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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Research bias

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

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Case Study | Definition, Examples & Methods

Case Study | Definition, Examples & Methods

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Cite this Scribbr article

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McCombes, S. (2023, January 30). Case Study | Definition, Examples & Methods. Scribbr. Retrieved 15 April 2024, from https://www.scribbr.co.uk/research-methods/case-studies/

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Writing a Case Study

What is a case study?

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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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A Quick Guide to Case Study with Examples

Published by Alvin Nicolas at August 14th, 2021 , Revised On August 29, 2023

A case study is a documented history and detailed analysis of a situation concerning organisations, industries, and markets.

A case study:

Focuses on discovering new facts of the situation under observation.
Includes data collection from multiple sources over time.
Widely used in social sciences to study the underlying information, organisation, community, or event.
It does not provide any solution to the problem .

When to Use Case Study?

You can use a case study in your research when:

The focus of your study is to find answers to how and why questions .
You don’t have enough time to conduct extensive research; case studies are convenient for completing your project successfully.
You want to analyse real-world problems in-depth, then you can use the method of the case study.

You can consider a single case to gain in-depth knowledge about the subject, or you can choose multiple cases to know about various aspects of your research problem .

What are the Aims of the Case Study?

The case study aims at identifying weak areas that can be improved.
This method is often used for idiographic research (focuses on individual cases or events).
Another aim of the case study is nomothetic research (aims to discover new theories through data analysis of multiple cases).

Types of Case Studies

There are different types of case studies that can be categorised based on the purpose of the investigation.

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How to Conduct a Case Study?

Select the Case to Investigate
Formulate the Research Question
Review of Literature
Choose the Precise Case to Use in your Study
Select Data Collection and Analysis Techniques
Collect the Data
Analyse the Data
Prepare the Report

Step1: Select the Case to Investigate

The first step is to select a case to conduct your investigation. You should remember the following points.

Make sure that you perform the study in the available timeframe.
There should not be too much information available about the organisation.
You should be able to get access to the organisation.
There should be enough information available about the subject to conduct further research.

Step2: Formulate the Research Question

It’s necessary to formulate a research question to proceed with your case study. Most of the research questions begin with how, why, what, or what can .

You can also use a research statement instead of a research question to conduct your research which can be conditional or non-conditional.

Step 3: Review of Literature

Once you formulate your research statement or question, you need to extensively review the documentation about the existing discoveries related to your research question or statement.

Step 4: Choose the Precise Case to Use in your Study

You need to select a specific case or multiple cases related to your research. It would help if you treated each case individually while using multiple cases. The outcomes of each case can be used as contributors to the outcomes of the entire study. You can select the following cases.

Representing various geographic regions
Cases with various size parameters
Explaining the existing theories or assumptions
Leading to discoveries
Providing a base for future research.

Step 5: Select Data Collection and Analysis Techniques

You can choose both qualitative or quantitative approaches for collecting the data . You can use interviews , surveys , artifacts, documentation, newspapers, and photographs, etc. To avoid biased observation, you can triangulate your research to provide different views of your case. Even if you are focusing on a single case, you need to observe various case angles. It would help if you constructed validity, internal and external validity, as well as reliability.

Example: Identifying the impacts of contaminated water on people’s health and the factors responsible for it. You need to gather the data using qualitative and quantitative approaches to understand the case in such cases.

Construct validity: You should select the most suitable measurement tool for your research.

Internal validity: You should use various methodological tools to triangulate the data. Try different methods to study the same hypothesis.

External validity: You need to effectively apply the data beyond the case’s circumstances to more general issues.

Reliability: You need to be confident enough to formulate the new direction for future studies based on your findings.

Step 6: Collect the Data

Beware of the following when collecting data:

Information should be gathered systematically, and the collected evidence from various sources should contribute to your research objectives.
Don’t collect your data randomly.
Recheck your research questions to avoid mistakes.
You should save the collected data in any popular format for clear understanding.
While making any changes to collecting information, make sure to record the changes in a document.
You should maintain a case diary and note your opinions and thoughts evolved throughout the study.

Step 7: Analyse the Data

The research data identifies the relationship between the objects of study and the research questions or statements. You need to reconfirm the collected information and tabulate it correctly for better understanding.

Step 8: Prepare the Report

It’s essential to prepare a report for your case study. You can write your case study in the form of a scientific paper or thesis discussing its detail with supporting evidence.

A case study can be represented by incorporating quotations, stories, anecdotes, interview transcripts , etc., with empirical data in the result section.

You can also write it in narrative styles using textual analysis or discourse analysis . Your report should also include evidence from published literature, and you can put it in the discussion section.

Advantages and Disadvantages of Case Study

Frequently asked questions, what is the case study.

A case study is a research method where a specific instance, event, or situation is deeply examined to gain insights into real-world complexities. It involves detailed analysis of context, data, and variables to understand patterns, causes, and effects, often used in various disciplines for in-depth exploration.

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Literature as a Foundation for Research: Case Studies and Examples

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Writing Articles & Reviews
November 2, 2023

When conducting research, a solid foundation is essential for ensuring the credibility and depth of your work. One such foundation that has been proven effective time and again is literature. By utilizing literature as a basis for research, scholars can draw upon existing knowledge, build upon established theories, and gain insights from previous studies. In this article, we explore the importance of literature in research through case studies and provide examples of how IT can be effectively incorporated into various disciplines.

The Importance of Literature in Research

Literature plays a crucial role in research as IT provides a comprehensive understanding of the existing body of knowledge on a particular topic. IT offers a platform for scholars to engage in scholarly conversations, critically evaluate previous studies, and identify gaps or areas that require further exploration.

By examining literature, researchers can gain insights into various theories, methodologies, and findings that have been developed over time. This allows them to position their research within the existing scholarly discourse and contribute something novel to the field.

Case Study: Literature Review in a Scientific Research Paper

Let’s consider a case study to highlight how literature can be effectively incorporated into research. Imagine a scientific research paper aiming to investigate the effects of a new drug on a specific disease. Before conducting any experiments or data collection, the researchers must undertake a comprehensive literature review.

In this literature review, the researchers will identify and analyze existing studies related to the disease, previous treatments, and any prior research on the drug. They will evaluate the methodologies used, the results obtained, and any gaps in knowledge. By doing so, the researchers gather relevant information that helps them design their own study, ensuring IT aligns with the current understanding of the disease and the drug’s potential impact.

The literature review also allows the researchers to identify the limitations or challenges faced in previous studies. By taking note of these, they can design their experiments and data collection methods to address those limitations and produce more robust results. This demonstrates the fundamental role literature can play in shaping the research process.

Examples of Literature-Based Research

Various disciplines leverage literature as a foundation for research. Here are a few examples:

1. Social Sciences

In social sciences, literature-based research is often used to conduct critical reviews, explore theoretical frameworks, and identify relevant variables. By analyzing previous studies, researchers can gain insights into social trends, cultural dynamics, and various behavioral patterns.

2. Literature and Humanities

In literary and humanities research, scholars analyze literature works, historical documents, and artistic creations to gain a deeper understanding of cultural movements, intellectual exchanges, and societal developments. By studying these texts and artifacts, researchers can provide critical interpretations and theoretical frameworks to enhance our understanding of the human experience.

