a little more deeply, we can ask ourselves how the participant might have come to feel that the doctor assumed he or she was aware of the diagnosis or indeed that they had only just been told the diagnosis. There are a number of pauses in the narrative that might suggest the participant is finding it difficult to recall that experience. Later in the text, the participant says “nobody asked me any questions about my life” (line 19). This could be coded simply as “health care professionals’ consultation skills”, but that would not reflect how the participant must have felt never to be asked anything about his or her personal life, about the participant as a human being. At the end of this excerpt, the participant just trails off, recalling that no-one showed any interest, which makes for very moving reading. For practitioners in pharmacy, it might also be pertinent to explore the participant’s experience of akathisia and why this was left untreated for 20 years.

One of the questions that arises about qualitative research relates to the reliability of the interpretation and representation of the participants’ narratives. There are no statistical tests that can be used to check reliability and validity as there are in quantitative research. However, work by Lincoln and Guba 11 suggests that there are other ways to “establish confidence in the ‘truth’ of the findings” (p. 218). They call this confidence “trustworthiness” and suggest that there are 4 criteria of trustworthiness: credibility (confidence in the “truth” of the findings), transferability (showing that the findings have applicability in other contexts), dependability (showing that the findings are consistent and could be repeated), and confirmability (the extent to which the findings of a study are shaped by the respondents and not researcher bias, motivation, or interest).

One way of establishing the “credibility” of the coding is to ask another researcher to code the same transcript and then to discuss any similarities and differences in the 2 resulting sets of codes. This simple act can result in revisions to the codes and can help to clarify and confirm the research findings.

Theming refers to the drawing together of codes from one or more transcripts to present the findings of qualitative research in a coherent and meaningful way. For example, there may be examples across participants’ narratives of the way in which they were treated in hospital, such as “not being listened to” or “lack of interest in personal experiences” (see Appendix 1 ). These may be drawn together as a theme running through the narratives that could be named “the patient’s experience of hospital care”. The importance of going through this process is that at its conclusion, it will be possible to present the data from the interviews using quotations from the individual transcripts to illustrate the source of the researchers’ interpretations. Thus, when the findings are organized for presentation, each theme can become the heading of a section in the report or presentation. Underneath each theme will be the codes, examples from the transcripts, and the researcher’s own interpretation of what the themes mean. Implications for real life (e.g., the treatment of people with chronic mental health problems) should also be given.

DATA SYNTHESIS

In this final section of this paper, we describe some ways of drawing together or “synthesizing” research findings to represent, as faithfully as possible, the meaning that participants ascribe to their life experiences. This synthesis is the aim of the final stage of qualitative research. For most readers, the synthesis of data presented by the researcher is of crucial significance—this is usually where “the story” of the participants can be distilled, summarized, and told in a manner that is both respectful to those participants and meaningful to readers. There are a number of ways in which researchers can synthesize and present their findings, but any conclusions drawn by the researchers must be supported by direct quotations from the participants. In this way, it is made clear to the reader that the themes under discussion have emerged from the participants’ interviews and not the mind of the researcher. The work of Latif and others 12 gives an example of how qualitative research findings might be presented.

Planning and Writing the Report

As has been suggested above, if researchers code and theme their material appropriately, they will naturally find the headings for sections of their report. Qualitative researchers tend to report “findings” rather than “results”, as the latter term typically implies that the data have come from a quantitative source. The final presentation of the research will usually be in the form of a report or a paper and so should follow accepted academic guidelines. In particular, the article should begin with an introduction, including a literature review and rationale for the research. There should be a section on the chosen methodology and a brief discussion about why qualitative methodology was most appropriate for the study question and why one particular methodology (e.g., interpretative phenomenological analysis rather than grounded theory) was selected to guide the research. The method itself should then be described, including ethics approval, choice of participants, mode of recruitment, and method of data collection (e.g., semistructured interviews or focus groups), followed by the research findings, which will be the main body of the report or paper. The findings should be written as if a story is being told; as such, it is not necessary to have a lengthy discussion section at the end. This is because much of the discussion will take place around the participants’ quotes, such that all that is needed to close the report or paper is a summary, limitations of the research, and the implications that the research has for practice. As stated earlier, it is not the intention of qualitative research to allow the findings to be generalized, and therefore this is not, in itself, a limitation.

Planning out the way that findings are to be presented is helpful. It is useful to insert the headings of the sections (the themes) and then make a note of the codes that exemplify the thoughts and feelings of your participants. It is generally advisable to put in the quotations that you want to use for each theme, using each quotation only once. After all this is done, the telling of the story can begin as you give your voice to the experiences of the participants, writing around their quotations. Do not be afraid to draw assumptions from the participants’ narratives, as this is necessary to give an in-depth account of the phenomena in question. Discuss these assumptions, drawing on your participants’ words to support you as you move from one code to another and from one theme to the next. Finally, as appropriate, it is possible to include examples from literature or policy documents that add support for your findings. As an exercise, you may wish to code and theme the sample excerpt in Appendix 1 and tell the participant’s story in your own way. Further reading about “doing” qualitative research can be found at the end of this paper.

CONCLUSIONS

Qualitative research can help researchers to access the thoughts and feelings of research participants, which can enable development of an understanding of the meaning that people ascribe to their experiences. It can be used in pharmacy practice research to explore how patients feel about their health and their treatment. Qualitative research has been used by pharmacists to explore a variety of questions and problems (see the “Further Reading” section for examples). An understanding of these issues can help pharmacists and other health care professionals to tailor health care to match the individual needs of patients and to develop a concordant relationship. Doing qualitative research is not easy and may require a complete rethink of how research is conducted, particularly for researchers who are more familiar with quantitative approaches. There are many ways of conducting qualitative research, and this paper has covered some of the practical issues regarding data collection, analysis, and management. Further reading around the subject will be essential to truly understand this method of accessing peoples’ thoughts and feelings to enable researchers to tell participants’ stories.

Appendix 1. Excerpt from a sample transcript

The participant (age late 50s) had suffered from a chronic mental health illness for 30 years. The participant had become a “revolving door patient,” someone who is frequently in and out of hospital. As the participant talked about past experiences, the researcher asked:

• What was treatment like 30 years ago?
• Umm—well it was pretty much they could do what they wanted with you because I was put into the er, the er kind of system er, I was just on
• endless section threes.
• Really…
• But what I didn’t realize until later was that if you haven’t actually posed a threat to someone or yourself they can’t really do that but I didn’t know
• that. So wh-when I first went into hospital they put me on the forensic ward ’cause they said, “We don’t think you’ll stay here we think you’ll just
• run-run away.” So they put me then onto the acute admissions ward and – er – I can remember one of the first things I recall when I got onto that
• ward was sitting down with a er a Dr XXX. He had a book this thick [gestures] and on each page it was like three questions and he went through
• all these questions and I answered all these questions. So we’re there for I don’t maybe two hours doing all that and he asked me he said “well
• when did somebody tell you then that you have schizophrenia” I said “well nobody’s told me that” so he seemed very surprised but nobody had
• actually [pause] whe-when I first went up there under police escort erm the senior kind of consultants people I’d been to where I was staying and
• ermm so er [pause] I . . . the, I can remember the very first night that I was there and given this injection in this muscle here [gestures] and just
• having dreadful side effects the next day I woke up [pause]
• . . . and I suffered that akathesia I swear to you, every minute of every day for about 20 years.
• Oh how awful.
• And that side of it just makes life impossible so the care on the wards [pause] umm I don’t know it’s kind of, it’s kind of hard to put into words
• [pause]. Because I’m not saying they were sort of like not friendly or interested but then nobody ever seemed to want to talk about your life [pause]
• nobody asked me any questions about my life. The only questions that came into was they asked me if I’d be a volunteer for these student exams
• and things and I said “yeah” so all the questions were like “oh what jobs have you done,” er about your relationships and things and er but
• nobody actually sat down and had a talk and showed some interest in you as a person you were just there basically [pause] um labelled and you
• know there was there was [pause] but umm [pause] yeah . . .

This article is the 10th in the CJHP Research Primer Series, an initiative of the CJHP Editorial Board and the CSHP Research Committee. The planned 2-year series is intended to appeal to relatively inexperienced researchers, with the goal of building research capacity among practising pharmacists. The articles, presenting simple but rigorous guidance to encourage and support novice researchers, are being solicited from authors with appropriate expertise.

Previous articles in this series:

Bond CM. The research jigsaw: how to get started. Can J Hosp Pharm . 2014;67(1):28–30.

Tully MP. Research: articulating questions, generating hypotheses, and choosing study designs. Can J Hosp Pharm . 2014;67(1):31–4.

Loewen P. Ethical issues in pharmacy practice research: an introductory guide. Can J Hosp Pharm. 2014;67(2):133–7.

Tsuyuki RT. Designing pharmacy practice research trials. Can J Hosp Pharm . 2014;67(3):226–9.

Bresee LC. An introduction to developing surveys for pharmacy practice research. Can J Hosp Pharm . 2014;67(4):286–91.

Gamble JM. An introduction to the fundamentals of cohort and case–control studies. Can J Hosp Pharm . 2014;67(5):366–72.

Austin Z, Sutton J. Qualitative research: getting started. C an J Hosp Pharm . 2014;67(6):436–40.

Houle S. An introduction to the fundamentals of randomized controlled trials in pharmacy research. Can J Hosp Pharm . 2014; 68(1):28–32.

Charrois TL. Systematic reviews: What do you need to know to get started? Can J Hosp Pharm . 2014;68(2):144–8.

Competing interests: None declared.

Further Reading

Examples of qualitative research in pharmacy practice.

• Farrell B, Pottie K, Woodend K, Yao V, Dolovich L, Kennie N, et al. Shifts in expectations: evaluating physicians’ perceptions as pharmacists integrated into family practice. J Interprof Care. 2010; 24 (1):80–9. [ PubMed ] [ Google Scholar ]
• Gregory P, Austin Z. Postgraduation employment experiences of new pharmacists in Ontario in 2012–2013. Can Pharm J. 2014; 147 (5):290–9. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Marks PZ, Jennnings B, Farrell B, Kennie-Kaulbach N, Jorgenson D, Pearson-Sharpe J, et al. “I gained a skill and a change in attitude”: a case study describing how an online continuing professional education course for pharmacists supported achievement of its transfer to practice outcomes. Can J Univ Contin Educ. 2014; 40 (2):1–18. [ Google Scholar ]
• Nair KM, Dolovich L, Brazil K, Raina P. It’s all about relationships: a qualitative study of health researchers’ perspectives on interdisciplinary research. BMC Health Serv Res. 2008; 8 :110. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Pojskic N, MacKeigan L, Boon H, Austin Z. Initial perceptions of key stakeholders in Ontario regarding independent prescriptive authority for pharmacists. Res Soc Adm Pharm. 2014; 10 (2):341–54. [ PubMed ] [ Google Scholar ]

Qualitative Research in General

• Breakwell GM, Hammond S, Fife-Schaw C. Research methods in psychology. Thousand Oaks (CA): Sage Publications; 1995. [ Google Scholar ]
• Given LM. 100 questions (and answers) about qualitative research. Thousand Oaks (CA): Sage Publications; 2015. [ Google Scholar ]
• Miles B, Huberman AM. Qualitative data analysis. Thousand Oaks (CA): Sage Publications; 2009. [ Google Scholar ]
• Patton M. Qualitative research and evaluation methods. Thousand Oaks (CA): Sage Publications; 2002. [ Google Scholar ]
• Willig C. Introducing qualitative research in psychology. Buckingham (UK): Open University Press; 2001. [ Google Scholar ]

Group Dynamics in Focus Groups

• Farnsworth J, Boon B. Analysing group dynamics within the focus group. Qual Res. 2010; 10 (5):605–24. [ Google Scholar ]

Social Constructivism

• Social constructivism. Berkeley (CA): University of California, Berkeley, Berkeley Graduate Division, Graduate Student Instruction Teaching & Resource Center; [cited 2015 June 4]. Available from: http://gsi.berkeley.edu/gsi-guide-contents/learning-theory-research/social-constructivism/ [ Google Scholar ]

Mixed Methods

• Creswell J. Research design: qualitative, quantitative, and mixed methods approaches. Thousand Oaks (CA): Sage Publications; 2009. [ Google Scholar ]

Collecting Qualitative Data

• Arksey H, Knight P. Interviewing for social scientists: an introductory resource with examples. Thousand Oaks (CA): Sage Publications; 1999. [ Google Scholar ]
• Guest G, Namey EE, Mitchel ML. Collecting qualitative data: a field manual for applied research. Thousand Oaks (CA): Sage Publications; 2013. [ Google Scholar ]

Constructivist Grounded Theory

• Charmaz K. Grounded theory: objectivist and constructivist methods. In: Denzin N, Lincoln Y, editors. Handbook of qualitative research. 2nd ed. Thousand Oaks (CA): Sage Publications; 2000. pp. 509–35. [ Google Scholar ]

Research Writing and Analysis

• NVivo Group and Study Sessions
• SPSS This link opens in a new window
• Statistical Analysis Group sessions
• Using Qualtrics
• Dissertation and Data Analysis Group Sessions
• Defense Schedule - Commons Calendar This link opens in a new window
• Research Process Flow Chart
• Research Alignment Chapter 1 This link opens in a new window
• Step 1: Seek Out Evidence
• Step 2: Explain
• Step 3: The Big Picture
• Step 4: Own It
• Step 5: Illustrate
• Annotated Bibliography
• Literature Review This link opens in a new window
• Systematic Reviews & Meta-Analyses
• How to Synthesize and Analyze
• Synthesis and Analysis Practice
• Synthesis and Analysis Group Sessions
• Problem Statement
• Purpose Statement
• Conceptual Framework
• Theoretical Framework
• Quantitative Research Questions
• Qualitative Research Questions
• Trustworthiness of Qualitative Data
• Analysis and Coding Example- Qualitative Data
• Thematic Data Analysis in Qualitative Design
• Dissertation to Journal Article This link opens in a new window
• International Journal of Online Graduate Education (IJOGE) This link opens in a new window
• Journal of Research in Innovative Teaching & Learning (JRIT&L) This link opens in a new window

Writing a Case Study

What is a case study?

A Case study is: 

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

What are the different types of case studies?

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

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

Who are your case study participants?

What is triangulation ? 

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

How to write a Case Study?

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

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Qualitative Data Analysis Methods

In the following, we will discuss basic approaches to analyzing data in all six of the acceptable qualitative designs.

After reviewing the information in this document, you will be able to:

• Recognize the terms for data analysis methods used in the various acceptable designs.
• Recognize the data preparation tasks that precede actual analysis in all the designs.
• Understand the basic analytic methods used by the respective qualitative designs.
• Identify and apply the methods required by your selected design.

Terms Used in Data Analysis by the Six Designs

Each qualitative research approach or design has its own terms for methods of data analysis:

• Ethnography—uses modified thematic analysis and life histories.
• Case study—uses description, categorical aggregation, or direct interpretation.
• Grounded theory—uses open, axial, and selective coding (although recent writers are proposing variations on those basic analysis methods).
• Phenomenology—describes textures and structures of the essential meaning of the lived experience of the phenomenon
• Heuristics—patterns, themes, and creative synthesis along with individual portraits.
• Generic qualitative inquiry—thematic analysis, which is really a foundation for all the other analytic methods. Thematic analysis is the starting point for the other five, and the endpoint for generic qualitative inquiry. Because it is the basic or foundational method, we'll take it first.