3. Education

In education research, literature plays a crucial role in identifying best practices, understanding pedagogy, and evaluating teaching methods. Literature-based research in this field helps educators and policymakers make informed decisions based on the existing body of knowledge.

Literature serves as a foundation for research by offering a deep-rooted and well-established body of knowledge on various subjects. IT enables scholars to position their work within existing frameworks and identify gaps that require further exploration. Literature-based research not only helps build credibility but also strengthens the overall quality of research findings.

Q1: What is a literature review in research?

A1: A literature review is a crucial component of research that involves analyzing and summarizing previous scholarly works related to a specific topic. IT provides an overview of existing knowledge, theories, and methodologies, allowing researchers to position their own work within the broader landscape of the field.

Q2: Why is literature important in research?

A2: Literature serves as the foundation for research by providing a comprehensive understanding of existing knowledge on a particular topic. IT helps researchers identify gaps, develop research questions, and design studies that contribute to the field’s growth.

Q3: How can literature-based research be applied in natural sciences?

A3: In natural sciences, literature-based research is utilized in various ways, including reviewing previous studies, understanding theoretical frameworks, and identifying potential research avenues. IT helps scientists consider existing knowledge and build upon IT to create new hypotheses or develop innovative methods.

Q4: Can literature-based research lead to original contributions?

A4: Absolutely. Literature-based research allows scholars to identify gaps or areas with limited study, enabling them to propose novel research questions or approaches. By building on existing knowledge, researchers can make original contributions to their respective fields.

Q5: How should one approach conducting a literature review?

A5: Conducting a literature review requires a systematic approach. Start by defining your research question and search for relevant academic articles, books, and other sources. Analyze and critically evaluate each source, identifying key themes, theories, and findings. Finally, synthesize the information to present a comprehensive understanding of the topic within the context of your research.

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Open access
Published: 27 June 2011

The case study approach

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

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

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

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Introduction

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

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

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

What is a case study?

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

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

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

What are case studies used for?

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

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

How are case studies conducted?

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

Defining the case

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

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

Selecting the case(s)

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

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

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

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

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

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

Collecting the data

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

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

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

Analysing, interpreting and reporting case studies

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

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

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

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

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

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

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

Conclusions

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

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Acknowledgements

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

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

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

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CC0006 Basics of Report Writing

Structure of a report (case study, literature review or survey).

Structure of report (Site visit)
Citing Sources
Tips and Resources

The information in the report has to be organised in the best possible way for the reader to understand the issue being investigated, analysis of the findings and recommendations or implications that relate directly to the findings. Given below are the main sections of a standard report. Click on each section heading to learn more about it.

Tells the reader what the report is about
Informative, short, catchy

Example - Sea level rise in Singapore : Causes, Impact and Solution

The title page must also include group name, group members and their matriculation numbers.

Content s Page

Has headings and subheadings that show the reader where the various sections of the report are located
Written on a separate page
Includes the page numbers of each section
Briefly summarises the report, the process of research and final conclusions
Provides a quick overview of the report and describes the main highlights
Short, usually not more than 150 words in length
Mention briefly why you choose this project, what are the implications and what kind of problems it will solve

Usually, the abstract is written last, ie. after writing the other sections and you know the key points to draw out from these sections. Abstracts allow readers who may be interested in the report to decide whether it is relevant to their purposes.

Introduction

Discusses the background and sets the context
Introduces the topic, significance of the problem, and the purpose of research
Gives the scope ie shows what it includes and excludes

In the introduction, write about what motivates your project, what makes it interesting, what questions do you aim to answer by doing your project. The introduction lays the foundation for understanding the research problem and should be written in a way that leads the reader from the general subject area of the topic to the particular topic of research.

Literature Review

Helps to gain an understanding of the existing research in that topic
To develop on your own ideas and build your ideas based on the existing knowledge
Prevents duplication of the research done by others

Search the existing literature for information. Identify the data pertinent to your topic. Review, extract the relevant information for eg how the study was conducted and the findings. Summarise the information. Write what is already known about the topic and what do the sources that you have reviewed say. Identify conflicts in previous studies, open questions, or gaps that may exist. If you are doing

Case study - look for background information and if any similar case studies have been done before.
Literature review - find out from literature, what is the background to the questions that you are looking into
Site visit - use the literature review to read up and prepare good questions before hand.
Survey - find out if similar surveys have been done before and what did they find?

Keep a record of the source details of any information you want to use in your report so that you can reference them accurately.

Methodology

Methodology is the approach that you take to gather data and arrive at the recommendation(s). Choose a method that is appropriate for the research topic and explain it in detail.

In this section, address the following: a) How the data was collected b) How it was analysed and c) Explain or justify why a particular method was chosen.

Usually, the methodology is written in the past tense and can be in the passive voice. Some examples of the different methods that you can use to gather data are given below. The data collected provides evidence to build your arguments. Collect data, integrate the findings and perspectives from different studies and add your own analysis of its feasibility.

Explore the literature/news/internet sources to know the topic in depth
Give a description of how you selected the literature for your project
Compare the studies, and highlight the findings, gaps or limitations.
An in-depth, detailed examination of specific cases within a real-world context.
Enables you to examine the data within a specific context.
Examine a well defined case to identify the essential factors, process and relationship.
Write the case description, the context and the process involved.
Make sense of the evidence in the case(s) to answer the research question
Gather data from a predefined group of respondents by asking relevant questions
Can be conducted in person or online
Why you chose this method (questionnaires, focus group, experimental procedure, etc)
How you carried out the survey. Include techniques and any equipment you used
If there were participants in your research, who were they? How did you select them and how may were there?
How the survey questions address the different aspects of the research question
Analyse the technology / policy approaches by visiting the required sites
Make a detailed report on its features and your understanding of it

Results and Analysis

Present the results of the study. You may consider visualising the results in tables and graphs, graphics etc.
Analyse the results to obtain answer to the research question.
Provide an analysis of the technical and financial feasibility, social acceptability etc

Discussion, Limitation(s) and Implication(s)

Discuss your interpretations of the analysis and the significance of your findings
Explain any new understanding or insights that emerged as a result of your research
Consider the different perspectives (social, economic and environmental)in the discussion
Explain the limitation(s)
Explain how could what you found be used to make a difference for sustainability

Conclusion and Recommendations

Summarise the significance and outcome of the study highlighting the key points.
Come up with alternatives and propose specific actions based on the alternatives
Describe the result or improvement it would achieve
Explain how it will be implemented

Recommendations should have an innovative approach and should be feasible. It should make a significant difference in solving the issue under discussion.

List the sources you have referred to in your writing
Use the recommended citation style consistently in your report

Appendix (if necessary/any)

Include any material relating to the report and research that does not fit in the body of the report, in the appendix. For example, you may include survey questionnaire and results in the appendix.

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A Review of the Literature on Case Study Research

This paper presents a review of the literature on case study research and comments on the ongoing debate of the value of case study. A research paradigm and its theoretical framework is described. This review focuses extensively on the positions of

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Acknowledgments

Definition and Introduction

Case analysis is a problem-based teaching and learning method that involves critically analyzing complex scenarios within an organizational setting for the purpose of placing the student in a “real world” situation and applying reflection and critical thinking skills to contemplate appropriate solutions, decisions, or recommended courses of action. It is considered a more effective teaching technique than in-class role playing or simulation activities. The analytical process is often guided by questions provided by the instructor that ask students to contemplate relationships between the facts and critical incidents described in the case.

Cases generally include both descriptive and statistical elements and rely on students applying abductive reasoning to develop and argue for preferred or best outcomes [i.e., case scenarios rarely have a single correct or perfect answer based on the evidence provided]. Rather than emphasizing theories or concepts, case analysis assignments emphasize building a bridge of relevancy between abstract thinking and practical application and, by so doing, teaches the value of both within a specific area of professional practice.

Given this, the purpose of a case analysis paper is to present a structured and logically organized format for analyzing the case situation. It can be assigned to students individually or as a small group assignment and it may include an in-class presentation component. Case analysis is predominately taught in economics and business-related courses, but it is also a method of teaching and learning found in other applied social sciences disciplines, such as, social work, public relations, education, journalism, and public administration.

Ellet, William. The Case Study Handbook: A Student's Guide . Revised Edition. Boston, MA: Harvard Business School Publishing, 2018; Christoph Rasche and Achim Seisreiner. Guidelines for Business Case Analysis . University of Potsdam; Writing a Case Analysis . Writing Center, Baruch College; Volpe, Guglielmo. "Case Teaching in Economics: History, Practice and Evidence." Cogent Economics and Finance 3 (December 2015). doi:https://doi.org/10.1080/23322039.2015.1120977.

How to Approach Writing a Case Analysis Paper

The organization and structure of a case analysis paper can vary depending on the organizational setting, the situation, and how your professor wants you to approach the assignment. Nevertheless, preparing to write a case analysis paper involves several important steps. As Hawes notes, a case analysis assignment “...is useful in developing the ability to get to the heart of a problem, analyze it thoroughly, and to indicate the appropriate solution as well as how it should be implemented” [p.48]. This statement encapsulates how you should approach preparing to write a case analysis paper.

Before you begin to write your paper, consider the following analytical procedures:

Review the case to get an overview of the situation . A case can be only a few pages in length, however, it is most often very lengthy and contains a significant amount of detailed background information and statistics, with multilayered descriptions of the scenario, the roles and behaviors of various stakeholder groups, and situational events. Therefore, a quick reading of the case will help you gain an overall sense of the situation and illuminate the types of issues and problems that you will need to address in your paper. If your professor has provided questions intended to help frame your analysis, use them to guide your initial reading of the case.
Read the case thoroughly . After gaining a general overview of the case, carefully read the content again with the purpose of understanding key circumstances, events, and behaviors among stakeholder groups. Look for information or data that appears contradictory, extraneous, or misleading. At this point, you should be taking notes as you read because this will help you develop a general outline of your paper. The aim is to obtain a complete understanding of the situation so that you can begin contemplating tentative answers to any questions your professor has provided or, if they have not provided, developing answers to your own questions about the case scenario and its connection to the course readings,lectures, and class discussions.
Determine key stakeholder groups, issues, and events and the relationships they all have to each other . As you analyze the content, pay particular attention to identifying individuals, groups, or organizations described in the case and identify evidence of any problems or issues of concern that impact the situation in a negative way. Other things to look for include identifying any assumptions being made by or about each stakeholder, potential biased explanations or actions, explicit demands or ultimatums , and the underlying concerns that motivate these behaviors among stakeholders. The goal at this stage is to develop a comprehensive understanding of the situational and behavioral dynamics of the case and the explicit and implicit consequences of each of these actions.
Identify the core problems . The next step in most case analysis assignments is to discern what the core [i.e., most damaging, detrimental, injurious] problems are within the organizational setting and to determine their implications. The purpose at this stage of preparing to write your analysis paper is to distinguish between the symptoms of core problems and the core problems themselves and to decide which of these must be addressed immediately and which problems do not appear critical but may escalate over time. Identify evidence from the case to support your decisions by determining what information or data is essential to addressing the core problems and what information is not relevant or is misleading.
Explore alternative solutions . As noted, case analysis scenarios rarely have only one correct answer. Therefore, it is important to keep in mind that the process of analyzing the case and diagnosing core problems, while based on evidence, is a subjective process open to various avenues of interpretation. This means that you must consider alternative solutions or courses of action by critically examining strengths and weaknesses, risk factors, and the differences between short and long-term solutions. For each possible solution or course of action, consider the consequences they may have related to their implementation and how these recommendations might lead to new problems. Also, consider thinking about your recommended solutions or courses of action in relation to issues of fairness, equity, and inclusion.
Decide on a final set of recommendations . The last stage in preparing to write a case analysis paper is to assert an opinion or viewpoint about the recommendations needed to help resolve the core problems as you see them and to make a persuasive argument for supporting this point of view. Prepare a clear rationale for your recommendations based on examining each element of your analysis. Anticipate possible obstacles that could derail their implementation. Consider any counter-arguments that could be made concerning the validity of your recommended actions. Finally, describe a set of criteria and measurable indicators that could be applied to evaluating the effectiveness of your implementation plan.

Use these steps as the framework for writing your paper. Remember that the more detailed you are in taking notes as you critically examine each element of the case, the more information you will have to draw from when you begin to write. This will save you time.

NOTE : If the process of preparing to write a case analysis paper is assigned as a student group project, consider having each member of the group analyze a specific element of the case, including drafting answers to the corresponding questions used by your professor to frame the analysis. This will help make the analytical process more efficient and ensure that the distribution of work is equitable. This can also facilitate who is responsible for drafting each part of the final case analysis paper and, if applicable, the in-class presentation.

Framework for Case Analysis . College of Management. University of Massachusetts; Hawes, Jon M. "Teaching is Not Telling: The Case Method as a Form of Interactive Learning." Journal for Advancement of Marketing Education 5 (Winter 2004): 47-54; Rasche, Christoph and Achim Seisreiner. Guidelines for Business Case Analysis . University of Potsdam; Writing a Case Study Analysis . University of Arizona Global Campus Writing Center; Van Ness, Raymond K. A Guide to Case Analysis . School of Business. State University of New York, Albany; Writing a Case Analysis . Business School, University of New South Wales.

Structure and Writing Style

A case analysis paper should be detailed, concise, persuasive, clearly written, and professional in tone and in the use of language . As with other forms of college-level academic writing, declarative statements that convey information, provide a fact, or offer an explanation or any recommended courses of action should be based on evidence. If allowed by your professor, any external sources used to support your analysis, such as course readings, should be properly cited under a list of references. The organization and structure of case analysis papers can vary depending on your professor’s preferred format, but its structure generally follows the steps used for analyzing the case.

Introduction

The introduction should provide a succinct but thorough descriptive overview of the main facts, issues, and core problems of the case . The introduction should also include a brief summary of the most relevant details about the situation and organizational setting. This includes defining the theoretical framework or conceptual model on which any questions were used to frame your analysis.