Preliminary Tasks in Analysis in all Methods

In all the approaches—case study, grounded theory, generic inquiry, and phenomenology—there are preliminary tasks that must be performed prior to the analysis itself. For each, you will need to:

• Arrange for secure storage of original materials. Storage should be secure and guaranteed to protect the privacy and confidentiality of the participants' information and identities.
• Transcribe interviews or otherwise transform raw data into usable formats.
• Make master copies and working copies of all materials. Master copies should be kept securely with the original data. Working copies will be marked up, torn apart, and used heavily: make plenty.
• Arrange secure passwords or other protection for all electronic data and copies.
• When ready to begin, read all the transcripts repeatedly—at least three times—for a sense of the whole. Don't force it—allow the participants' words to speak to you.

These tasks are done in all forms of qualitative analysis. Now let's look specifically at generic qualitative inquiry.

Data Analysis in Generic Qualitative Inquiry: Thematic Analysis

The primary tool for conducting the analysis of data when using the generic qualitative inquiry approach is thematic analysis, a flexible analytic method for deriving the central themes from verbal data. A thematic analysis can also be used to conduct analysis of the qualitative data in some types of case study.

Thematic analysis essentially creates theme-statements for ideas or categories of ideas (codes) that the researcher extracts from the words of the participants.

There are two main types of thematic analysis:

• Inductive thematic analysis, in which the data are interpreted inductively, that is, without bringing in any preselected theoretical categories.
• Theoretical thematic analysis, in which the participants' words are interpreted according to categories or constructs from the existing literature.

Analytic Steps in Thematic Analysis: Reading

Remember that the last preliminary task listed above was to read the transcripts for a sense of the whole. In this discussion, we'll assume you're working with transcribed data, usually from interviews. You can apply each step, with changes, to any kind of qualitative data. Now, before you start analyzing, take the first transcript and read it once more, as often as necessary, for a sense of what this participant told you about the topic of your study. If you're using other sources of data, spend time with them holistically.

Thematic Analysis: Steps in the Process

When you have a feel for the data,

• Underline any passages (phases, sentences, or paragraphs) that appear meaningful to you. Don't make any interpretations yet! Review the underlined data.
• Decide if the underlined data are relevant to the research question and cross out or delete all data unrelated to the research question. Some information in the transcript may be interesting but unrelated to the research question.
• Create a name or "code" for each remaining underlined passage (expressions or meaning units) that focus on one single idea. The code should be:
• Briefer than the passage, should
• Sum up its meaning, and should be
• Supported by the meaning unit (the participant's words).
• Find codes that recur; cluster these together. Now begin the interpretation, but only with the understanding that the codes or patterns may shift and change during the process of analysis.
• After you have developed the clusters or patterns of codes, name each pattern. The pattern name is a theme. Use language supported by the original data in the language of your discipline and field.
• Write a brief description of each theme. Use brief direct quotations from the transcript to show the reader how the patterns emerged from the data.
• Compose a paragraph integrating all the themes you developed from the individual's data.
• Repeat this process for each participant, the "within-participant" analysis.
• Finally, integrate all themes from all participants in "across-participants" analysis, showing what general themes are found across all the data.

Some variation of thematic analysis will appear in most of the other forms of qualitative data analysis, but the other methods tend to be more complex. Let's look at them one at a time. If you are already clear as to which approach or design your study will use, you can skip to the appropriate section below.

Ethnographic Data Analysis

Ethnographic data analysis relies on a modified thematic analysis. It is called modified because it combines standard thematic analysis as previously described for interview data with modified thematic methods applied to artifacts, observational notes, and other non-interview data.

Depending on the kinds of data to be interpreted (for instance pictures and historical documents) Ethnographers devise unique ways to find patterns or themes in the data. Finally, the themes must be integrated across all sources and kinds of data to arrive at a composite thematic picture of the culture.

(Adapted from Bogdan and Taylor, 1975; Taylor and Bogdan, 1998; Aronson, 1994.)

Data Analysis in Grounded Theory

Going beyond the descriptive and interpretive goals of many other qualitative models, grounded theory's goal is building a theory. It seeks explanation, not simply description.

It uses a constant comparison method of data analysis that begins as soon as the researcher starts collecting data. Each data collection event (for example, an interview) is analyzed immediately, and later data collection events can be modified to seek more information on emerging themes.

In other words, analysis goes on during each step of the data collection, not merely after data collection.

The heart of the grounded theory analysis is coding, which is analogous to but more rigorous than coding in thematic analysis.

Coding in Grounded Theory Method

There are three different types of coding used in a sequential manner.

• The first type of coding is open coding, which is like basic coding in thematic analysis. During open coding, the researcher performs:
• A line-by-line analysis (or sentence or paragraph analysis) of the data.
• Labels and categorizes the dimensions or aspects of the phenomenon being studied.
• The researcher also uses memos to describe the categories that are found.
• The second type of coding is axial coding, which involves finding links between categories and subcategories found in the open coding.
• The open codes are examined for their relationships: cause and effect, co-occurrence, and so on.
• The goal here is to picture how the various dimensions or categories of data interact with one another in time and space.
• The third type of coding is selective coding, which identifies a core category and relates the categories subsidiary to this core.
• Selective coding selects the main phenomenon, (core category) around which subsidiary phenomena, (all other categories) are grouped, arranging the groupings, studying the results, and rearranging where the data require it.

The Final Stages of Grounded Theory Analysis, after Coding

From selective coding, the grounded theory researcher develops:

• A model of the process, which is the description of which actions and interactions occur in a sequence or series.
• A transactional system, which is the description of how the interactions of different events explain the phenomenon being investigated.
• Finally, A conditional matrix is diagrammed to help consider the conditions and consequences related to the phenomenon under study.

These three essentially tell the story of the outcome of the research, in other words, the description of the process by which the phenomenon seems to happen, the transactional system supporting it, and the conditional matrix that pictures the explanation of the phenomenon are the findings of a grounded theory study.

(Adapted from Corbin and Strauss, 2008; Strauss and Corbin, 1990, 1998.)

Data Analysis in Qualitative Case Study: Background

There are a few points to consider in analyzing case study data:

• Analysis can be:
• Holistic—the entire case.
• Embedded—a specific aspect of the case.
• Multiple sources and kinds of data must be collected and analyzed.
• Data must be collected, analyzed, and described about both:
• The contexts of the case (its social, political, economic contexts, its affiliations with other organizations or cases, and so on).
• The setting of the case (geography, location, physical grounds, or set-up, business organization, etc.).

Qualitative Case Study Data Analysis Methods

Data analysis is detailed in description and consists of an analysis of themes. Especially for interview or documentary analysis, thematic analysis can be used (see the section on generic qualitative inquiry). A typical format for data analysis in a case study consists of the following phases:

• Description: This entails developing a detailed description of each instance of the case and its setting. The words "instance" and "case" can be confusing. Let's say we're conducting a case study of gay and lesbian members of large urban evangelical Christian congregations in the Southeast. The case would be all such people and their congregations. Instances of the case would be any individual person or congregation. In this phase, all the congregations (the settings) and their larger contexts would be described in detail, along with the individuals who are interviewed or observed.
• Categorical Aggregation: This involves seeking a collection of themes from the data, hoping that relevant meaning about lessons to be learned about the case will emerge. Using our example, a kind of thematic analysis from all the data would be performed, looking for common themes.
• Direct Interpretation: By looking at the single instance or member of the case and drawing meaning from it without looking for multiple instances, direct interpretation pulls the data apart and puts it together in more meaningful ways. Here, the interviews with all the gay and lesbian congregation members would be subjected to thematic analysis or some other form of analysis for themes.
• Within-Case Analysis: This would identify the themes that emerge from the data collected from each instance of the case, including connections between or among the themes. These themes would be further developed using verbatim passages and direct quotation to elucidate each theme. This would serve as the summary of the thematic analysis for each individual participant.
• Cross-Case Analysis: This phase develops a thematic analysis across cases as well as assertions and interpretations of the meaning of the themes emerging from all participants in the study.
• Interpretive Phase: In the final phase, this is the creation of naturalistic generalizations from the data as a whole and reporting on the lesson learned from the case study.

(Adapted from Creswell, 1998; Stake, 1995.)

Data Analysis in Phenomenological Research

There are a few existing models of phenomenological research, and they each propose slightly different methods of data analysis. They all arrive at the same goal, however. The goal of phenomenological analysis is to describe the essence or core structures and textures of some conscious psychological experience. One such model, empirical, was developed at Duquesne University. This method of analysis consists of five essential steps and represents the other variations well. Whichever model is chosen, those wishing to conduct phenomenological research must choose a model and abide by its procedures. Empirical phenomenology is presented as an example.

• Sense of the whole. One reads the entire description in order to get a general sense of the whole statement. This often takes a few readings, which should be approached contemplatively.
• Discrimination of meaning units. Once the sense of the whole has been grasped, the researcher returns to the beginning and reads through the text once more, delineating each transition in meaning.
• The researcher adopts a psychological perspective to do this. This means that the researcher looks for shifts in psychological meaning.
• The researcher focuses on the phenomenon being investigated. This means that the researcher keeps in mind the study's topic and looks for meaningful passages related to it.
• The researcher next eliminates redundancies and unrelated meaning units.
• Transformation of subjects' everyday expressions (meaning units) into psychological language. Once meaning units have been delineated,
• The researcher reflects on each of the meaning units, which are still expressed in the concrete language of the participants, and describes the essence of the statement for the participant.
• The researcher makes these descriptions in the language of psychological science.
• Synthesis of transformed meaning units into a consistent statement of the structure of the experience.
• Using imaginative variation on these transformed meaning units, the researcher discovers what remains unchanged when variations are imaginatively applied, and
• From this develops a consistent statement regarding the structure of the participant's experience.
• The researcher completes this process for each transcript in the study.
• Final synthesis. Finally, the researcher synthesizes all of the statements regarding each participant's experience into one consistent statement that describes and captures [of] the essence of the experience being studied.

(Adapted from Giorgi, 1985, 1997; Giorgi and Giorgi, 2003.)

Data Analysis in Heuristics

Six steps typically characterize the heuristic process of data analysis, consisting of:

• Initial engagement.
• Incubation.
• Illumination.
• Explication.

To start, place all the material drawn from one participant before you (recordings, transcriptions, journals, notes, poems, artwork, and so on). This material may either be data gathered by self-search or by interviews with co-researchers.

• Immerse yourself fully in the material until you are aware of and understand everything that is before you.
• Incubate the material. Put the material aside for a while. Let it settle in you. Live with it but without particular attention or focus. Return to the immersion process. Make notes where they would enable you to remember or classify the material. Continue this rhythm of working with the data and resting until an illumination or essential configuration emerges. From your core or global sense, list the essential components or patterns and themes that characterize the fundamental nature and meaning of the experience. Reflectively study the patterns and themes, dwell inside them, and develop a full depiction of the experience. The depiction must include the essential components of the experience.
• Illustrate the depiction of the experience with verbatim samples, poems, stories, or other materials to highlight and accentuate the person's lived experience.
• Return to the raw material of your co-researcher (participant). Does your depiction of the experience fit the data from which you have developed it? Does it contain all that is essential?
• Develop a full reflective depiction of the experience, one that characterizes the participant's experience reflecting core meanings for the individuals as a whole. Include in the depiction, verbatim samples, poems, stories, and the like to highlight and accentuate the lived nature of the experience. This depiction will serve as the creative synthesis, which will combine the themes and patterns into a representation of the whole in an aesthetically pleasing way. This synthesis will communicate the essence of the lived experience under inquiry. The synthesis is more than a summary: it is like a chemical reaction, a creation anew.
• Return to the data and develop a portrait of the person in such a way that the phenomenon and the person emerge as real.

(Adapted from Douglass and Moustakas, l985; Moustakas, 1990.)

Bogdan, R., & Taylor, S. J. (1975). Introduction to qualitative research methods: A phenomenological approach (3rd ed.). New York, NY: Wiley.

Corbin, J., & Strauss, A. (2008). Basics of qualitative research: Techniques and procedures for developing grounded theory (3rd ed.). Los Angeles, CA: Sage.

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

Douglass, B. G., & Moustakas, C. (1985). Heuristic inquiry: The internal search to know. Journal of Humanistic Psychology , 25(3), 39–55.

Giorgi, A. (Ed.). (1985). Phenomenology and psychological research . Pittsburgh, PA: Duquesne University Press.

Giorgi, A. (1997). The theory, practice and evaluation of phenomenological methods as a qualitative research procedure. Journal of Phenomenological Psychology , 28, 235–260.

Giorgi, A. P., & Giorgi, B. M. (2003). The descriptive phenomenological psychological method. In P. M. Camic, J. E. Rhodes, & L. Yardley (Eds.), Qualitative research in psychology: Expanding perspectives in methodology and design (pp. 243–273). Washington, DC: American Psychological Association.

Moustakas, C. (1990). Heuristic research: Design, methodology, and applications . Newbury Park, CA: Sage.

Stake, R. E. (1995). The art of case study research . Thousand Oaks, CA: Sage.

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

Strauss, A., & Corbin, J. (1998). Basics of qualitative research: Techniques and theory for developing grounded theory (2nd ed.). Thousand Oaks, CA: Sage.

Taylor, S. J., & Bogdan, R. (1998). Introduction to qualitative research methods: A guidebook and resource (3rd ed.). New York: Wiley.

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Today, the university is releasing the findings from qualitative data received from Stanford’s first-ever campus-wide Diversity, Equity and Inclusion (DEI) survey . The quantitative data were released in November 2021.

“I want to thank the nearly 7,000 people who took the time and expended the emotional energy to both share their stories and experiences, and help convey what we are doing well and how we can improve,” said Patrick Dunkley, vice provost for institutional equity, access, and community.

He added: “What we see in this report from the community input is consistency between the quantitative and qualitative data. The qualitative findings include firsthand accounts of discriminatory, harassing, and other harmful behavior, such as microaggression and experiences where community members felt isolated, marginalized, or excluded. We hope these accounts will serve as learning opportunities of what harmful behaviors look like, and the impact they have on members of our community so they can be avoided in the future. This information will also prove to be extremely valuable as we plot our course toward improvement.”

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The DEI survey

Conducted in May 2021, the DEI survey focused on the individual experiences of community members, and included questions about inclusion and belonging, as well as questions about experiences with harassing and discriminatory behavior. The survey also collected data about race/ethnicity and other identities. Nearly 15,000 students, postdocs, faculty, and staff took part in the survey. Stanford released the quantitative findings in November 2021.

The DEI survey included three open-ended questions, where community members could provide feedback to the university and share their own experiences with issues of belonging, discrimination, harassment, and other harmful behavior. The questions were as follows:

• If you would like to tell us more, please tell us about your experiences and perspectives on these and other issues that are important to you.
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A total of 6,886 responses to those questions were received. In order to preserve anonymity and privacy, a third-party contractor convened a team with extensive experience in analyzing qualitative data. The analysis involved systematically reading and coding open-ended survey responses to identify common themes across the content.

The report contains representative quotes, presented without compromising individual privacy, that illustrate major themes of the challenges that Stanford community members have experienced. The quotes provided in the report are representative of many other very similar comments.

Themes include: interpersonal interactions/harmful experiences; experiences of isolation and lack of voice; and university structures and status hierarchy.

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Data analysis Previous     Next

Qualitative case study data analysis: an example from practice, catherine houghton lecturer, school of nursing and midwifery, national university of ireland, galway, republic of ireland, kathy murphy professor of nursing, national university of ireland, galway, ireland, david shaw lecturer, open university, milton keynes, uk, dympna casey senior lecturer, national university of ireland, galway, ireland.

Aim To illustrate an approach to data analysis in qualitative case study methodology.

Background There is often little detail in case study research about how data were analysed. However, it is important that comprehensive analysis procedures are used because there are often large sets of data from multiple sources of evidence. Furthermore, the ability to describe in detail how the analysis was conducted ensures rigour in reporting qualitative research.

Data sources The research example used is a multiple case study that explored the role of the clinical skills laboratory in preparing students for the real world of practice. Data analysis was conducted using a framework guided by the four stages of analysis outlined by Morse ( 1994 ): comprehending, synthesising, theorising and recontextualising. The specific strategies for analysis in these stages centred on the work of Miles and Huberman ( 1994 ), which has been successfully used in case study research. The data were managed using NVivo software.

Review methods Literature examining qualitative data analysis was reviewed and strategies illustrated by the case study example provided.

Discussion Each stage of the analysis framework is described with illustration from the research example for the purpose of highlighting the benefits of a systematic approach to handling large data sets from multiple sources.

Conclusion By providing an example of how each stage of the analysis was conducted, it is hoped that researchers will be able to consider the benefits of such an approach to their own case study analysis.

Implications for research/practice This paper illustrates specific strategies that can be employed when conducting data analysis in case study research and other qualitative research designs.

Nurse Researcher . 22, 5, 8-12. doi: 10.7748/nr.22.5.8.e1307

This article has been subject to double blind peer review

None declared

Received: 02 February 2014

Accepted: 16 April 2014

Case study data analysis - case study research methodology - clinical skills research - qualitative case study methodology - qualitative data analysis - qualitative research

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Exploring the significant problems confronting secondary schools history education: a baseline study

• Open access
• Published: 14 May 2024
• Volume 3 , article number  52 , ( 2024 )

Cite this article

You have full access to this open access article

• Fekede Sileshi Fufa   ORCID: orcid.org/0000-0001-6035-8205 1 ,
• Abera Husen Tulu   ORCID: orcid.org/0000-0002-0408-9028 2 &
• Ketebo Abdiyo Ensene   ORCID: orcid.org/0000-0001-8492-9340 1  

The purpose of this baseline study is to determine the significant problems confronting history education in secondary school. The researchers employed qualitative research methods and case study design. The techniques that were employed to acquire credible data were document analysis, interviews, and classroom observation. Six experienced history education teachers and eight top-ten students from Sebeta town public secondary school were interviewed, and academic achievement statistics of 174 students in history education were analyzed. In addition eight lesson observations were carried out to validate the information gleaned from the interviews and document analysis. The study's findings show that the primary challenges influencing history education in Sebeta town public secondary schools were teaching strategy, a lack of awareness about implementing participatory teaching methods, a lack of comprehensiveness of the contents of history education teaching materials, and the issue of the bulkiness and scope of history education texts being covered on time. The findings also indicate the significance of training history education teachers to use participatory teaching tactics, as well as the need for curriculum experts to better coordinate the range of history education content and teaching strategies. The findings of this study will help teachers, practitioners, scholars, policymakers, and educational professionals find solutions to significant problems in secondary school history education, as well as develop effective techniques for teaching history education in secondary schools that involve twenty-first century skills and abilities.

Avoid common mistakes on your manuscript.

1 Introduction

History education as an academic discipline has a long history in the world. In the nineteenth century a German historian Leopold von Ranke an indispensable contribution to modernizing history writing [ 1 , p. 2, 2 , p. 171]. Ranke (1795–1886) not only established history as a major discipline, but he also established the idea that all accurate history must be based on primary sources and rigorous methodology [ 1 , p.13, 3 ]. As a result, he is regarded as the father of modern historiography [ 1 , p. 2]. Since the nineteenth century, history education has developed as an independent discipline across the world.

In terms of teaching strategies, evidence shows that teaching approaches play an important role in any subject of study in enhancing students' academic achievements [ 4 , p. 601, 5 ]. Many research findings demonstrate that the approach employed to develop any operation significantly determines the end product [ 6 , p. 7]. Several factors influence students' academic achievement; evidence suggests that teachers are the most essential ones in terms of students’ education and achievements [ 7 , pp. 2633–34]. According to the research findings conducted on student learning, the way teachers engage their pupils is crucial in the teaching and learning process [ 8 , p. 39]. The approaches used by the teacher should be matched to the demands of the students [ 6 , p.7]. Students’ motivation and achievement are mostly dependent on the teachers’ activities [ 9 , p. 15). Several researches have indicated that among the subjects offered in schools, students do have not much interest in history education [ 10 , p. 45]. According to a study conducted on secondary schools, history education has been taught through lectures rather than participatory and student- centred strategies [ 11 , p. 1). According to Kiio [ 11 , pp. 1–2], effective implementation of participatory teaching and learning methodologies can increase students' interest in history education. Issar [ 10 , p. 49] also emphasized the significance of learning history education, stating that learning history education should help students understand the complexities of human lives, the diversity and relationships between different groups, the changes and continuities and connect the past, present, and future events.

Scholars confirm that constructive learning approaches allow students to participate actively in the lessons [ 12 , p. 35]. Since 1980, the theory of social constructivism has been advocated as an effective way of learning and teaching [ 12 , pp. 35–36]. It is a theory developed by Russian psychologist Lev Vygotsky (1896–1934), which holds that individuals are active participants in the creation of their knowledge [ 13 , p.783]. Vygotsky’s social constructivism focuses on pedagogies that encourage active learning, effective and meaningful learning, constructive learning, and learning by doing [ 13 , p.783]. Current research in the field of history education supports the notion that participatory approaches to teaching the subject at the secondary school level are the preferred method for developing the skills required to handle the world's future historiographical needs [ 14 , p. 81]. In several works of literature, interactive teaching approaches are vital in increasing student academic achievement. The purpose of this baseline study is to investigate the significant problems confronting history education in Sebeta government secondary schools.

2 Statement of the problem

History education is frequently a source of public debate, a source of unrest, and a site of struggle over what and how should be taught in schools in Ethiopia [ 15 , p. 2]. National history is taught as a compulsory subject in different countries. Several countries believe that knowing the country’s history is a requirement for all citizens [ 16 , pp. 1–2]. In the case of history education teaching in Ethiopia, for the first time, a history syllabus was included in the education curriculum after 1943 [ 17 , p.87]. However, no specific research on significant problems confronting history education in Ethiopian secondary schools has been conducted. Researchers who have studied the problem of education in Ethiopia have directly and indirectly addressed the issue of history education [ 18 , pp.18–19].

According to research conducted by Resource and Guide [ 19 , p. 8], teaching is important by incorporating 21st-century skills such as critical thinking skills, problem-solving, language proficiency, communication and collaborative skills, cognitive skills, adaptability skills and the ability to make decisions. Furthermore, student-centred teaching method fosters students' comprehension, deep learning, problem-solving, critical thinking, and communication [ 20 , p. 4]. Research conducted on history education has discovered a link between teaching approaches and students' attitudes towards history education [ 21 , p. 3]. A scant study has been conducted on significant problems confronting history education in Ethiopian secondary schools and on approaches more appropriate for teaching history.

This motivated the researchers to conduct research on major problems confronting history education in Ethiopian secondary schools in Sebeta town. To fill this gap, the researchers used a variety of tools to analyze significant problems confront history education in Ethiopian secondary schools in general, and Sebeta town public Secondary School in particular.

Thus, this study attempts to answer the following questions:

What are the most significant problems facing history education at Sebeta town public secondary school?

What are the most common teaching strategies employed at Sebeta town government secondary school?

How is the student’s academic achievement in history at Sebeta public secondary school?

3 Objectives of the study

To find out the most significant problems facing history education at Sebeta Town Government Secondary School.

To identify the most common teaching strategies employed at Sebeta town government secondary school.

To determine a student’s academic achievement in history at Sebeta government secondary school.

4 Literature review

Any research project needs theory to provide direction and help on how things are implemented. Theoretical foundation aids in deciphering the way phenomena happen and the basis of specific actions [ 22 , p. 75]. This research is founded on Vygotsky’s social constructivist learning theory, which supports historical thinking. According to a social learning theory developed by Russian psychologist Lev Vygotsky (1896–1934), individuals are active participants in the development of their knowledge [ 23 , p. 395]. This social constructivism approach places a strong emphasis on pairs and small groups [ 24 , pp.13–15]. According to this theory, students learn primarily through interactions with their classmates, instructors, and parents, whereas teachers are expected to facilitate dialogue in the classroom [ 25 , p. 243]. According to Richard [ 26 , p. 380], good teaching and learning are strongly reliant on interpersonal interaction and conversation, with the primary focus on the student’s understanding of the topic.

Scholarly works reveal that there is very little study on the significant problems confronting history education. The existing scholarly works on teaching approach and students’ learning, on the other hand, demonstrate that there are strong relationships between the effects of teaching strategies and students’ achievement. Sugano and Mamolo [ 27 , p. 827] conducted a study on the “Effects of Teaching Methodologies on Students’ Attitude and Motivation,’’ found that teaching methods had an enormous positive impact (Cohen’s d = 0.379) on student attitude. The study also found that cooperative learning had a greater power than traditional teaching methods in improving students’ positive attitudes, motivation and interest.

History teaching should not only be mastery of the basic content (substantive knowledge) but also enhance the acquisition of subject skills and competencies that will make students learn on their own and manage their own lives and carry it through the adversities of life in society [ 26 , 28 ]. Luka [ 14 , p. VII] discovered in his study, “The Impact of Teaching Methods on Attitudes of Secondary School Students Towards Learning of History in Malawi,” that students in secondary schools have negative attitudes towards learning history. One of the reasons he highlighted is that student-centred techniques of teaching are not regularly used in the subject of history education ( Ibid , [ 29 ]).

Moreover, Mazibuko [ 30 , p. 142] revealed that teaching methods in history education greatly contributed to students' negative perceptions of the subject. He discovered that traditional methods of teaching history utilized by teachers contributed to students decreasing interest in the subject ( Ibid ). Besides, Zhu and Kaiser [ 31 , p. 191] discovered that teaching methods influence students’ motivation, attitudes towards school, willingness to do homework, and confidence in their learning.

In his study on effective teaching in history, Boadu [ 8 , p. 39] discovered that effective teaching of history should bring the subject closer to students’ lives, hearts, and minds. He argued that effective teaching cannot emerge from traditional history teaching, because the teacher lectures on the subject intensely, and students are forced to take and memorize notes.

Silver and Perini [ 32 , p. 16) argued that teachers who use a variety of teaching techniques have well-behaved and motivated students, resulting in high student academic achievement.

Adding to this, according to [ 33 , p. 74], the quality of teaching strategies influences student learning and contributes to a 15 to 20 times improvement in student achievement. These researches highlighted that effective teaching strategies played a crucial influence on student motivation, developing students’ positive attitudes, and improving students’ academic achievement more than traditional teacher-centred approaches. There has been no research undertaken in Ethiopian secondary schools to determine which methodologies could be better appropriate for teaching history. Using the designed study instruments, the researchers examine and determine the significant problems confronting history education in Sebeta government secondary schools.

5 Research methodology

The study was conducted using the constructivist paradigm view with the qualitative research approach. In this study, the researchers utilized a qualitative research approach. The qualitative research approach allows the researchers to conduct an in-depth investigation of the problem under study [ 34 , pp. 177–179, 35 , p. 12]. The qualitative research approach has different specific designs. These are Phenomenology, Ethnography, Narrative inquiry, Case study, Grounded theory and Historical research [ 36 , p. 49]. In this study, the qualitative case study design was used. Case studies are ways to explain, describe, or explore phenomena. According to Hatch [ 37 , p. 37], case studies are the type of qualitative work that investigates a contextualized contemporary phenomenon within specific boundaries. This study was carried out using document analysis, interviews, and classroom observation techniques.

The researchers received the accreditation letter from their institution and submitted it to the relevant authorities to confirm the legality of the research. The letter was then submitted to the Sebeta town’s education office and Sebeta secondary schools to acquire authorization to collect primary data from sampled respondents. The data collection process was started after getting all relevant permits from the authorities. Before interviews with respondents, the researchers described the goal of the study to the participants to acquire their permission. The researchers told participants that the study's primary aim was to collect data for the research titled "The significant problems confronting history education in history education in Sebeta town public secondary schools, Ethiopia." After extensive verbal discussions with the respondents, interviews were conducted with those who expressed full interest in participating in the study.

5.1 Sampling procedure

This study employed a purposive sampling technique. In the first stage, the study site was chosen purposively, which is Sebeta town. In the following step, this baseline study was confined to two out of four government secondary schools in Sebeta town with similar standards, a higher number of students and staff than the others. The schools that were purposely selected for the study are those that have been in existence for a long time, have more experienced staff than others, and are expected to provide firsthand information. Purposive sampling was used to select knowledgeable research participants [ 38 , pp. 512–513]. Because it allows the researcher to select the research participants who were believed informed sources of information, thoughtful, informative, articulate, and experienced with the problem under the study [ 35 , p.142, 39 , pp. 100–114]. The researchers selected individuals who have a good source of information about the issue under study (history education teachers and students [ 39 , p. 100]. In the selected two secondary schools, there are six history education teachers, five males and one female. These teachers were purposefully included in the study. The researchers believed that the experienced teachers who were chosen were useful as a primary source of data because they were familiar with the subject's contents, as well as its problems. Eight top-ten grade ten students from the two schools also took part in the study directly. The researchers believed the top-ten students were able to explain the area of study more accurately than the others. Grade ten students were purposefully chosen for the study. The following are the grounds for choosing grade ten students: First history education in Ethiopia begins in grade nine. Students began studying history education grade nine onwards. Because it is assumed that grade ten students know more about history education contents than grade nine students. Second, it is assumed that grade ten comprises all types of students (higher achievers, moderate, and slow learners), as well as grade 10 students who will choose a major (social sciences and natural sciences) in their future grade eleven. As a result, the researchers opted to gather the finest information from grade ten students to establish their perspectives toward history.

6 Results and discussions

6.1 what are the significant problems facing history education in sebeta town government secondary school, 6.1.1 interviews analysis.

For explanation, the abbreviation SSST stands for “Sebeta Secondary School Teacher”, similarly, BSSST stands for “Burka Sebeta Secondary School Teacher” and the numbers denote the order. As shown in Table  1 , six history education teachers were interviewed for this study. Of the six teachers interviewed, five had more than 15 years of teaching experience. Five of these teachers hold a bachelor's degree and one has an MA in history. Five of the teachers interviewed were male and one was female. During the interviews, the teachers revealed to the researchers that three of the six teachers had an MA in another academic discipline (Table 2 ).

For clarification, the abbreviation SSSS stands for, “Sebeta Secondary School Student”, BSSS, “Burka Sebeta Secondary School Student” and the numbers represent the order. Eight students’ four males and four females from both schools were chosen for the interview of this study.

An interview is one of the data collection instruments that were used to explore the significant problems confronting history education in government secondary schools. An interview allows the researchers to gather information that is directly related to the research objectives [ 40 , p. 411]. It is typically conducted one-on-one with informants who have firsthand experience with the research topic [ 25 , p. 144]. An interview was conducted with six experienced history education teachers, and eight secondary school students to gather adequate data about the topic under investigation.