Following the rules of most college-level research papers, the introduction should then inform the reader how the paper will be organized. This includes describing the major sections of the paper and the order in which they will be presented. Unless you are told to do so by your professor, you do not need to preview your final recommendations in the introduction. U nlike most college-level research papers , the introduction does not include a statement about the significance of your findings because a case analysis assignment does not involve contributing new knowledge about a research problem.

Background Analysis

Background analysis can vary depending on any guiding questions provided by your professor and the underlying concept or theory that the case is based upon. In general, however, this section of your paper should focus on:

Providing an overarching analysis of problems identified from the case scenario, including identifying events that stakeholders find challenging or troublesome,
Identifying assumptions made by each stakeholder and any apparent biases they may exhibit,
Describing any demands or claims made by or forced upon key stakeholders, and
Highlighting any issues of concern or complaints expressed by stakeholders in response to those demands or claims.

These aspects of the case are often in the form of behavioral responses expressed by individuals or groups within the organizational setting. However, note that problems in a case situation can also be reflected in data [or the lack thereof] and in the decision-making, operational, cultural, or institutional structure of the organization. Additionally, demands or claims can be either internal and external to the organization [e.g., a case analysis involving a president considering arms sales to Saudi Arabia could include managing internal demands from White House advisors as well as demands from members of Congress].

Throughout this section, present all relevant evidence from the case that supports your analysis. Do not simply claim there is a problem, an assumption, a demand, or a concern; tell the reader what part of the case informed how you identified these background elements.

Identification of Problems

In most case analysis assignments, there are problems, and then there are problems . Each problem can reflect a multitude of underlying symptoms that are detrimental to the interests of the organization. The purpose of identifying problems is to teach students how to differentiate between problems that vary in severity, impact, and relative importance. Given this, problems can be described in three general forms: those that must be addressed immediately, those that should be addressed but the impact is not severe, and those that do not require immediate attention and can be set aside for the time being.

All of the problems you identify from the case should be identified in this section of your paper, with a description based on evidence explaining the problem variances. If the assignment asks you to conduct research to further support your assessment of the problems, include this in your explanation. Remember to cite those sources in a list of references. Use specific evidence from the case and apply appropriate concepts, theories, and models discussed in class or in relevant course readings to highlight and explain the key problems [or problem] that you believe must be solved immediately and describe the underlying symptoms and why they are so critical.

Alternative Solutions

This section is where you provide specific, realistic, and evidence-based solutions to the problems you have identified and make recommendations about how to alleviate the underlying symptomatic conditions impacting the organizational setting. For each solution, you must explain why it was chosen and provide clear evidence to support your reasoning. This can include, for example, course readings and class discussions as well as research resources, such as, books, journal articles, research reports, or government documents. In some cases, your professor may encourage you to include personal, anecdotal experiences as evidence to support why you chose a particular solution or set of solutions. Using anecdotal evidence helps promote reflective thinking about the process of determining what qualifies as a core problem and relevant solution .

Throughout this part of the paper, keep in mind the entire array of problems that must be addressed and describe in detail the solutions that might be implemented to resolve these problems.

Recommended Courses of Action

In some case analysis assignments, your professor may ask you to combine the alternative solutions section with your recommended courses of action. However, it is important to know the difference between the two. A solution refers to the answer to a problem. A course of action refers to a procedure or deliberate sequence of activities adopted to proactively confront a situation, often in the context of accomplishing a goal. In this context, proposed courses of action are based on your analysis of alternative solutions. Your description and justification for pursuing each course of action should represent the overall plan for implementing your recommendations.

For each course of action, you need to explain the rationale for your recommendation in a way that confronts challenges, explains risks, and anticipates any counter-arguments from stakeholders. Do this by considering the strengths and weaknesses of each course of action framed in relation to how the action is expected to resolve the core problems presented, the possible ways the action may affect remaining problems, and how the recommended action will be perceived by each stakeholder.

In addition, you should describe the criteria needed to measure how well the implementation of these actions is working and explain which individuals or groups are responsible for ensuring your recommendations are successful. In addition, always consider the law of unintended consequences. Outline difficulties that may arise in implementing each course of action and describe how implementing the proposed courses of action [either individually or collectively] may lead to new problems [both large and small].

Throughout this section, you must consider the costs and benefits of recommending your courses of action in relation to uncertainties or missing information and the negative consequences of success.

The conclusion should be brief and introspective. Unlike a research paper, the conclusion in a case analysis paper does not include a summary of key findings and their significance, a statement about how the study contributed to existing knowledge, or indicate opportunities for future research.

Begin by synthesizing the core problems presented in the case and the relevance of your recommended solutions. This can include an explanation of what you have learned about the case in the context of your answers to the questions provided by your professor. The conclusion is also where you link what you learned from analyzing the case with the course readings or class discussions. This can further demonstrate your understanding of the relationships between the practical case situation and the theoretical and abstract content of assigned readings and other course content.

Problems to Avoid

The literature on case analysis assignments often includes examples of difficulties students have with applying methods of critical analysis and effectively reporting the results of their assessment of the situation. A common reason cited by scholars is that the application of this type of teaching and learning method is limited to applied fields of social and behavioral sciences and, as a result, writing a case analysis paper can be unfamiliar to most students entering college.

After you have drafted your paper, proofread the narrative flow and revise any of these common errors:

Unnecessary detail in the background section . The background section should highlight the essential elements of the case based on your analysis. Focus on summarizing the facts and highlighting the key factors that become relevant in the other sections of the paper by eliminating any unnecessary information.
Analysis relies too much on opinion . Your analysis is interpretive, but the narrative must be connected clearly to evidence from the case and any models and theories discussed in class or in course readings. Any positions or arguments you make should be supported by evidence.
Analysis does not focus on the most important elements of the case . Your paper should provide a thorough overview of the case. However, the analysis should focus on providing evidence about what you identify are the key events, stakeholders, issues, and problems. Emphasize what you identify as the most critical aspects of the case to be developed throughout your analysis. Be thorough but succinct.
Writing is too descriptive . A paper with too much descriptive information detracts from your analysis of the complexities of the case situation. Questions about what happened, where, when, and by whom should only be included as essential information leading to your examination of questions related to why, how, and for what purpose.
Inadequate definition of a core problem and associated symptoms . A common error found in case analysis papers is recommending a solution or course of action without adequately defining or demonstrating that you understand the problem. Make sure you have clearly described the problem and its impact and scope within the organizational setting. Ensure that you have adequately described the root causes w hen describing the symptoms of the problem.
Recommendations lack specificity . Identify any use of vague statements and indeterminate terminology, such as, “A particular experience” or “a large increase to the budget.” These statements cannot be measured and, as a result, there is no way to evaluate their successful implementation. Provide specific data and use direct language in describing recommended actions.
Unrealistic, exaggerated, or unattainable recommendations . Review your recommendations to ensure that they are based on the situational facts of the case. Your recommended solutions and courses of action must be based on realistic assumptions and fit within the constraints of the situation. Also note that the case scenario has already happened, therefore, any speculation or arguments about what could have occurred if the circumstances were different should be revised or eliminated.