The researchers began their interview with teachers by asking, “What are the significant problems facing history education in Sebeta town government secondary school?” The researchers interviewed teachers concerning the organization of the history education curriculum. Teacher SSST1’s response to this question is as follows: “I have been teaching history education for 18 years but I have never seen or read the curriculum of history education until today.’’ Furthermore, BSSST1 shared the same point of view saying: “So far, I have not read any history education syllabus or seen what it contains except students’ textbook. There is no available history education syllabus in secondary school for teachers. ” Teacher SSST2 also made a similar note: “We do not have a history syllabus, and the teaching materials that we use to teach students are only students’ textbooks.”

All of the teachers interviewed stated that they did not have a history curriculum and had never utilized it. The researchers found that teachers do not see contents, structures, recommended teaching aids, and methodologies in the history education syllabus and teachers’ guide.

Teachers explained that the history education textbook is divided into three parts: world history, African history, and Ethiopian history. According to the teachers interviewed, the history of the Ethiopian peoples are not written inclusively in students’ textbooks, and Ethiopian history education does not adequately addressed the political, social, and economic history of the Ethiopian people (BSSST1, BSSST2, SSST1, SSSS2, SSST3). However, research work suggests that in multi-ethnic countries, all students should be able to learn about themselves and their culture from the books they learn from Hodkinson et al. [ 41 , p. 3] stated that “all learners must be able to find themselves and their world represented in the books from which they learn.”.

In addition, teachers were asked as history education teaching materials in the same way as other Subjects. To this question, all of the teachers interviewed consistently said no. Teachers claim that “since our country’s political changes, textbooks for all disciplines have been updated three to four times, but history education has not been updated in the same way” (BSSST1, BSSST2, SSST1, SSSS2, SSST3, SSSST4). They demonstrated this to the researchers by referring to the textbook they were using. In this instance, a history grade 10 students’ textbook was published in 2002 GC/1994, reprinted in 2005/1997 and renewed in 2023 after 18 years. According to the teachers interviewed, there has been no detailed reform of history education in terms of adding or removing content, implementing new teaching strategies, or keeping up with the 21st-century world. One interviewed teacher said, ‘’I have been teaching history for 18 years and have not observed any changes in history education contents since I started teaching history education.’’ (SSST1).

The researchers continued their interview with teachers by asking, is the content of the history education curriculum appropriate for the student's abilities? This question is to gather evidence to understand that the content of the history curriculum is appropriate for the student's abilities. Teachers and students were asked this question. When asked about the content of history education in grade ten, teachers made two comments:

Students who did not study history as a subject in elementary school (1st grade to grade eight) may find it more difficult when they begin studying history education as a subject in grade nine (SSST1 and SSST2).

They have been studying in their mother tongue in primary school (grades 1 to 8) and studying in English from grade 9 onwards will make it difficult for students to understand the contents (SSST1 and SSST2). The students interviewed strongly agree with the latter. According to the students, “the content of history is very difficult to understand, history is not like other subjects, it requires proper knowledge of English” SSSS1, SSSS2, BSSSS1 and BSSS2).

Follow-up questions were also raised for teachers, to determine the teaching methods included in the history education curriculum. However, teachers were unable to respond to this question because they were not implementing the teaching practices outlined in the history education curriculum due to a lack of a history syllabus. A well-designed teaching strategy has a crucial role in improving students' academic achievement [ 42 , p. 51–64]. Therefore, teachers teach history using their own teaching and learning methods. When asked what teaching method they used, the teachers stated that they used the lecture teaching method (SSSS1, SSSS2, BSSSS1 and BSSS2). The reason they use lecture methods more than other teaching and learning methods is that the content of history lessons is extensive and the time allocated for history lessons is 80 min per week (SSSS1, SSSS2, BSSSS1 and BSSS2).

6.1.2 Classroom observation analysis

The researchers used lesson observations to obtain firsthand and ‘real' facts and data about the significant problems confronting history education in Sebeta government secondary schools. This is because many people do not want to discuss all topics during an interview [ 43 , p. 117]. The researchers employed the lesson observation checklist, which included activities such as the teacher's teaching strategies, teacher and student activities throughout the session, teacher-student interaction during the lesson, student seating arrangements, and teaching aids used. Using this checklist, the researchers observed the teacher’s teaching practice during the lesson. The researchers observed four different classrooms. The primary aim of this observation was to strengthen the data obtained from teachers and students during an interview. The teachers in all of the classrooms first ask students what they learned in their last class. Aside from that, they only used to give notes and lectures to the students in every class.

Another point that the researchers visited in the classroom was the teachers’ and students’ activities during the lesson. The teachers gave notes, and lectures and many students were busy writing notes. When the teachers lecture the content some students do not pay attention and instead take notes. Some students do not take notes, do not listen and look elsewhere. As observed by the researchers, teacher-student interaction during the lesson is very weak. Based on the observation students' seating arrangements were traditional in that three students' seats occur on a wave which is not convenient for group discussion, group work and collaborative learning.

During classroom observation, there are no teaching aids used in all classrooms visited by the teachers to make the lessons practical.

Finally, based on the findings of the study through classroom observation, traditional methods of teaching and learning in history classrooms are still the dominant teaching strategies in the twenty-first century. Researchers who research teaching strategies confirm that participatory teaching is an effective way to improve students’ academic achievement. Madar and Baban [ 42 , pp. 51–64] also discovered that participatory teaching is a good strategy to develop students’ skills and increase their academic achievements. They added that participatory teaching strategies put students at the centre of the teaching and learning process (p. 51). However, through interviews with teachers, students, and lesson observation, the researchers discovered that teachers are not employing student-centred approaches that are fitting for students' learning and achievement.

The responses of teachers and students are consistent with the literature on strategies for teaching. Researchers who conducted studies on teaching strategies found that the teacher- centred method is a traditional strategy that is not very effective in enhancing student achievement. The findings of this study also agree with Mohammed [ 44 , p. 11] who conducted a study on, “strategies in the teaching of geography …” , and stated that the lecture method of teaching has a negative effect on students’ creativity, critical thinking, ability to produce new ideas, and academic achievement of students. Similarly, this study’s findings also concur with Ezurike [ 45 , pp. 1120–124] conducted a study on, “The Influence of Teacher-Centered and Student-Centered Teaching Methods on Academic Achievement of Students,” which discovered that poor methods, mostly teacher-centred and conventional teaching methods used by teachers, are one of the major factors contributing to students’ poor achievement.

Finally, it is better to conclude that teaching strategies can positively and negatively influence students' academic achievement. If teachers only employ the lecture approach without involving students in the lesson, it may result in low student academic achievement in contrast if teachers employ student-centred strategies students can understand the main point of the lesson and enhance the academic achievement of students.

6.2 How do teaching strategies influence students' academic achievement in Sebeta secondary schools?

To answer this question, the researchers conducted interviews with teachers and students, as well as document reviews and classroom observations. This issue was addressed by both teachers and students. Methods of teaching have a wide range of effects on the academic success of learners. When asked this question, they all had similar answers. According to teachers, good teaching strategies play a significant role in improving students’ academic achievement. They state this as follows:

Using collaborative teaching practices can significantly improve students' academic achievement. Because collaborative instruction is a teaching technique in which students learn together by assisting one another. Higher achiever students support the low achiever learner in this instructional learning process. However, if teachers utilize traditional teaching methods without involving students in the teaching-learning process, students' academic achievement may suffer (BSSST1, SSST2, and SSST3).

However, for a variety of reasons, teachers do not use collaborative teaching strategies to improve the academic achievement of their students. Rather than focusing on improving the academic achievements of students’ teachers are only concerned with completing their content. Furthermore, the student stated that teaching strategy can positively and negatively influence students' academic achievement. According to students:

…if teachers employ interactive teaching strategies during teaching lessons, students can understand the main point of the lesson and profit much from it. In contrast, if teachers exclusively employ the lecture approach without involving students in the lesson, it may result in low student achievement in the subject. Furthermore, students responded with two statements: excellent teaching strategies encourage students’ interest in the subject and are also, critical for improving students' academic achievement (BSSSS1, BSSSS2, SSSS1, SSSS3, and SSSS6).

The teachers were interviewed about teaching methods they implement when teaching a history education lesson. The teachers were asked to mention teaching methods that they always use in teaching history. The majority of the teachers claimed to use lecture approaches when teaching history education lessons. Teachers noted: “huge class sizes and low time allotted to history subjects, making it difficult to apply participator/student-centred methods (BSSST3, SSST, and SSST2). Furthermore, when asked about their teachers’ teaching methods in history class, students stated that “teachers only use teacher-centred strategies (lecture, dictation, note-giving and reading notes on the blackboard)” (BSSSS3, SSSS1, SSSS2).

During the interview all interviewed teachers acknowledged the use of the lecture method in their teaching. The justifications provided for the use of the lecture method include saving time, the convenience of covering content on time and the nature of students. Teachers said, “A lecture method helps the teacher to cover a lot of content in a short period” (SSST1, SSST2, SSST3, SSST4, BSST1, and BSST2). The findings of this study are consistent with the findings of a study conducted by Luka [ 14 , p. 30] on the topic of “the impact of teaching methods on attitudes of secondary school students towards learning of history in Malawi,” which discovered that teachers use boring lecture methods to complete their courses rather than focusing on students' results.

History teachers' perceptions of the use of the participatory approach were very low. Based on the interview conducted with history education teachers they were not interested in using student-center teaching strategies (BSSST1, BSSST2, SSST1, SSST2, SSST3, and SSSST4). Teachers claimed that participatory teaching strategies were time-consuming and unsuitable for large-class settings ( Ibid ). Instead of using participatory teaching strategies teachers choose teacher-centred methods to cover a large portion within a given time.

The researchers interviewed history teachers at Sebeta secondary schools about the challenges that they confront when implementing the participatory approach. The interviewed teachers stated that the time allotted for history education did not correspond to the content (BSSST1, BSSST2, SSST1, SSST2, SSST3, and SSST4). They were unwilling to utilize student-centred teaching methodologies because they believed it would be time-consuming and difficult to cover the contents of the student’s textbooks within the academic year. According to the teachers, the time allotted to history education every week was only two periods (80 min), although history education included more than 246 pages ( Ibid ). Students also stated that teachers frequently employ lecture methods when teaching history lessons. Both teachers and students agree that collaborative learning methods are more beneficial than traditional teaching methods in improving students’ academic achievement (SSST1, SSST2, SSST3, SSST4, BSST1, and BSST2). Teachers claim that "due to the wide range of topics covered in history education, we use lecture methods of teaching rather than participatory approaches" (SSST1, SSST3, BSST1, and BSST2).

6.3 How is the student's academic achievement in history at Sebeta government secondary school? To answer this question, the researchers used document review

6.3.1 document analysis.

Document analysis is part of the qualitative data collection strategy that every researcher engages in throughout the research period. In this research researchers reviewed, history education students’ textbooks, published articles and roasters of students (students’ mark list). The history education achievement of 174 Sebeta government secondary school students scored in grade 9 in 2020/2021 was compared to look at their achievement in grade 10 in 2021/2022. As a result, one student achieved less than 50% out of 100%, 39 students’ scores ranged from 50 to 60 out of 100%, 98 students scored from 61 to 70 out of 100%, 27 students scored between 71 and 80 out of 100%, 8 students scored between 81 and 90 out of 100%, and 1 student scored between 91 and 100, in grade nine. In grade 10, 11 students scored below 50, 103 students scored between 50 and 60, 45 students scored between 61 and 70, 9 students scored between 71 and 80, 4 students scored between 81 and 90, and 2 students scored between 91 and 100 out of 100%.

Based on this analysis, we can witness students’ achievement in two ways. The first is that in grade 9, 138 out of 174 students scored less than 70% out of 100% and the results of students scoring from 70 to 100% declined significantly. The second point to mention is that student achievement in history education has been highly declining at the subsequent grade level. In Grade 10, the number of students scoring less than 50% grew, and 159 out of 174 students scored less than 70% in history education. This indicates students' achievement in history in grade 9 decreased in grade 10. This suggests that students' achievement in history education was inadequate. Following the analysis of student achievement, interviews were conducted with students and teachers to identify why students' achievement in history education was so low.

7 Conclusion and recommendations

Research shows that teaching strategies are a crucial aspect in successful learning because they enable learners to learn, create, and take a proactive attitude towards learning. The significant issues confronting history education have been identified were teaching strategy, a lack of awareness about implementing participatory teaching methods, a lack of comprehensiveness of the contents of history education teaching materials, and the issue of the bulkiness and scope of history education texts being covered on time and Lack of teachers’ understanding of employing creative teaching strategies to improve students’ academic progress. Despite this, the study found that teachers in Sebeta government secondary schools use the teacher-centered lecture approach rather than interactive or student-centered strategies, which are recommended for students' learning. Teachers were cognizant of student-center teaching and learning improved student achievement. Conversely, teachers are hesitant to adopt participatory teaching methodologies due to the vastness of history textbooks and the lack of time provided to history education to cover bulky texts. As a result, they employ teaching approaches that they believe will allow them to complete the history education contents in the allocated time rather than focusing on enhancing students' academic achievement.

Furthermore, the study also found out that teachers are reluctant to use participatory student-centred learning methods because the two periods per week allocated (80 min) to teaching history education are not enough to cover a wide range of history education content. They believe participatory student-center teaching is ineffective in large classrooms and takes more time than the lecture method. Such thinking stems from a lack of understanding (imparting knowledge) on the use of innovative teaching strategies. The researchers examined the lecture teaching approach that students had learned as well as their results. Several students' achievement in history education shows below 70% out of 100% at Sebeta government secondary schools. The main reason for this low achievement is the teachers’ teaching strategies (the use of teacher-centred approach) to teaching history education to complete a wide content within the allotted time. Teachers do not consider which strategies could improve students’ achievement rather than focus on completing their content. This has also resulted in students’ negative attitudes towards the subject.

The outcomes of this study can serve as the foundation for future research in academic and professional studies. This discovery is notable for the fact that teaching and learning approaches influence students' academic achievement in both directions. Accordingly, if teachers only employ the lecture approach without involving students in the lesson, it may result in low student academic achievement in contrast if teachers employ student-centred strategies students can understand the main point of the lesson and enhance the academic achievement of students.

Thus, for future studies intervention exprimental research in history education is required to measure the extent to which participatory methods of instruction increase the academic achievement of students over teacher-centred strategies. More research, according to the researchers, should be conducted using participatory teaching methods in one classroom and lecture methods in others to determine to what extent participatory teaching methods improve the academic achievement of students when compared to teacher-centred strategies. Following the findings, researchers provided the following recommendations: national and regional education experts should collaborate closely in making history education content inclusive, as well as training history education teachers in the use of participatory teaching approaches. Curriculum experts should effectively organize the breadth of history education contents. To ensure that students learn successfully, the relevant authorities should rigorously monitor the state of the teaching and learning processes in general and history education in particular.

Data availability

The data of this study is the primary source, which is the roster of students' results and education policies. The student results/ marks analyzed for this study are from two Sebeta town public secondary schools: Sebeta secondary school and Burka Sebeta secondary school and Ethiopian education policies. So, the data are available from the corresponding author upon reasonable request from anyone.

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Fufa, F.S., Tulu, A.H. & Ensene, K.A. Exploring the significant problems confronting secondary schools history education: a baseline study. Discov Educ 3 , 52 (2024). https://doi.org/10.1007/s44217-024-00132-8

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Evaluation of integrated community case management of the common childhood illness program in Gondar city, northwest Ethiopia: a case study evaluation design

• Mekides Geta 1 ,
• Geta Asrade Alemayehu 2 ,
• Wubshet Debebe Negash 2 ,
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BMC Pediatrics volume  24 , Article number:  310 ( 2024 ) Cite this article

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Integrated Community Case Management (ICCM) of common childhood illness is one of the global initiatives to reduce mortality among under-five children by two-thirds. It is also implemented in Ethiopia to improve community access and coverage of health services. However, as per our best knowledge the implementation status of integrated community case management in the study area is not well evaluated. Therefore, this study aimed to evaluate the implementation status of the integrated community case management program in Gondar City, Northwest Ethiopia.

A single case study design with mixed methods was employed to evaluate the process of integrated community case management for common childhood illness in Gondar town from March 17 to April 17, 2022. The availability, compliance, and acceptability dimensions of the program implementation were evaluated using 49 indicators. In this evaluation, 484 mothers or caregivers participated in exit interviews; 230 records were reviewed, 21 key informants were interviewed; and 42 observations were included. To identify the predictor variables associated with acceptability, we used a multivariable logistic regression analysis. Statistically significant variables were identified based on the adjusted odds ratio (AOR) with a 95% confidence interval (CI) and p-value. The qualitative data was recorded, transcribed, and translated into English, and thematic analysis was carried out.

The overall implementation of integrated community case management was 81.5%, of which availability (84.2%), compliance (83.1%), and acceptability (75.3%) contributed. Some drugs and medical equipment, like Cotrimoxazole, vitamin K, a timer, and a resuscitation bag, were stocked out. Health care providers complained that lack of refreshment training and continuous supportive supervision was the common challenges that led to a skill gap for effective program delivery. Educational status (primary AOR = 0.27, 95% CI:0.11–0.52), secondary AOR = 0.16, 95% CI:0.07–0.39), and college and above AOR = 0.08, 95% CI:0.07–0.39), prescribed drug availability (AOR = 2.17, 95% CI:1.14–4.10), travel time to the to the ICCM site (AOR = 3.8, 95% CI:1.99–7.35), and waiting time (AOR = 2.80, 95% CI:1.16–6.79) were factors associated with the acceptability of the program by caregivers.

Conclusion and recommendation

The overall implementation status of the integrated community case management program was judged as good. However, there were gaps observed in the assessment, classification, and treatment of diseases. Educational status, availability of the prescribed drugs, waiting time and travel time to integrated community case management sites were factors associated with the program acceptability. Continuous supportive supervision for health facilities, refreshment training for HEW’s to maximize compliance, construction clean water sources for HPs, and conducting longitudinal studies for the future are the forwarded recommendation.

Peer Review reports

Integrated Community Case Management (ICCM) is a critical public health strategy for expanding the coverage of quality child care services [ 1 , 2 ]. It mainly concentrated on curative care and also on the diagnosis, treatment, and referral of children who are ill with infectious diseases [ 3 , 4 ].

Based on the World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF) recommendations, Ethiopia adopted and implemented a national policy supporting community-based treatment of common childhood illnesses like pneumonia, Diarrhea, uncomplicated malnutrition, malaria and other febrile illness and Amhara region was one the piloted regions in late 2010 [ 5 ]. The Ethiopian primary healthcare units, established at district levels include primary hospitals, health centers (HCs), and health posts (HPs). The HPs are run by Health Extension Workers (HEWs), and they have function of monitoring health programs and disease occurrence, providing health education, essential primary care services, and timely referrals to HCs [ 6 , 7 ]. The Health Extension Program (HEP) uses task shifting and community ownership to provide essential health services at the first level using the health development army and a network of woman volunteers. These groups are organized to promote health and prevent diseases through community participation and empowerment by identifying the salient local bottlenecks which hinder vital maternal, neonatal, and child health service utilization [ 8 , 9 ].

One of the key steps to enhance the clinical case of health extension staff is to encourage better growth and development among under-five children by health extension. Healthy family and neighborhood practices are also encouraged [ 10 , 11 ]. The program also combines immunization, community-based feeding, vitamin A and de-worming with multiple preventive measures [ 12 , 13 ]. Now a days rapidly scaling up of ICCM approach to efficiently manage the most common causes of morbidity and mortality of children under the age of five in an integrated manner at the community level is required [ 14 , 15 ].

Over 5.3 million children are died at a global level in 2018 and most causes (75%) are preventable or treatable diseases such as pneumonia, malaria and diarrhea [ 16 ]. About 99% of the global burden of mortality and morbidity of under-five children which exists in developing countries are due to common childhood diseases such as pneumonia, diarrhea, malaria and malnutrition [ 17 ].

In 2013, the mortality rate of under-five children in Sub-Saharan Africa decreased to 86 deaths per 1000 live birth and estimated to be 25 per 1000live births by 2030. However, it is a huge figure and the trends are not sufficient to reach the target [ 18 ]. About half of global under-five deaths occurred in sub-Saharan Africa. And from the top 26 nations burdened with 80% of the world’s under-five deaths, 19 are in sub-Saharan Africa [ 19 ].

To alleviate the burden, the Ethiopian government tries to deliver basic child care services at the community level by trained health extension workers. The program improves the health of the children not only in Ethiopia but also in some African nations. Despite its proven benefits, the program implementation had several challenges, in particular, non-adherence to the national guidelines among health care workers [ 20 ]. Addressing those challenges could further improve the program performance. Present treatment levels in sub-Saharan Africa are unacceptably poor; only 39% of children receive proper diarrhea treatment, 13% of children with suspected pneumonia receive antibiotics, 13% of children with fever receive a finger/heel stick to screen for malaria [ 21 ].

To improve the program performance, program gaps should be identified through scientific evaluations and stakeholder involvement. This evaluation not only identify gaps but also forward recommendations for the observed gaps. Furthermore, the implementation status of ICCM of common childhood illnesses has not been evaluated in the study area yet. Therefore, this work aimed to evaluate the implementation status of integrated community case management program implementation in Gondar town, northwest Ethiopia. The findings may be used by policy makers, healthcare providers, funders and researchers.

Method and material

Evaluation design and settings.

A single-case study design with concurrent mixed-methods evaluation was conducted in Gondar city, northwest Ethiopia, from March 17 to April 17, 2022. The evaluability assessment was done from December 15–30, 2021. Both qualitative and quantitative data were collected concurrently, analyzed separately, and integrated at the result interpretation phase.

The evaluation area, Gondar City, is located in northwest Ethiopia, 740 km from Addis Ababa, the capital city of the country. It has six sub-cities and thirty-six kebeles (25 urban and 11 rural). In 2019, the estimated total population of the town was 338,646, and 58,519 (17.3%) were under-five children. In the town there are eight public health centers and 14 health posts serving the population. All health posts provide ICCM service for more than 70,852 populations.

Evaluation approach and dimensions

Program stakeholders.

The evaluation followed a formative participatory approach by engaging the potential stakeholders in the program. Prior to the development of the proposal, an extensive discussion was held with the Gondar City Health Department to identify other key stakeholders in the program. Service providers at each health facility (HCs and HPs), caretakers of sick children, the Gondar City Health Office (GCHO), the Amhara Regional Health Bureau (ARHB), the Minister of Health (MoH), and NGOs (IFHP and Save the Children) were considered key stakeholders. During the Evaluability Assessment (EA), the stakeholders were involved in the development of evaluation questions, objectives, indicators, and judgment criteria of the evaluation.

Evaluation dimensions

The availability and acceptability dimensions from the access framework [ 22 ] and compliance dimension from the fidelity framework [ 23 ] were used to evaluate the implementation of ICCM.

Population and samplings

All under-five children and their caregivers attended at the HPs; program implementers (health extension workers, healthcare providers, healthcare managers, PHCU focal persons, MCH coordinators, and other stakeholders); and ICCM records and registries in the health posts of Gondar city administration were included in the evaluation. For quantitative data, the required sample size was proportionally allocated for each health post based on the number of cases served in the recent one month. But the qualitative sample size was determined by data saturation, and the samples were selected purposefully.

The data sources and sample size for the compliance dimension were all administrative records/reports and ICCM registration books (230 documents) in all health posts registered from December 1, 2021, to February 30, 2022 (three months retrospectively) included in the evaluation. The registries were assessed starting from the most recent registration number until the required sample size was obtained for each health post.

The sample size to measure the mothers’/caregivers’ acceptability towards ICCM was calculated by taking prevalence of caregivers’ satisfaction on ICCM program p  = 74% from previously similar study [ 24 ] and considering standard error 4% at 95% CI and 10% non- responses, which gave 508. Except those who were seriously ill, all caregivers attending the ICCM sites during data collection were selected and interviewed consecutively.

The availability of required supplies, materials and human resources for the program were assessed in all 14HPs. The data collectors observed the health posts and collected required data by using a resources inventory checklist.

A total of 70 non-participatory patient-provider interactions were also observed. The observations were conducted per each health post and for health posts which have more than one health extension workers one of them were selected randomly. The observation findings were used to triangulate the findings obtained through other data collection techniques. Since people may act accordingly to the standards when they know they are observed for their activities, we discarded the first two observations from analysis. It is one of the strategies to minimize the Hawthorne effect of the study. Finally a total of 42 (3 in each HPs) observations were included in the analysis.

Twenty one key informants (14 HEWs, 3 PHCU focal person, 3 health center heads and one MCH coordinator) were interviewed. These key informants were selected since they are assumed to be best teachers in the program. Besides originally developed key informant interview questions, the data collectors probed them to get more detail and clear information.

Variables and measurement

The availability of resources, including trained healthcare workers, was examined using 17 indicators, with weighted score of 35%. Compliance was used to assess HEWs’ adherence to the ICCM treatment guidelines by observing patient-provider interactions and conducting document reviews. We used 18 indicators and a weighted value of 40%.

Mothers’ /caregivers’/ acceptance of ICCM service was examined using 14 indicators and had a weighted score of 25%. The indicators were developed with a five-point Likert scale (1: strongly disagree, 2: disagree, 3: neutral, 4: agree and 5: strongly agree). The cut off point for this categorization was calculated using the demarcation threshold formula: ( \(\frac{\text{t}\text{o}\text{t}\text{a}\text{l}\, \text{h}\text{i}\text{g}\text{h}\text{e}\text{s}\text{t}\, \text{s}\text{c}\text{o}\text{r}\text{e}-\,\text{t}\text{o}\text{t}\text{a}\text{l}\, \text{l}\text{o}\text{w}\text{e}\text{s}\text{t} \,\text{s}\text{c}\text{o}\text{r}\text{e}}{2}) +total lowest score\) ( 25 – 27 ). Those mothers/caregivers/ who scored above cut point (42) were considered as “satisfied”, otherwise “dissatisfied”. The indicators were adapted from the national ICCM and IMNCI implementation guideline and other related evaluations with the participation of stakeholders. Indicator weight was given by the stakeholders during EA. Indicators score was calculated using the formula \(\left(achieved \,in \%=\frac{indicator \,score \,x \,100}{indicator\, weight} \right)\) [ 26 , 28 ].

The independent variables for the acceptability dimension were socio-demographic and economic variables (age, educational status, marital status, occupation of caregiver, family size, income level, and mode of transport), availability of prescribed drugs, waiting time, travel time to ICCM site, home to home visit, consultation time, appointment, and source of information.

The overall implementation of ICCM was measured by using 49 indicators over the three dimensions: availability (17 indicators), compliance (18 indicators) and acceptability (14 indicators).

Program logic model

Based on the constructed program logic model and trained health care providers, mothers/caregivers received health information and counseling on child feeding; children were assessed, classified, and treated for disease, received follow-up; they were checked for vitamin A; and deworming and immunization status were the expected outputs of the program activities. Improved knowledge of HEWs on ICCM, increased health-seeking behavior, improved quality of health services, increased utilization of services, improved data quality and information use, and improved child health conditions are considered outcomes of the program. Reduction of under-five morbidity and mortality and improving quality of life in the society are the distant outcomes or impacts of the program (Fig.  1 ).

Integrated community case management of childhood illness program logic model in Gondar City in 2022

Data collection tools and procedure

Resource inventory and data extraction checklists were adapted from standard ICCM tool and check lists [ 29 ]. A structured interviewer administered questionnaire was adapted by referring different literatures [ 30 , 31 ] to measure the acceptability of ICCM. The key informant interview (KII) guide was also developed to explore the views of KIs. The interview questionnaire and guide were initially developed in English and translated into the local language (Amharic) and finally back to English to ensure consistency. All the interviews were done in the local language, Amharic.

Five trained clinical nurses and one BSC nurse were recruited from Gondar zuria and Wegera district as data collectors and supervisors, respectively. Two days training on the overall purpose of the evaluation and basic data collection procedures were provided prior to data collection. Then, both quantitative and qualitative data were gathered at the same time. The quantitative data were gathered from program documentation, charts of ICCM program visitors and, exit interview. Interviews with 21 KIIs and non-participatory observations of patient-provider interactions were used to acquire qualitative data. Key informant interviews were conducted to investigate the gaps and best practices in the implementation of the ICCM program.

A pretest was conducted to 26 mothers/caregivers/ at Maksegnit health post and appropriate modifications were made based on the pretest results. The data collectors were supervised and principal evaluator examined the completeness and consistency of the data on a daily basis.

Data management and analysis

For analysis, quantitative data were entered into epi-data version 4.6 and exported to Stata 14 software for analysis. Narration and tabular statistics were used to present descriptive statistics. Based on established judgment criteria, the total program implementation was examined and interpreted as a mix of the availability, compliance, and acceptability dimensions. To investigate the factors associated with ICCM acceptance, a binary logistic regression analysis was performed. During bivariable analysis, variables with p-values less than 0.25 were included in multivariable analysis. Finally, variables having a p-value less than 0.05 and an adjusted odds ratio (AOR) with a 95% confidence interval (CI) were judged statistically significant. Qualitative data were collected recorded, transcribed into Amharic, then translated into English and finally coded and thematically analyzed.

Judgment matrix analysis

The weighted values of availability, compliance, and acceptability dimensions were 35, 40, and 25 based on the stakeholder and investigator agreement on each indicator, respectively. The judgment parameters for each dimension and the overall implementation of the program were categorized as poor (< 60%), fair (60–74.9%), good (75-84.9%), and very good (85–100%).

Availability of resources

A total of 26 HEWs were assigned within the fourteen health posts, and 72.7% of them were trained on ICCM to manage common childhood illnesses in under-five children. However, the training was given before four years, and they didn’t get even refreshment training about ICCM. The KII responses also supported that the shortage of HEWs at the HPs was the problem in implementing the program properly.

I am the only HEW in this health post and I have not been trained on ICCM program. So, this may compromise the quality of service and client satisfaction.(25 years old HEW with two years’ experience)

All observed health posts had ICCM registration books, monthly report and referral formats, functional thermometer, weighting scale and MUAC tape meter. However, timer and resuscitation bag was not available in all HPs. Most of the key informant finding showed that, in all HPs there was no shortage of guideline, registration book and recording tool; however, there was no OTP card in some health posts.