Bee, Lian Song et al. "Business Students' Perspectives on Case Method Coaching for Problem-Based Learning: Impacts on Student Engagement and Learning Performance in Higher Education." Education & Training 64 (2022): 416-432; The Case Analysis . Fred Meijer Center for Writing and Michigan Authors. Grand Valley State University; Georgallis, Panikos and Kayleigh Bruijn. "Sustainability Teaching using Case-Based Debates." Journal of International Education in Business 15 (2022): 147-163; Hawes, Jon M. "Teaching is Not Telling: The Case Method as a Form of Interactive Learning." Journal for Advancement of Marketing Education 5 (Winter 2004): 47-54; Georgallis, Panikos, and Kayleigh Bruijn. "Sustainability Teaching Using Case-based Debates." Journal of International Education in Business 15 (2022): 147-163; .Dean, Kathy Lund and Charles J. Fornaciari. "How to Create and Use Experiential Case-Based Exercises in a Management Classroom." Journal of Management Education 26 (October 2002): 586-603; Klebba, Joanne M. and Janet G. Hamilton. "Structured Case Analysis: Developing Critical Thinking Skills in a Marketing Case Course." Journal of Marketing Education 29 (August 2007): 132-137, 139; Klein, Norman. "The Case Discussion Method Revisited: Some Questions about Student Skills." Exchange: The Organizational Behavior Teaching Journal 6 (November 1981): 30-32; Mukherjee, Arup. "Effective Use of In-Class Mini Case Analysis for Discovery Learning in an Undergraduate MIS Course." The Journal of Computer Information Systems 40 (Spring 2000): 15-23; Pessoa, Silviaet al. "Scaffolding the Case Analysis in an Organizational Behavior Course: Making Analytical Language Explicit." Journal of Management Education 46 (2022): 226-251: Ramsey, V. J. and L. D. Dodge. "Case Analysis: A Structured Approach." Exchange: The Organizational Behavior Teaching Journal 6 (November 1981): 27-29; Schweitzer, Karen. "How to Write and Format a Business Case Study." ThoughtCo. https://www.thoughtco.com/how-to-write-and-format-a-business-case-study-466324 (accessed December 5, 2022); Reddy, C. D. "Teaching Research Methodology: Everything's a Case." Electronic Journal of Business Research Methods 18 (December 2020): 178-188; Volpe, Guglielmo. "Case Teaching in Economics: History, Practice and Evidence." Cogent Economics and Finance 3 (December 2015). doi:https://doi.org/10.1080/23322039.2015.1120977.

Writing Tip

Ca se Study and Case Analysis Are Not the Same!

Confusion often exists between what it means to write a paper that uses a case study research design and writing a paper that analyzes a case; they are two different types of approaches to learning in the social and behavioral sciences. Professors as well as educational researchers contribute to this confusion because they often use the term "case study" when describing the subject of analysis for a case analysis paper. But you are not studying a case for the purpose of generating a comprehensive, multi-faceted understanding of a research problem. R ather, you are critically analyzing a specific scenario to argue logically for recommended solutions and courses of action that lead to optimal outcomes applicable to professional practice.

To avoid any confusion, here are twelve characteristics that delineate the differences between writing a paper using the case study research method and writing a case analysis paper:

Case study is a method of in-depth research and rigorous inquiry ; case analysis is a reliable method of teaching and learning . A case study is a modality of research that investigates a phenomenon for the purpose of creating new knowledge, solving a problem, or testing a hypothesis using empirical evidence derived from the case being studied. Often, the results are used to generalize about a larger population or within a wider context. The writing adheres to the traditional standards of a scholarly research study. A case analysis is a pedagogical tool used to teach students how to reflect and think critically about a practical, real-life problem in an organizational setting.
The researcher is responsible for identifying the case to study; a case analysis is assigned by your professor . As the researcher, you choose the case study to investigate in support of obtaining new knowledge and understanding about the research problem. The case in a case analysis assignment is almost always provided, and sometimes written, by your professor and either given to every student in class to analyze individually or to a small group of students, or students select a case to analyze from a predetermined list.
A case study is indeterminate and boundless; a case analysis is predetermined and confined . A case study can be almost anything [see item 9 below] as long as it relates directly to examining the research problem. This relationship is the only limit to what a researcher can choose as the subject of their case study. The content of a case analysis is determined by your professor and its parameters are well-defined and limited to elucidating insights of practical value applied to practice.
Case study is fact-based and describes actual events or situations; case analysis can be entirely fictional or adapted from an actual situation . The entire content of a case study must be grounded in reality to be a valid subject of investigation in an empirical research study. A case analysis only needs to set the stage for critically examining a situation in practice and, therefore, can be entirely fictional or adapted, all or in-part, from an actual situation.
Research using a case study method must adhere to principles of intellectual honesty and academic integrity; a case analysis scenario can include misleading or false information . A case study paper must report research objectively and factually to ensure that any findings are understood to be logically correct and trustworthy. A case analysis scenario may include misleading or false information intended to deliberately distract from the central issues of the case. The purpose is to teach students how to sort through conflicting or useless information in order to come up with the preferred solution. Any use of misleading or false information in academic research is considered unethical.
Case study is linked to a research problem; case analysis is linked to a practical situation or scenario . In the social sciences, the subject of an investigation is most often framed as a problem that must be researched in order to generate new knowledge leading to a solution. Case analysis narratives are grounded in real life scenarios for the purpose of examining the realities of decision-making behavior and processes within organizational settings. A case analysis assignments include a problem or set of problems to be analyzed. However, the goal is centered around the act of identifying and evaluating courses of action leading to best possible outcomes.
The purpose of a case study is to create new knowledge through research; the purpose of a case analysis is to teach new understanding . Case studies are a choice of methodological design intended to create new knowledge about resolving a research problem. A case analysis is a mode of teaching and learning intended to create new understanding and an awareness of uncertainty applied to practice through acts of critical thinking and reflection.
A case study seeks to identify the best possible solution to a research problem; case analysis can have an indeterminate set of solutions or outcomes . Your role in studying a case is to discover the most logical, evidence-based ways to address a research problem. A case analysis assignment rarely has a single correct answer because one of the goals is to force students to confront the real life dynamics of uncertainly, ambiguity, and missing or conflicting information within professional practice. Under these conditions, a perfect outcome or solution almost never exists.
Case study is unbounded and relies on gathering external information; case analysis is a self-contained subject of analysis . The scope of a case study chosen as a method of research is bounded. However, the researcher is free to gather whatever information and data is necessary to investigate its relevance to understanding the research problem. For a case analysis assignment, your professor will often ask you to examine solutions or recommended courses of action based solely on facts and information from the case.
Case study can be a person, place, object, issue, event, condition, or phenomenon; a case analysis is a carefully constructed synopsis of events, situations, and behaviors . The research problem dictates the type of case being studied and, therefore, the design can encompass almost anything tangible as long as it fulfills the objective of generating new knowledge and understanding. A case analysis is in the form of a narrative containing descriptions of facts, situations, processes, rules, and behaviors within a particular setting and under a specific set of circumstances.
Case study can represent an open-ended subject of inquiry; a case analysis is a narrative about something that has happened in the past . A case study is not restricted by time and can encompass an event or issue with no temporal limit or end. For example, the current war in Ukraine can be used as a case study of how medical personnel help civilians during a large military conflict, even though circumstances around this event are still evolving. A case analysis can be used to elicit critical thinking about current or future situations in practice, but the case itself is a narrative about something finite and that has taken place in the past.
Multiple case studies can be used in a research study; case analysis involves examining a single scenario . Case study research can use two or more cases to examine a problem, often for the purpose of conducting a comparative investigation intended to discover hidden relationships, document emerging trends, or determine variations among different examples. A case analysis assignment typically describes a stand-alone, self-contained situation and any comparisons among cases are conducted during in-class discussions and/or student presentations.