“Guideline, ICCM registration book for 2–59 months of age, and other different recording and reporting formats and booklet charts are available since September/2016. However, OTP card is not available in most HPs.”. (A 30 years male health center director)

Only one-fifth (21%) of HPs had a clean water source for drinking and washing of equipment. Most of Key-informant interview findings showed that the availability of infrastructures like water was not available in most HPs. Poor linkage between HPs, HCs, town health department, and local Kebele administer were the reason for unavailability.

Since there is no water for hand washing, or drinking, we obligated to bring water from our home for daily consumptions. This increases the burden for us in our daily activity. (35 years old HEW)

Most medicines, such as anti-malaria drugs with RDT, Quartem, Albendazole, Amoxicillin, vitamin A capsules, ORS, and gloves, were available in all the health posts. Drugs like zinc, paracetamol, TTC eye ointment, and folic acid were available in some HPs. However, cotrimoxazole and vitamin K capsules were stocked-out in all health posts for the last six months. The key informant also revealed that: “Vitamin K was not available starting from the beginning of this program and Cotrimoxazole was not available for the past one year and they told us they would avail it soon but still not availed. Some essential ICCM drugs like anti malaria drugs, De-worming, Amoxicillin, vitamin A capsules, ORS and medical supplies were also not available in HCs regularly.”(28 years’ Female PHCU focal)

The overall availability of resources for ICCM implementation was 84.2% which was good based on our presetting judgment parameter (Table  1 ).

Health extension worker’s compliance

From the 42 patient-provider interactions, we found that 85.7%, 71.4%, 76.2%, and 95.2% of the children were checked for body temperature, weight, general danger signs, and immunization status respectively. Out of total (42) observation, 33(78.6%) of sick children were classified for their nutritional status. During observation time 29 (69.1%) of caregivers were counseled by HEWs on food, fluid and when to return back and 35 (83.3%) of children were appointed for next follow-up visit. Key informant interviews also affirmed that;

“Most of our health extension workers were trained on ICCM program guidelines but still there are problems on assessment classification and treatment of disease based on guidelines and standards this is mainly due to lack refreshment training on the program and lack of continuous supportive supervision from the respective body.” (27years’ Male health center head)

From 10 clients classified as having severe pneumonia cases, all of them were referred to a health center (with pre-referral treatment), and from those 57 pneumonia cases, 50 (87.7%) were treated at the HP with amoxicillin or cotrimoxazole. All children with severe diarrhea, very severe disease, and severe complicated malnutrition cases were referred to health centers with a pre-referral treatment for severe dehydration, very severe febrile disease, and severe complicated malnutrition, respectively. From those with some dehydration and no dehydration cases, (82.4%) and (86.8%) were treated at the HPs for some dehydration (ORS; plan B) and for no dehydration (ORS; plan A), respectively. Moreover, zinc sulfate was prescribed for 63 (90%) of under-five children with some dehydration or no dehydration. From 26 malaria cases and 32 severe uncomplicated malnutrition and moderate acute malnutrition cases, 20 (76.9%) and 25 (78.1%) were treated at the HPs, respectively. Of the total reviewed documents, 56 (93.3%), 66 (94.3%), 38 (84.4%), and 25 (78.1%) of them were given a follow-up date for pneumonia, diarrhea, malaria, and malnutrition, respectively.

Supportive supervision and performance review meetings were conducted only in 10 (71.4%) HPs, but all (100%) HPs sent timely reports to the next supervisory body.

Most of the key informants’ interview findings showed that supportive supervision was not conducted regularly and for all HPs.

I had mentored and supervised by supportive supervision teams who came to our health post at different times from health center, town health office and zonal health department. I received this integrated supervision from town health office irregularly, but every month from catchment health center and last integrated supportive supervision from HC was on January. The problem is the supervision was conducted for all programs.(32 years’ old and nine years experienced female HEW)

Moreover, the result showed that there was poor compliance of HEWs for the program mainly due to weak supportive supervision system of managerial and technical health workers. It was also supported by key informants as:

We conducted supportive supervision and performance review meeting at different time, but still there was not regular and not addressed all HPs. In addition to this the supervision and review meeting was conducted as integration of ICCM program with other services. The other problem is that most of the time we didn’t used checklist during supportive supervision. (Mid 30 years old male HC director)

Based on our observation and ICCM document review, 83.1% of the HEWs were complied with the ICCM guidelines and judged as fair (Table  2 ).

Acceptability of ICCM program

Sociodemographic and obstetric characteristics of participants.

A total of 484 study participants responded to the interviewer-administered questionnaire with a response rate of 95.3%. The mean age of study participants was 30.7 (SD ± 5.5) years. Of the total caregivers, the majority (38.6%) were categorized under the age group of 26–30 years. Among the total respondents, 89.3% were married, and regarding religion, the majorities (84.5%) were Orthodox Christian followers. Regarding educational status, over half of caregivers (52.1%) were illiterate (unable to read or write). Nearly two-thirds of the caregivers (62.6%) were housewives (Table  3 ).

All the caregivers came to the health post on foot, and most of them 418 (86.4%) arrived within one hour. The majority of 452 (93.4%) caregivers responded that the waiting time to get the service was less than 30 min. Caregivers who got the prescribed drugs at the health post were 409 (84.5%). Most of the respondents, 429 (88.6%) and 438 (90.5%), received counseling services on providing extra fluid and feeding for their sick child and were given a follow-up date.

Most 298 (61.6%) of the caregivers were satisfied with the convenience of the working hours of HPs, and more than three-fourths (80.8%) were satisfied with the counseling services they received. Most of the respondents, 366 (75.6%), were satisfied with the appropriateness of waiting time and 431 (89%) with the appropriateness of consultation time. The majority (448 (92.6%) of caregivers were satisfied with the way of communicating with HEWs, and 269 (55.6%) were satisfied with the knowledge and competence of HEWs. Nearly half of the caregivers (240, or 49.6%) were satisfied with the availability of drugs at health posts.

The overall acceptability of the ICCM program was 75.3%, which was judged as good. A low proportion of acceptability was measured on the cleanliness of the health posts, the appropriateness of the waiting area, and the competence and knowledge of the HEWs. On the other hand, high proportion of acceptability was measured on appropriateness of waiting time, way of communication with HEWs, and the availability of drugs (Table  4 ).

Factors associated with acceptability of ICCM program

In the final multivariable logistic regression analysis, educational status of caregivers, availability of prescribed drugs, time to arrive, and waiting time were factors significantly associated with the satisfaction of caregivers with the ICCM program.

Accordingly, the odds of caregivers with primary education, secondary education, and college and above were 73% (AOR = 0.27, 95% CI: 0.11–0.52), 84% (AOR = 0.16, 95% CI: 0.07–0.39), and 92% (AOR = 0.08, 95% CI: 0.07–0.40) less likely to accept the program as compared to mothers or caregivers who were not able to read and write, respectively. The odds of caregivers or mothers who received prescribed drugs were 2.17 times more likely to accept the program as compared to their counters (AOR = 2.17, 95% CI: 1.14–4.10). The odds of caregivers or mothers who waited for services for less than 30 min were 2.8 times more likely to accept the program as compared to those who waited for more than 30 min (AOR = 2.80, 95% CI: 1.16–6.79). Moreover, the odds of caregivers/mothers who traveled an hour or less for service were 3.8 times more likely to accept the ICCM program as compared to their counters (AOR = 3.82, 95% CI:1.99–7.35) (Table  5 ).

Overall ICCM program implementation and judgment

The implementation of the ICCM program in Gondar city administration was measured in terms of availability (84.2%), compliance (83.1%), and acceptability (75.3%) dimensions. In the availability dimension, amoxicillin, antimalarial drugs, albendazole, Vit. A, and ORS were available in all health posts, but only six HPs had Ready-to-Use Therapeutic Feedings, three HPs had ORT Corners, and none of the HPs had functional timers. In all health posts, the health extension workers asked the chief to complain, correctly assessed for pneumonia, diarrhea, malaria, and malnutrition, and sent reports based on the national schedule. However, only 70% of caretakers counseled about food, fluids, and when to return, 66% and 76% of the sick children were checked for anemia and other danger signs, respectively. The acceptability level of the program by caretakers and caretakers’/mothers’ educational status, waiting time to get the service and travel time ICCM sites were the factors affecting its acceptability. The overall ICCM program in Gondar city administration was 81.5% and judged as good (Fig.  2 ).

Overall ICCM program implementation and the evaluation dimensions in Gondar city administration, 2022

The implementation status of ICCM was judged by using three dimensions including availability, compliance and acceptability of the program. The judgment cut of points was determined during evaluability assessment (EA) along with the stakeholders. As a result, we found that the overall implementation status of ICCM program was good as per the presetting judgment parameter. Availability of resources for the program implementation, compliance of HEWs to the treatment guideline and acceptability of the program services by users were also judged as good as per the judgment parameter.

This evaluation showed that most medications, equipment and recording and reporting materials available. This finding was comparable with the standard ICCM treatment guide line [ 10 ]. On the other hand trained health care providers, some medications like Zink, Paracetamol and TTC eye ointment, folic acid and syringes were not found in some HPs. However the finding was higher than the study conducted in SNNPR on selected health posts [ 33 ] and a study conducted in Soro district, southern Ethiopia [ 24 ]. The possible reason might be due to low interruption of drugs at town health office or regional health department stores, regular supplies of essential drugs and good supply management and distribution of drug from health centers to health post.

The result of this evaluation showed that only one fourth of health posts had functional ORT Corner which was lower compared to the study conducted in SNNPR [ 34 ]. This might be due poor coverage of functional pipe water in the kebeles and the installation was not set at the beginning of health post construction as reported from one of ICCM program coordinator.

Compliance of HEWs to the treatment guidelines in this evaluation was higher than the study done in southern Ethiopia (65.6%) [ 24 ]. This might be due to availability of essential drugs educational level of HEWs and good utilization of ICCM guideline and chart booklet by HEWs. The observations showed most of the sick children were assessed for danger sign, weight, and temperature respectively. This finding is lower than the study conducted in Rwanda [ 35 ]. This difference might be due to lack of refreshment training and regular supportive supervision for HEWs. This also higher compared to the study done in three regions of Ethiopia indicates that 88%, 92% and 93% of children classified as per standard for Pneumonia, diarrhea and malaria respectively [ 36 ]. The reason for this difference may be due to the presence of medical equipment and supplies including RDT kit for malaria, and good educational level of HEWs.

Moreover most HPs received supportive supervision and performance review meeting was conducted and all of them send reports timely to next level. The finding of this evaluation was lower than the study conducted on implementation evaluation of ICCM program southern Ethiopia [ 24 ] and study done in three regions of Ethiopia (Amhara, Tigray and SNNPR) [ 37 ]. This difference might be due sample size variation.

The overall acceptability of the ICCM program was less than the presetting judgment parameter but slightly higher compared to the study in southern Ethiopia [ 24 ]. This might be due to presence of essential drugs for treating children, reasonable waiting and counseling time provided by HEWs, and smooth communication between HEWs and caregivers. In contrast, this was lower than similar studies conducted in Wakiso district, Uganda [ 38 ]. The reason for this might be due to contextual difference between the two countries, inappropriate waiting area to receive the service and poor cleanness of the HPs in our study area. Low acceptability of caregivers to ICCM service was observed in the appropriateness of waiting area, availability of drugs, cleanness of health post, and competence of HEWs while high level of caregiver’s acceptability was consultation time, counseling service they received, communication with HEWs, treatment given for their sick children and interest to return back for ICCM service.

Caregivers who achieved primary, secondary, and college and above were more likely accept the program services than those who were illiterate. This may more educated mothers know about their child health condition and expect quality service from healthcare providers which is more likely reduce the acceptability of the service. The finding is congruent with a study done on implementation evaluation of ICCM program in southern Ethiopia [ 24 ]. However, inconsistent with a study conducted in wakiso district in Uganda [ 38 ]. The possible reason for this might be due to contextual differences between the two countries. The ICCM program acceptability was high in caregivers who received all prescribed drugs than those did not. Caregivers those waited less than 30 min for service were more accepted ICCM services compared to those more than 30 minutes’ waiting time. This finding is similar compared with the study conducted on implementation evaluation of ICCM program in southern Ethiopia [ 24 ]. In contrary, the result was incongruent with a survey result conducted by Ethiopian public health institute in all regions and two administrative cities of Ethiopia [ 39 ]. This variation might be due to smaller sample size in our study the previous one. Moreover, caregivers who traveled to HPs less than 60 min were more likely accepted the program than who traveled more and the finding was similar with the study finding in Jimma zone [ 40 ].

Strengths and limitations

This evaluation used three evaluation dimensions, mixed method and different data sources that would enhance the reliability and credibility of the findings. However, the study might have limitations like social desirability bias, recall bias and Hawthorne effect.

The implementation of the ICCM program in Gondar city administration was measured in terms of availability (84.2%), compliance (83.1%), and acceptability (75.3%) dimensions. In the availability dimension, amoxicillin, antimalarial drugs, albendazole, Vit. A, and ORS were available in all health posts, but only six HPs had Ready-to-Use Therapeutic Feedings, three HPs had ORT Corners, and none of the HPs had functional timers.

This evaluation assessed the implementation status of the ICCM program, focusing mainly on availability, compliance, and acceptability dimensions. The overall implementation status of the program was judged as good. The availability dimension is compromised due to stock-outs of chloroquine syrup, cotrimoxazole, and vitamin K and the inaccessibility of clean water supply in some health posts. Educational statuses of caregivers, availability of prescribed drugs at the HPs, time to arrive to HPs, and waiting time to receive the service were the factors associated with the acceptability of the ICCM program.

Therefore, continuous supportive supervision for health facilities, and refreshment training for HEW’s to maximize compliance are recommended. Materials and supplies shall be delivered directly to the health centers or health posts to solve the transportation problem. HEWs shall document the assessment findings and the services provided using the registration format to identify their gaps, limitations, and better performances. The health facilities and local administrations should construct clean water sources for health facilities. Furthermore, we recommend for future researchers and program evaluators to conduct longitudinal studies to know the causal relationship of the program interventions and the outcomes.

Data availability

Data will be available upon reasonable request from the corresponding author.

Abbreviations

Ethiopian Demographic and Health Survey

Health Center/Health Facility

Health Extension Program

Health Extension Workers

Health Post

Health Sector Development Plan

Integrated Community Case Management of Common Childhood Illnesses

Information Communication and Education

Integrated Family Health Program

Integrated Management of Neonatal and Childhood Illness

Integrated Supportive Supervision

Maternal and Child Health

Mid Upper Arm Circumference

Non-Government Organization

Oral Rehydration Salts

Outpatient Therapeutic program

Primary health care unit

Rapid Diagnostics Test

Ready to Use Therapeutic Foods

Sever Acute Malnutrition

South Nation Nationalities People Region

United Nations International Child Emergency Fund

World Health Organization

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Acknowledgements

We are very grateful to University of Gondar and Gondar town health office for its welcoming approaches. We would also like to thank all of the study participants of this evaluation for their information and commitment. Our appreciation also goes to the data collectors and supervisors for their unreserved contribution.

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Mekides Geta

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Geta Asrade Alemayehu, Wubshet Debebe Negash, Tadele Biresaw Belachew, Chalie Tadie Tsehay & Getachew Teshale

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All authors contributed to the preparation of the manuscript. M.G. conceived and designed the evaluation and performed the analysis then T.B.B., W.D.N., G.A.A., C.T.T. and G.T. revised the analysis. G.T. prepared the manuscript and all the authors revised and approved the final manuscript.

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Geta, M., Alemayehu, G.A., Negash, W.D. et al. Evaluation of integrated community case management of the common childhood illness program in Gondar city, northwest Ethiopia: a case study evaluation design. BMC Pediatr 24 , 310 (2024). https://doi.org/10.1186/s12887-024-04785-0

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Examining the feasibility of assisted index case testing for HIV case-finding: a qualitative analysis of barriers and facilitators to implementation in Malawi

• Caroline J. Meek 1 , 2 ,
• Tiwonge E. Mbeya Munkhondya 3 ,
• Mtisunge Mphande 4 ,
• Tapiwa A. Tembo 4 ,
• Mike Chitani 4 ,
• Milenka Jean-Baptiste 2 ,
• Dhrutika Vansia 4 ,
• Caroline Kumbuyo 4 ,
• Jiayu Wang 2 ,
• Katherine R. Simon 4 ,
• Sarah E. Rutstein 5 ,
• Clare Barrington 2 ,
• Maria H. Kim 4 ,
• Vivian F. Go 2 &
• Nora E. Rosenberg 2  

BMC Health Services Research volume  24 , Article number:  606 ( 2024 ) Cite this article

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Metrics details

Assisted index case testing (ICT), in which health care workers take an active role in referring at-risk contacts of people living with HIV for HIV testing services, has been widely recognized as an evidence-based intervention with high potential to increase status awareness in people living with HIV. While the available evidence from eastern and southern Africa suggests that assisted ICT can be an effective, efficient, cost-effective, acceptable, and low-risk strategy to implement in the region, it reveals that feasibility barriers to implementation exist. This study aims to inform the design of implementation strategies to mitigate these feasibility barriers by examining “assisting” health care workers’ experiences of how barriers manifest throughout the assisted ICT process, as well as their perceptions of potential opportunities to facilitate feasibility.

In-depth interviews were conducted with 26 lay health care workers delivering assisted ICT in Malawian health facilities. Interviews explored health care workers’ experiences counseling index clients and tracing these clients’ contacts, aiming to inform development of a blended learning implementation package. Transcripts were inductively analyzed using Dedoose coding software to identify and describe key factors influencing feasibility of assisted ICT. Analysis included multiple rounds of coding and iteration with the data collection team.

Participants reported a variety of barriers to feasibility of assisted index case testing implementation, including sensitivities around discussing ICT with clients, privacy concerns, limited time for assisted index case testing amid high workloads, poor quality contact information, and logistical obstacles to tracing. Participants also reported several health care worker characteristics that facilitate feasibility (knowledge, interpersonal skills, non-stigmatizing attitudes and behaviors, and a sense of purpose), as well as identified process improvements with the potential to mitigate barriers.

Conclusions

Maximizing assisted ICT’s potential to increase status awareness in people living with HIV requires equipping health care workers with effective training and support to address and overcome the many feasibility barriers that they face in implementation. Findings demonstrate the need for, as well as inform the development of, implementation strategies to mitigate barriers and promote facilitators to feasibility of assisted ICT.

Trial registration

NCT05343390. Date of registration: April 25, 2022.

Peer Review reports

Introduction

To streamline progress towards its goal of ending AIDS as a public health threat by 2030, the Joint United Nations Programme on HIV/AIDS (UNAIDS) launched a set of HIV testing and treatment targets [ 1 ]. Adopted by United Nations member states in June 2021, the targets call for 95% of all people living with HIV (PLHIV) to know their HIV status, 95% of all PLHIV to be accessing sustained antiretroviral therapy (ART), and 95% of all people receiving ART to achieve viral suppression by 2025 [ 2 ]. Eastern and southern Africa has seen promising regional progress towards these targets in recent years, and the region is approaching the first target related to status awareness in PLHIV- in 2022, 92% of PLHIV in the region were aware of their status [ 3 ]. However, several countries in the region lag behind [ 4 ], and as 2025 approaches, it is critical to scale up adoption of evidence-based interventions to sustain and accelerate progress.

Index case testing (ICT), which targets provision of HIV testing services (HTS) for sexual partners, biological children, and other contacts of known PLHIV (“index clients”), is a widely recognized evidence-based intervention used to identify PLHIV by streamlining testing efforts to populations most at risk [ 5 , 6 , 7 ]. Traditional approaches to ICT rely on passive referral, in which index clients invite their contacts for testing [ 5 ]. However, the World Health Organization (WHO) and the President’s Emergency Plan for HIV/AIDS Relief (PEPFAR) have both recommended assisted approaches to ICT [ 6 , 8 , 9 , 10 ], in which health care workers (HCWs) take an active role in referral of at-risk contacts for testing, due to evidence of improved effectiveness in identifying PLHIV compared to passive approaches [ 10 , 11 , 12 , 13 , 14 ]. As a result, there have been several efforts to scale assisted ICT throughout eastern and southern Africa in recent years [ 15 , 16 , 17 , 18 , 19 , 20 ]. In addition to evidence indicating that assisted ICT can be effective in increasing HIV testing and case-finding [ 16 , 17 , 21 , 22 , 23 , 24 ], implementation evidence [ 25 ] from the region suggests that assisted ICT can be an efficient [ 14 ], acceptable [ 5 , 13 , 15 , 18 , 20 , 21 , 26 ], cost-effective [ 27 ], and low-risk [ 21 , 22 , 24 , 28 , 29 ] strategy to promote PLHIV status awareness. However, the few studies that focus on feasibility, or the extent to which HCWs can successfully carry out assisted ICT [ 25 ], suggest that barriers exist to feasibility of effective implementation [ 18 , 19 , 20 , 30 , 31 , 32 ]. Developing informed implementation strategies to mitigate these barriers requires more detailed examination of how these barriers manifest throughout the assisted ICT process, as well as of potential opportunities to facilitate feasibility, from the perspective of the HCWs who are doing the “assisting”.

This qualitative analysis addresses this need for further detail by exploring “assisting” HCWs’ perspectives of factors that influence the feasibility of assisted ICT, with a unique focus on informing development of effective implementation strategies to best support assisted ICT delivery in the context of an implementation science trial in Malawi.

This study was conducted in the Machinga and Balaka districts of Malawi. Malawi is a country in southeastern Africa in which 7.1% of the population lives with HIV and 94% of PLHIV know their status [ 4 ]. Machinga and Balaka are two relatively densely populated districts in the southern region of Malawi [ 33 ] with HIV prevalence rates similar to the national average [ 34 ]. We selected Machinga and Balaka because they are prototypical of districts in Malawi implementing Ministry of Health programs with support from an implementing partner.

Malawi has a long-established passive ICT program, and in 2019 the country also adopted an assisted component, known as voluntary assisted partner notification, as part of its national HIV testing policy [ 32 ]. In Malawi, ICT is conducted through the following four methods, voluntarily selected by the index client: 1) passive referral, in which HCWs encourage the index client to refer partners for voluntary HTS, 2) contract referral, in which HCWs establish an informal ‘contract’ with index clients that agrees upon a date that the HCW can contact the contact clients if they have not yet presented for HTS; 3) provider referral, in which HCWs contact and offer voluntary HTS to contact clients; and 3) dual referral, in which HCWs accompany and provide support to index clients in disclosing their status and offering HTS to their partners [ 8 ]. 

While Malawi has one of the lowest rates of qualified clinical HCWs globally (< 5 clinicians per 100,000 people) [ 35 ], the country has a strong track record of shifting HTS tasks to lay HCWs, who have been informally trained to perform certain health care delivery functions but do not have a formal professional/para-professional certification or tertiary education degree, in order to mitigate this limited medical workforce capacity [ 32 , 36 ]. In Malawi, lay HCW roles include HIV Diagnostic Assistants (who are primarily responsible for HIV testing and counseling, including index case counseling) and community health workers (who are responsible for a wider variety of tasks, including index case counseling and contact tracing) [ 32 ]. Non-governmental organization implementing partners, such as the Tingathe Program, play a critical role in harnessing Malawian lay HCW capacity to rapidly and efficiently scale up HTS, including assisted ICT [ 32 , 37 , 38 , 39 ].

Study design

Data for this analysis were collected as part of formative research for a two-arm cluster randomized control trial examining a blended learning implementation package as a strategy for building HCW capacity in assisted ICT [ 40 ]. Earlier work [ 32 ] established the theoretical basis for testing the blended learning implementation package, which combines individual asynchronous modules with synchronous small-group interactive sessions to enhance training and foster continuous quality improvement. The formative research presented in this paper aimed to further explore factors influencing feasibility of the assisted ICT from the perspective of HCWs in order to inform development of the blended learning implementation package.

Prior to the start of the trial (October-December 2021), the research team conducted 26 in-depth interviews (IDIs) with lay HCWs at 14 of the 34 facilities included in the parent trial. We purposively selected different types of facilities (hospitals, health centers, and dispensaries) in both districts and from both randomization arms, as this served as a qualitative baseline for a randomized trial. Within these facilities, we worked with facility supervisors to purposively select HCWs who were actively engaged in Malawi’s ICT program from the larger sample of HCWs eligible for the parent trial (had to be at least 18 years old, employed full-time at one of the health facilities included in the parent trial, and involved in counseling index clients and/or tracing their contacts). The parent trial enrolled 306 HCWs, who were primarily staff hired by Tingathe Program to support facilities implementing Malawi’s national HIV program.

Data collection

IDIs were conducted by three trained Malawian interviewers in a private setting using a semi-structured guide. IDIs were conducted over the phone when possible ( n  = 18) or in-person at sites with limited phone service ( n  = 8). The semi-structured guide was developed for this study through a series of rigorous, iterative discussions among the research team (Additional file 1 ). The questions used for this analysis were a subset of a larger interview. The interview guide questions for this analysis explored HCWs’ experiences with assisted ICT, including barriers and facilitators to implementation. Probing separately about the processes of counseling index clients and tracing their contacts, interviewers asked questions such as “What is the first thing that comes to mind when you think of counseling index clients/tracing contacts?”, “What aspects do you [like/not like] about…?” and “What do your colleagues say about…?”. When appropriate, interviewers probed further about how specific factors mentioned by the participant facilitate or impede the ICT implementation experience.

The IDIs lasted from 60–90 min and were conducted in Chichewa, a local language in Malawi. Eleven audio recordings were transcribed verbatim in Chichewa before being translated into English and 15 recordings were directly translated and transcribed into English. Interviewers summarized each IDI after it was completed, and these summaries were discussed with the research team routinely.

Data analysis

The research team first reviewed all of the interview summaries individually and then met multiple times to discuss initial observations, refining the research question and scope of analysis. A US-based analyst (CJM) with training in qualitative analysis used an inductive approach to develop a codebook, deriving broad codes from the implementation factors mentioned by participants throughout their interviews. Along with focused examination of the transcripts, she consulted team members who had conducted the IDIs with questions or clarifications. CJM regularly met with Malawian team members (TEMM, MM, TAT) who possess the contextual expertise necessary to verify and enhance meaning. She used the Dedoose (2019) web application to engage in multiple rounds of coding, starting with codes representing broad implementation factors and then further refining the codebook as needed to capture the nuanced manifestations of these barriers and facilitators. Throughout codebook development and refinement, the analyst engaged in memoing to track first impressions, thought processes, and coding decisions. The analyst presented the codebook and multiple rounds of draft results to the research team. All transcripts and applied codes were also reviewed in detail by additional team members (MJB, DV). Additional refinements to the codebook and results interpretations were iteratively made based on team feedback.

Ethical clearance

Ethical clearance was provided by UNC’s IRB, Malawi’s National Health Sciences Research Committee, and the Baylor College of Medicine IRB. Written informed consent was obtained from all participants in the main study and interviewers confirmed verbal consent before starting the IDIs.

Participant characteristics are described in Table  1 below.

Factors influencing feasibility of assisted ICT: barriers and facilitators

Participants described a variety of barriers and facilitators to feasibility of assisted ICT, manifesting across the index client counseling and contact client tracing phases of the implementation process. Identified barriers included sensitivities around discussing ICT with clients, privacy concerns, limited time for ICT amid high workloads, poor quality contact information, and logistical obstacles to tracing. In addition to these barriers, participants also described several HCW characteristics that facilitated feasibility: ICT knowledge, interpersonal skills, positive attitudes towards clients, and sense of purpose. Barriers and facilitators are mapped to the ICT process in Fig.  1 and described in greater detail in further sections.

Conceptual diagram mapping feasibility barriers and facilitators to the ICT process

Feasibility barriers

Sensitivities around discussing ict with clients.

Participants described ICT as a highly sensitive topic to approach with clients. Many expressed a feeling of uncertainty around how open index clients will be to sharing information about their contacts, as well as how contacts will react when approached for HTS. When asked about difficult aspects of counseling index clients, many HCWs mentioned clients’ hesitance or declination to participate in assisted ICT and share their contacts. Further, several HCWs mentioned that some index clients would provide false contact information. These index client behaviors were often attributed to confidentiality concerns, fear of unwanted status disclosure, and fear of the resulting implications of status disclosure: “They behave that way because they think you will be telling other people about their status…they also think that since you know it means their life is done, you will be looking at them differently .” Populations commonly identified as particularly likely to hesitate, refuse, or provide false information included youth (described as “ shy ” “ thinking they know a lot ” and “ difficult to reveal their contacts ”) and newly diagnosed clients (“it may be hard for them to accept [their HIV diagnosis]” ). One participant suggested that efforts to pair index clients with same-sex HCWs could make them more comfortable to discuss their contacts.

When asked about the first things that come to mind when starting to trace contacts, many participants discussed wondering how they will be received by the contact and preparing themselves to approach the contact. When conducting provider or contract referral, HCWs described a variety of challenging reactions that can occur when they approach a contact for HTS- including delay or refusal of testing, excessive questioning about the identity of the index client who referred them for testing, and even anger or aggression. Particularly mentioned in the context of male clients, these kinds of reactions can lead to stress and uncertain next steps for HCWs: “I was very tensed up. I was wondering to myself what was going to happen…he was talking with anger.”

Participants also noted the unique sensitivities inherent in conducting dual referral and interacting with sexual partners of index clients, explaining that HIV disclosure can create acute conflict in couples due to perceived blame and assumptions of infidelity. They recounted these scenarios as particularly difficult to navigate, with high stakes that require high-quality counseling skills: “sometimes if you do not have good counseling the marriage happens to get to an end.” . Some participants discussed concern about index client risk of intimate partner violence (IPV) upon partner disclosure: “they think that if they go home and [disclose their HIV status], the marriage will end right there, or for some getting to a point of [being] beaten.”

Privacy concerns

Participants also reported that clients highly value privacy, which can be difficult to secure throughout the ICT process. In the facility, while participants largely indicated that counseling index clients was much more successful when conducted in a private area, many reported limited availability of private counseling space. One participant described this challenge: “ if I’m counseling an index client and people keep coming into the room…this compromises the whole thing because the client becomes uncomfortable in the end.” Some HCWs mentioned working around this issue through use of screens, “do-not-disturb” signs, outdoor spots, and tents.

Participants also noted maintaining privacy as a challenge when tracing contact clients in the field, as they sometimes find clients in a situation that is not conducive to private conversations. One participant described: “ we get to the house and find that there are 4, 5 people with our [contact client]…it doesn’t go well…That is a mission gone wrong. ” Participants also noted that HCWs are also often easily recognizable in the community due to their bikes and cars, which exacerbates the risk of compromising privacy. To address privacy challenges in the community, participants reported strategies to increase discretion, including dressing to blend in with the community, preparing an alternate reason to be looking for the client, and offering HTS to multiple people or households to avoid singling out one person.