The Case Analysis . Fred Meijer Center for Writing and Michigan Authors. Grand Valley State University; Mills, Albert J. , Gabrielle Durepos, and Eiden Wiebe, editors. Encyclopedia of Case Study Research . Thousand Oaks, CA: SAGE Publications, 2010; Ramsey, V. J. and L. D. Dodge. "Case Analysis: A Structured Approach." Exchange: The Organizational Behavior Teaching Journal 6 (November 1981): 27-29; Yin, Robert K. Case Study Research and Applications: Design and Methods . 6th edition. Thousand Oaks, CA: Sage, 2017; Crowe, Sarah et al. “The Case Study Approach.” BMC Medical Research Methodology 11 (2011): doi: 10.1186/1471-2288-11-100; Yin, Robert K. Case Study Research: Design and Methods . 4th edition. Thousand Oaks, CA: Sage Publishing; 1994.

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Utilising patient and public involvement in stated preference research in health

Learning from the existing literature and a case study

Shields, G. E., Brown, L., Wells, A., Capobianco, L. , & Vass, C. (2021). Utilising patient and public involvement in stated preference research in health: Learning from the existing literature and a case study . The Patient , 14 (4), 399-412. https://doi.org/10.1007/s40271-020-00439-2

Publications reporting discrete choice experiments of healthcare interventions rarely discuss whether patient and public involvement (PPI) activities have been conducted. This paper presents examples from the existing literature and a detailed case study from the National Institute for Health Research-funded PATHWAY programme that comprehensively included PPI activities at multiple stages of preference research. Reflecting on these examples, as well as the wider PPI literature, we describe the different stages at which it is possible to effectively incorporate PPI across preference research, including the design, recruitment and dissemination of projects. Benefits of PPI activities include gaining practical insights from a wider perspective, which can positively impact experiment design as well as survey materials. Further benefits included advice around recruitment and reaching a greater audience with dissemination activities, amongst others. There are challenges associated with PPI activities; examples include time, cost and outlining expectations. Overall, although we acknowledge practical difficulties associated with PPI, this work highlights that it is possible for preference researchers to implement PPI across preference research. Further research systematically comparing methods related to PPI in preference research and their associated impact on the methods and results of studies would strengthen the literature.

10.1007/s40271-020-00439-2

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Toward a framework for selecting indicators of measuring sustainability and circular economy in the agri-food sector: a systematic literature review

LIFE CYCLE SUSTAINABILITY ASSESSMENT
Published: 02 March 2022

Cite this article

Cecilia Silvestri ORCID: orcid.org/0000-0003-2528-601X 1 ,
Luca Silvestri ORCID: orcid.org/0000-0002-6754-899X 2 ,
Michela Piccarozzi ORCID: orcid.org/0000-0001-9717-9462 1 &
Alessandro Ruggieri 1

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A Correction to this article was published on 24 March 2022

This article has been updated

The implementation of sustainability and circular economy (CE) models in agri-food production can promote resource efficiency, reduce environmental burdens, and ensure improved and socially responsible systems. In this context, indicators for the measurement of sustainability play a crucial role. Indicators can measure CE strategies aimed to preserve functions, products, components, materials, or embodied energy. Although there is broad literature describing sustainability and CE indicators, no study offers such a comprehensive framework of indicators for measuring sustainability and CE in the agri-food sector.

Starting from this central research gap, a systematic literature review has been developed to measure the sustainability in the agri-food sector and, based on these findings, to understand how indicators are used and for which specific purposes.

The analysis of the results allowed us to classify the sample of articles in three main clusters (“Assessment-LCA,” “Best practice,” and “Decision-making”) and has shown increasing attention to the three pillars of sustainability (triple bottom line). In this context, an integrated approach of indicators (environmental, social, and economic) offers the best solution to ensure an easier transition to sustainability.

Conclusions

The sample analysis facilitated the identification of new categories of impact that deserve attention, such as the cooperation among stakeholders in the supply chain and eco-innovation.

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Source: Authors’ elaboration. Notes: The graph shows the temporal distribution of the articles under analysis

Source: Authors’ elaborations. Notes: The graph shows the time distribution of articles from the three major journals

Source: Authors’ elaboration. Notes: The graph shows the composition of the sample according to the three clusters identified by the analysis

Source: Authors’ elaboration. Notes: The graph shows the distribution of articles over time by cluster

Source: Authors’ elaboration. Notes: The graph shows the network visualization

Source: Authors’ elaboration. Notes: The graph shows the overlay visualization

Source: Authors’ elaboration. Notes: The graph shows the classification of articles by scientific field

Source: Authors’ elaboration. Notes: Article classification based on their cluster to which they belong and scientific field

Source: Authors’ elaboration

Source: Authors’ elaboration. Notes: The graph shows the distribution of items over time based on TBL

Source: Authors’ elaboration. Notes: The graph shows the Pareto diagram highlighting the most used indicators in literature for measuring sustainability in the agri-food sector

Source: Authors’ elaboration. Notes: The graph shows the distribution over time of articles divided into conceptual and empirical

Source: Authors’ elaboration. Notes: The graph shows the classification of articles, divided into conceptual and empirical, in-depth analysis

Source: Authors’ elaboration. Notes: The graph shows the geographical distribution of the authors

Source: Authors’ elaboration. Notes: The graph shows the distribution of authors according to the continent from which they originate

Source: Authors’ elaboration. Notes: The graph shows the time distribution of publication of authors according to the continent from which they originate

Source: Authors’ elaboration. Notes: Sustainability measurement indicators and impact categories of LCA, S-LCA, and LCC tools should be integrated in order to provide stakeholders with best practices as guidelines and tools to support both decision-making and measurement, according to the circular economy approach

Common Methods and Sustainability Indicators

Transition heuristic frameworks in research on agro-food sustainability transitions

Hamid El Bilali

Research on agro-food sustainability transitions: where are food security and nutrition?

Change history, 24 march 2022.

A Correction to this paper has been published: https://doi.org/10.1007/s11367-022-02038-9

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The case study approach

Sarah crowe.

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

Kathrin Cresswell

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

Ann Robertson

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

Anthony Avery

Aziz sheikh.

Introduction

This paper is structured around the following main questions: What is a case study? What are case studies used for? How are case studies conducted? What are the potential pitfalls and how can these be avoided? We draw in particular on four of our own recently published examples of case studies (see Tables Tables1, 1 , ,2, 2 , ,3 3 and and4) 4 ) and those of others to illustrate our discussion[ 3 - 7 ].