Limited time for ICT amid high workloads

Some participants indicated that strained staffing capacity leads HCWs to have to perform multiple roles, expressing challenges in balancing their ICT work with their other tasks. As one participant described, “Sometimes it is found that you are assigned a task here at the hospital to screen anyone who comes for blood testing, but you are also supposed to follow up [with] the contacts the same day- so it becomes a problem…you fail to follow up [with] the contacts.” Some also described being the only, or one of few staff responsible for ICT: “You’re doing this work alone, so you can see that it is a big task to do it single-handedly.” The need to counsel each index client individually, as a result of confidentiality concerns, further increases workload for the limited staff assigned to this work. Further, HCWs often described contact tracing in the field as time-consuming and physically taxing, which leaves them less time and energy for counseling. Many HCWs noted the need to hire more staff dedicated to ICT work.

High workloads also resulted in shorter appointments and less time to counsel index clients, which participants reported limits the opportunity for rapport that facilitates openness or probes for detailed information about sexual partners. Participants emphasized the importance of having enough time to meaningfully engage with index clients: “For counseling you cannot have a limit to say, ‘I will talk to him for 5 min only.’ …That is not counseling then. You are supposed to stay up until…you feel that this [person] is fulfilled.” . In addition, high workload can reduce the capacity of HCWs to deliver quality counseling: “So you find that as you go along with the counseling, you can do better with the first three clients but the rest, you are tired and you do short cuts.”

High workloads also lead to longer queues, which may deter clients from coming into the clinic or cause them to leave before receiving services: “Sometimes because of shortage of staff, it happens that you have been assigned a certain task that you were supposed to do but at the same time there are clients who were supposed to be counseled. As a result, because you spent more time on the other task as a result you lose out some of the clients because you find that they have gone.” In response to long queues, several participants described ‘fast-tracking’ contact clients who come in for HTS in effort to maximize case-finding by prioritizing those who have been identified as at risk of HIV.

Poor quality contact information

Participants repeatedly discussed the importance of eliciting accurate information about a person’s sexual partners, including where, when, and how to best contact them. As one participant said, “ Once the index has given us the wrong information then everything cannot work, it becomes wrong…if he gives us full information [with] the right details then everything becomes successful and happens without a problem. ” Adequate information is a critical component of the ICT process, and incorrect or incomplete information delays or prevents communication with contact clients.

Inadequate information, which can include incorrect or incomplete names, phone numbers, physical addresses, and contextual details, can arise from a variety of scenarios. Most participants mentioned index clients providing incorrect information as a concern. This occurred either intentionally to avoid disclosure or unintentionally if information was not known. Poor quality contact information also results from insufficient probing and poor documentation, which is often exacerbated by aforementioned HCW time and energy constraints. In one participant’s words, “The person who has enlisted the contact…is the key person who can make sure that our tracing is made easy.” Participants noted the pivotal role of the original HCW who first interacts with the index client in not only eliciting correct locator information but also eliciting detailed contextual information. For example, details about a contact client’s profession are helpful to trace the client at a time when they will likely be at home. Other helpful information included nicknames, HIV testing history, and notes about confidentiality concerns.

Logistical obstacles to tracing

Some contact clients are reached by phone whereas others must be physically traced in the community. Some participants reported difficulty with tracing via phone, frequently citing network problems and lack of sufficient airtime allocated by the facility. Participants also reported that some clients were unreachable by phone, necessitating physical tracing. Physically tracing a contact client requires a larger investment of resources than phone tracing, especially when the client lives at a far distance from the clinic. Participants frequently discussed having to travel far distances to reach contact clients, an issue some saw as exacerbated by people who travel to clinics at far distances due to privacy concerns.

While most participants reported walking or biking to reach contact clients in the community, some mentioned using a motorcycle or Tingathe vehicle. However, access to vehicles is often limited and these transportation methods require additional expenses for fuel. Walking or biking was also reported to expose HCWs to inclement weather, including hot or rainy seasons, and potential safety risks such as violence.

Participants reported that traveling far distances can be physically taxing and time-consuming, sometimes rendering them too tired or busy to attend to other tasks. Frequent travel influenced HCW morale, particularly when a tracing effort did not result in successfully recruiting a contact client. Participants frequently described this perception of wasted time and energy as “ painful ”, with the level of distress often portrayed as increasing with the distance travelled. As one HCW said, “You [can] find out that he gave a false address. That is painful because it means you have done nothing for the person, you travelled for nothing.”

HCWs described multiple approaches used to strategically allocate limited resources for long distances. These approaches included waiting to physically trace until there are multiple clients in a particular area, reserving vehicle use for longer trips, and coordinating across HCWs to map out contact client locations. HCWs also mentioned provision of rain gear and sun protection to mitigate uncomfortable travel. Another approach involved allocating contact tracing to HCWs based in the same communities as the contact clients.

Feasibility facilitators

Hcw knowledge about ict.

Participants reported that HCWs with a thorough understanding of ICT’s rationale and purpose can facilitate client openness. Clients were more likely to engage with HCWs about assisted ICT if they understood the benefits to themselves and their loved ones. One HCW stated, “If the person understands why we need the information, they will give us accurate information.”

Participants also discussed the value of deep HCW familiarity with ICT procedures and processes, particularly regarding screening clients for IPV and choosing referral method. One participant described the importance of clearly explaining various referral methods to clients: “So…people come and choose the method they like…when you explain things clearly it is like the index client is free to choose a method which the contact can use for testing”. Thorough knowledge of available referral methods allows HCWs to actively engage with index clients to discuss strategies to refer contacts in a way that fits their unique confidentiality needs, which was framed as particularly important when IPV is identified as a concern. Multiple participants suggested the use of flipcharts or videos, saying these would save limited HCW time and energy, fill information gaps, and provide clients with a visual aid to supplement the counseling. Others suggested recurring opportunities for training, to continuously “refresh” their ICT knowledge in order to facilitate implementation.

HCW interpersonal skills

In addition, HCWs’ ability to navigate sensitive conversations about HIV was noted as a key facilitator of successful implementation. Interpersonal skills were mentioned as mitigating the role’s day-to-day uncertainty by preparing HCWs to engage with clients, especially newly diagnosed clients: “ I need to counsel them skillfully so that they understand what I mean regardless that they have just tested positive for HIV.”

When discussing strategies to build HCW skills in counseling index clients and tracing contact clients, participants suggested establishing regular opportunities to discuss challenges and share approaches to address these challenges: “ I think that there should be much effort on the [HCWs] doing [ICT]. For example, what do I mean, they should be having a meeting with the facility people to ask what challenges are you facing and how can we end them?”. Another participant further elaborated, saying “We should be able to share experiences with our [colleagues] so that we can all learn from one another. And also, there are other people who are really brilliant at their job. Those people ought to come visit us and see how we are doing. That is very motivating.”

HCW non-stigmatizing attitudes and behaviors

Participants also highlighted the role of empathy and non-judgement in building trust with clients: “ Put yourself in that other person’s shoes. In so doing, the counseling session goes well. Understanding that person, that what is happening to them can also happen to you. ”. Participants viewed trust-building as critical to facilitating client comfort and openness: “if they trust you enough, they will give you the right information.” Further, participants associated HCW assurance of confidentiality with promoting trust and greater information sharing: “ Also assuring them on the issue of confidentiality because confidentiality is a paramount. If there will not be confidentiality then the clients will not reveal.”

HCW sense of purpose

Lastly, several participants reported that a sense of purpose and desire to help people motivated them to overcome the challenges of delivering assisted ICT. One participant said, “ Some of these jobs are a ministry. Counseling is not easy. You just need to tell yourself that you are there to help that person. ” Many seemed to take comfort in the knowledge that their labors, however taxing, would ultimately allow people to know their status, take control of their health, and prevent the spread of HIV. Participants framed the sense of fulfillment from successful ICT implementation as a mitigating factor amidst challenges: “ If [the contact client] has accepted it then I feel that mostly I have achieved the aim of being in the health field…that is why it is appealing to me ”.

Participants described a variety of barriers to assisted ICT implementation, including sensitivities around discussing ICT with clients, privacy concerns, limited time for ICT amid high workloads, poor quality contact information, and logistical obstacles to tracing. These barriers manifested across each step of the process of counseling index clients and tracing contacts. However, participants also identified HCW characteristics and process improvements that can mitigate these barriers.

Further, participants’ descriptions of the assisted ICT process revealed the intimately interconnected nature of factors that influence feasibility of assisted ICT. Sensitivities around HIV, privacy limitations, time constraints, and HCW characteristics all contribute to the extent to which counseling index clients elicits adequate information to facilitate contact tracing. Information quality has implications for HCW capacity, as inadequate information can lead to wasted resources, including HCW time and energy, on contact tracing. The opportunity cost of wasted efforts, which increases as the distance from which the contact client lives from the clinic increases, depletes HCW morale. The resulting acceleration of burnout, which is already fueled by busy workloads and the inherent uncertainty of day-to-day ICT work, further impairs HCW capacity to effectively engage in quality counseling that elicits adequate information from index clients. This interconnectedness suggests that efforts to mitigate barriers at any step of the assisted ICT process may have the potential to ripple across the whole process.

Participants’ descriptions of client confidentiality and privacy concerns, as well as fear of consequences of disclosure, align with previous studies that emphasize stigma as a key barrier to assisted ICT [ 15 , 18 , 19 , 20 , 30 , 31 ] and the overall HIV testing and treatment cascade [ 41 ]. Our findings suggest that anticipated stigma, or the fear of discrimination upon disclosure [ 42 ], drives several key barriers to feasibility of assisted ICT implementation. Previous studies also highlight the key role of HCWs in mitigating barriers related to anticipated stigma; noting the key role of HCW ICT knowledge, interpersonal skills, and non-stigmatizing attitudes/behaviors in securing informed consent from clients for ICT, tailoring the referral strategy to minimize risk to client confidentiality and safety, building trust and rapport with the client, and eliciting accurate contact information from index clients to facilitate contact tracing [ 18 , 19 , 20 , 30 ].

Our findings also reflect previous evidence of logistical challenges related to limited time, space, and resources that can present barriers to feasibility for HCWs [ 18 , 19 , 20 , 30 , 31 ]. Participants in the current study described these logistical challenges as perpetuating HCW burnout, making it harder for them to engage in effective counseling. Cumulative evidence of barriers across different settings (further validated by this study) suggests that assisted ICT implementation may pose greater burden on HCWs than previously thought [ 7 ]. However, our findings also suggest that strategic investment in targeted implementation strategies has the potential to help overcome these feasibility barriers.

In our own work, these findings affirmed the rationale for and informed the development of the blended learning implementation package tested in our trial [ 40 , 43 ]. Findings indicated the need for evidence-based training and support to promote HCW capacity to foster facilitating characteristics. Participants discussed the value of "refresher" opportunities in building knowledge, as well as the value of learning from other’s experiences. The blended learning implementation package balances both needs by providing time for HCWs to master ICT knowledge and skills with a combination of asynchronous, digitally delivered content (which allows for continuous review as a "refresher") and in-person sessions (which allow for sharing, practicing, and feedback). Our findings also highlight the value of flexible referral methods that align with the client’s needs, so our training content includes a detailed description of each referral method process. Further, our training content emphasizes client-centered, non-judgmental counseling as our findings add to cumulative evidence of stigma as a key barrier to assisted ICT implementation [ 41 ].

In addition, participants frequently mentioned informal workarounds currently in use to mitigate barriers or offered up ideas for potential solutions to try. Our blended learning implementation package streamlines these problem-solving processes by offering monthly continuous quality improvement sessions at each facility in our enhanced arm. These sessions allow for structured time to discuss identified barriers, share ideas to mitigate barriers, and develop solutions for sustained process improvement tailored to their specific setting. Initial focus areas for continuous quality improvement discussions include use of space, staffing, allocation of airtime and vehicles, and documentation, which were identified as barriers to feasibility in the current study.

Our study provides a uniquely in-depth examination of HCWs’ experiences implementing assisted ICT, exploring how barriers can manifest and interact with each other at each step of the process to hinder successful implementation. Further, our study has a highly actionable focus on informing development of implementation strategies to support HCWs implementing assisted ICT. Our study also has limitations. Firstly, while our sole focus on HCWs allowed for deeper exploration of assisted ICT from the perspective of those actually implementing it on the ground, this meant that our analysis did not include perspectives of index or contact clients. In addition, we did not conduct sub-group analyses as interpretation of results would be limited by our small sample size.

Assisted ICT has been widely recognized as an evidence-based intervention with high promise to increase PLHIV status awareness [ 5 , 6 , 7 , 10 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , 23 , 24 , 26 , 27 , 28 , 29 ], which is important as countries in eastern and southern Africa strive to reach global UNAIDS targets. Study findings support cumulative evidence that HCWs face a variety of feasibility barriers to assisted ICT implementation in the region; further, the study’s uniquely in-depth focus on the experiences of those doing the “assisting” enhances understanding of how these barriers manifest and informs the development of implementation strategies to mitigate these barriers. Maximizing assisted ICT’s potential to increase HIV testing requires equipping HCWs with effective training and support to address and overcome the many feasibility barriers they face in implementation. Findings demonstrate the need for, as well as inform the development of, implementation strategies to mitigate barriers and promote facilitators to feasibility of assisted ICT.

Availability of data and materials

Qualitative data on which this analysis is based, as well as data collection materials and codebooks, are available from the last author upon reasonable request. The interview guide is included as an additional file.

Abbreviations

Acquired Immunodeficiency Syndrome

Antiretroviral Therapy

Health Care Worker

Human Immunodeficiency Virus

HIV Testing Services

Index Case Testing

In-Depth Interview

Intimate Partner Violence

Institutional Review Board

President’s Emergency Plan for HIV/AIDS Relief

People Living With HIV

Joint United Nations Programme on HIV/AIDS

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Acknowledgements

We are grateful to the Malawian health care workers who shared their experiences through in-depth interviews, as well as to the study team members in Malawi and the United States for their contributions.

Research reported in this publication was funded by the National Institutes of Health (R01 MH124526) with support from the University of North Carolina at Chapel Hill Center for AIDS Research (P30 AI50410) and the Fogarty International Center of the National Institutes of Health (D43 TW010060 and R01 MH115793-04). The funders had no role in trial design, data collection and analysis, decision to publish or preparation of the manuscript.

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Tiwonge E. Mbeya Munkhondya

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TAT, KRS, SER, MHK, VFG, and NER contributed to overall study conceptualization, with CJM, CB, and NER leading conceptualization of the analysis presented in this study. Material preparation and data collection were performed by TEMM, MM, TAT, MC, and CK. Analysis was led by CJM with support from MJB and DV. The first draft of the manuscript was written by CJM with consultation from NER, TEMM, MM, TAT, MJB, and DV. JW provided quantitative analysis support for participant characteristics. All authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

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Meek, C.J., Munkhondya, T.E.M., Mphande, M. et al. Examining the feasibility of assisted index case testing for HIV case-finding: a qualitative analysis of barriers and facilitators to implementation in Malawi. BMC Health Serv Res 24 , 606 (2024). https://doi.org/10.1186/s12913-024-10988-z

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