Example of a case study investigating the reasons for differences in recruitment rates of minority ethnic people in asthma research[ 3 ]

Example of a case study investigating the process of planning and implementing a service in Primary Care Organisations[ 4 ]

Example of a case study investigating the introduction of the electronic health records[ 5 ]

Example of a case study investigating the formal and informal ways students learn about patient safety[ 6 ]

What is a case study?

A case study is a research approach that is used to generate an in-depth, multi-faceted understanding of a complex issue in its real-life context. It is an established research design that is used extensively in a wide variety of disciplines, particularly in the social sciences. A case study can be defined in a variety of ways (Table (Table5), 5 ), the central tenet being the need to explore an event or phenomenon in depth and in its natural context. It is for this reason sometimes referred to as a "naturalistic" design; this is in contrast to an "experimental" design (such as a randomised controlled trial) in which the investigator seeks to exert control over and manipulate the variable(s) of interest.

Definitions of a case study

These are however not necessarily mutually exclusive categories. In the first of our examples (Table (Table1), 1 ), we undertook an intrinsic case study to investigate the issue of recruitment of minority ethnic people into the specific context of asthma research studies, but it developed into a instrumental case study through seeking to understand the issue of recruitment of these marginalised populations more generally, generating a number of the findings that are potentially transferable to other disease contexts[ 3 ]. In contrast, the other three examples (see Tables Tables2, 2 , ,3 3 and and4) 4 ) employed collective case study designs to study the introduction of workforce reconfiguration in primary care, the implementation of electronic health records into hospitals, and to understand the ways in which healthcare students learn about patient safety considerations[ 4 - 6 ]. Although our study focusing on the introduction of General Practitioners with Specialist Interests (Table (Table2) 2 ) was explicitly collective in design (four contrasting primary care organisations were studied), is was also instrumental in that this particular professional group was studied as an exemplar of the more general phenomenon of workforce redesign[ 4 ].

What are case studies used for?

According to Yin, case studies can be used to explain, describe or explore events or phenomena in the everyday contexts in which they occur[ 1 ]. These can, for example, help to understand and explain causal links and pathways resulting from a new policy initiative or service development (see Tables Tables2 2 and and3, 3 , for example)[ 1 ]. In contrast to experimental designs, which seek to test a specific hypothesis through deliberately manipulating the environment (like, for example, in a randomised controlled trial giving a new drug to randomly selected individuals and then comparing outcomes with controls),[ 9 ] the case study approach lends itself well to capturing information on more explanatory ' how ', 'what' and ' why ' questions, such as ' how is the intervention being implemented and received on the ground?'. The case study approach can offer additional insights into what gaps exist in its delivery or why one implementation strategy might be chosen over another. This in turn can help develop or refine theory, as shown in our study of the teaching of patient safety in undergraduate curricula (Table (Table4 4 )[ 6 , 10 ]. Key questions to consider when selecting the most appropriate study design are whether it is desirable or indeed possible to undertake a formal experimental investigation in which individuals and/or organisations are allocated to an intervention or control arm? Or whether the wish is to obtain a more naturalistic understanding of an issue? The former is ideally studied using a controlled experimental design, whereas the latter is more appropriately studied using a case study design.

Case studies may be approached in different ways depending on the epistemological standpoint of the researcher, that is, whether they take a critical (questioning one's own and others' assumptions), interpretivist (trying to understand individual and shared social meanings) or positivist approach (orientating towards the criteria of natural sciences, such as focusing on generalisability considerations) (Table (Table6). 6 ). Whilst such a schema can be conceptually helpful, it may be appropriate to draw on more than one approach in any case study, particularly in the context of conducting health services research. Doolin has, for example, noted that in the context of undertaking interpretative case studies, researchers can usefully draw on a critical, reflective perspective which seeks to take into account the wider social and political environment that has shaped the case[ 11 ].

Example of epistemological approaches that may be used in case study research

How are case studies conducted?

Defining the case

Carefully formulated research question(s), informed by the existing literature and a prior appreciation of the theoretical issues and setting(s), are all important in appropriately and succinctly defining the case[ 8 , 12 ]. Crucially, each case should have a pre-defined boundary which clarifies the nature and time period covered by the case study (i.e. its scope, beginning and end), the relevant social group, organisation or geographical area of interest to the investigator, the types of evidence to be collected, and the priorities for data collection and analysis (see Table Table7 7 )[ 1 ]. A theory driven approach to defining the case may help generate knowledge that is potentially transferable to a range of clinical contexts and behaviours; using theory is also likely to result in a more informed appreciation of, for example, how and why interventions have succeeded or failed[ 13 ].

Example of a checklist for rating a case study proposal[ 8 ]

For example, in our evaluation of the introduction of electronic health records in English hospitals (Table (Table3), 3 ), we defined our cases as the NHS Trusts that were receiving the new technology[ 5 ]. Our focus was on how the technology was being implemented. However, if the primary research interest had been on the social and organisational dimensions of implementation, we might have defined our case differently as a grouping of healthcare professionals (e.g. doctors and/or nurses). The precise beginning and end of the case may however prove difficult to define. Pursuing this same example, when does the process of implementation and adoption of an electronic health record system really begin or end? Such judgements will inevitably be influenced by a range of factors, including the research question, theory of interest, the scope and richness of the gathered data and the resources available to the research team.

Selecting the case(s)

The decision on how to select the case(s) to study is a very important one that merits some reflection. In an intrinsic case study, the case is selected on its own merits[ 8 ]. The case is selected not because it is representative of other cases, but because of its uniqueness, which is of genuine interest to the researchers. This was, for example, the case in our study of the recruitment of minority ethnic participants into asthma research (Table (Table1) 1 ) as our earlier work had demonstrated the marginalisation of minority ethnic people with asthma, despite evidence of disproportionate asthma morbidity[ 14 , 15 ]. In another example of an intrinsic case study, Hellstrom et al.[ 16 ] studied an elderly married couple living with dementia to explore how dementia had impacted on their understanding of home, their everyday life and their relationships.

The selected case study site(s) should allow the research team access to the group of individuals, the organisation, the processes or whatever else constitutes the chosen unit of analysis for the study. Access is therefore a central consideration; the researcher needs to come to know the case study site(s) well and to work cooperatively with them. Selected cases need to be not only interesting but also hospitable to the inquiry [ 8 ] if they are to be informative and answer the research question(s). Case study sites may also be pre-selected for the researcher, with decisions being influenced by key stakeholders. For example, our selection of case study sites in the evaluation of the implementation and adoption of electronic health record systems (see Table Table3) 3 ) was heavily influenced by NHS Connecting for Health, the government agency that was responsible for overseeing the National Programme for Information Technology (NPfIT)[ 5 ]. This prominent stakeholder had already selected the NHS sites (through a competitive bidding process) to be early adopters of the electronic health record systems and had negotiated contracts that detailed the deployment timelines.

Collecting the data

In order to develop a thorough understanding of the case, the case study approach usually involves the collection of multiple sources of evidence, using a range of quantitative (e.g. questionnaires, audits and analysis of routinely collected healthcare data) and more commonly qualitative techniques (e.g. interviews, focus groups and observations). The use of multiple sources of data (data triangulation) has been advocated as a way of increasing the internal validity of a study (i.e. the extent to which the method is appropriate to answer the research question)[ 8 , 18 - 21 ]. An underlying assumption is that data collected in different ways should lead to similar conclusions, and approaching the same issue from different angles can help develop a holistic picture of the phenomenon (Table (Table2 2 )[ 4 ].

Analysing, interpreting and reporting case studies

The Framework approach is a practical approach, comprising of five stages (familiarisation; identifying a thematic framework; indexing; charting; mapping and interpretation) , to managing and analysing large datasets particularly if time is limited, as was the case in our study of recruitment of South Asians into asthma research (Table (Table1 1 )[ 3 , 24 ]. Theoretical frameworks may also play an important role in integrating different sources of data and examining emerging themes. For example, we drew on a socio-technical framework to help explain the connections between different elements - technology; people; and the organisational settings within which they worked - in our study of the introduction of electronic health record systems (Table (Table3 3 )[ 5 ]. Our study of patient safety in undergraduate curricula drew on an evaluation-based approach to design and analysis, which emphasised the importance of the academic, organisational and practice contexts through which students learn (Table (Table4 4 )[ 6 ].

When reporting findings, it is important to provide the reader with enough contextual information to understand the processes that were followed and how the conclusions were reached. In a collective case study, researchers may choose to present the findings from individual cases separately before amalgamating across cases. Care must be taken to ensure the anonymity of both case sites and individual participants (if agreed in advance) by allocating appropriate codes or withholding descriptors. In the example given in Table Table3, 3 , we decided against providing detailed information on the NHS sites and individual participants in order to avoid the risk of inadvertent disclosure of identities[ 5 , 25 ].

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

The case study approach is, as with all research, not without its limitations. When investigating the formal and informal ways undergraduate students learn about patient safety (Table (Table4), 4 ), for example, we rapidly accumulated a large quantity of data. The volume of data, together with the time restrictions in place, impacted on the depth of analysis that was possible within the available resources. This highlights a more general point of the importance of avoiding the temptation to collect as much data as possible; adequate time also needs to be set aside for data analysis and interpretation of what are often highly complex datasets.

Case study research has sometimes been criticised for lacking scientific rigour and providing little basis for generalisation (i.e. producing findings that may be transferable to other settings)[ 1 ]. There are several ways to address these concerns, including: the use of theoretical sampling (i.e. drawing on a particular conceptual framework); respondent validation (i.e. participants checking emerging findings and the researcher's interpretation, and providing an opinion as to whether they feel these are accurate); and transparency throughout the research process (see Table Table8 8 )[ 8 , 18 - 21 , 23 , 26 ]. Transparency can be achieved by describing in detail the steps involved in case selection, data collection, the reasons for the particular methods chosen, and the researcher's background and level of involvement (i.e. being explicit about how the researcher has influenced data collection and interpretation). Seeking potential, alternative explanations, and being explicit about how interpretations and conclusions were reached, help readers to judge the trustworthiness of the case study report. Stake provides a critique checklist for a case study report (Table (Table9 9 )[ 8 ].

Potential pitfalls and mitigating actions when undertaking case study research

Stake's checklist for assessing the quality of a case study report[ 8 ]

Conclusions

Competing interests

The authors declare that they have no competing interests.

Authors' contributions

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

Pre-publication history

The pre-publication history for this paper can be accessed here:

http://www.biomedcentral.com/1471-2288/11/100/prepub

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Published: 16 April 2024

Transparent medical image AI via an image–text foundation model grounded in medical literature

Chanwoo Kim ORCID: orcid.org/0000-0002-1950-1230 1 ,
Soham U. Gadgil 1 ,
Alex J. DeGrave 1 , 2 ,
Jesutofunmi A. Omiye 3 , 4 ,
Zhuo Ran Cai 5 ,
Roxana Daneshjou ORCID: orcid.org/0000-0001-7988-9356 3 , 4 na1 &
Su-In Lee ORCID: orcid.org/0000-0001-5833-5215 1 na1

Nature Medicine ( 2024 ) Cite this article

Metrics details

Medical imaging
Medical research

Building trustworthy and transparent image-based medical artificial intelligence (AI) systems requires the ability to interrogate data and models at all stages of the development pipeline, from training models to post-deployment monitoring. Ideally, the data and associated AI systems could be described using terms already familiar to physicians, but this requires medical datasets densely annotated with semantically meaningful concepts. In the present study, we present a foundation model approach, named MONET (medical concept retriever), which learns how to connect medical images with text and densely scores images on concept presence to enable important tasks in medical AI development and deployment such as data auditing, model auditing and model interpretation. Dermatology provides a demanding use case for the versatility of MONET, due to the heterogeneity in diseases, skin tones and imaging modalities. We trained MONET based on 105,550 dermatological images paired with natural language descriptions from a large collection of medical literature. MONET can accurately annotate concepts across dermatology images as verified by board-certified dermatologists, competitively with supervised models built on previously concept-annotated dermatology datasets of clinical images. We demonstrate how MONET enables AI transparency across the entire AI system development pipeline, from building inherently interpretable models to dataset and model auditing, including a case study dissecting the results of an AI clinical trial.

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Data availability

The PMC Open Access Subset is publicly available from https://www.ncbi.nlm.nih.gov/pmc/tools/openftlist . Evaluation datasets are all publicly available and can be accessed from: ISIC ( https://challenge.isic-archive.com/data ), Derm7pt ( https://derm.cs.sfu.ca ), Fitzpatrick 17k ( https://github.com/mattgroh/fitzpatrick17k ) and DDI ( https://stanfordaimi.azurewebsites.net/datasets/35866158-8196-48d8-87bf-50dca81df965 ).

Code availability

The code used in our analysis is available at https://github.com/suinleelab/MONET (ref. 84 ). It includes various scripts for data collection and preprocessing, training the MONET model and conducting benchmark studies. Also, it provides the MONET model weights. The ADAE algorithm can be publicly accessed from https://github.com/ISIC-Research/ADAE .

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suinleelab/MONET. Github https://github.com/suinleelab/MONET (2024).

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Acknowledgements

We thank C. Lin and other people in S.-I.L.’s lab for helpful discussions. The members of S.-I.L.’s lab, including C.K., S.U.G., A.J.D. and S.-I.L., received support from the National Science Foundation (grant nos. CAREER DBI-1552309 and DBI-1759487) and the National Institutes of Health (NIH, grant nos. R35 GM 128638 and R01 AG061132). R.D. was supported by the NIH (5T32 AR007422-38) and the Stanford Catalyst Program.

Author information

These authors jointly supervised this work: Roxana Daneshjou, Su-In Lee.

Authors and Affiliations

Paul G. Allen School of Computer Science & Engineering, University of Washington, Seattle, WA, USA

Chanwoo Kim, Soham U. Gadgil, Alex J. DeGrave & Su-In Lee

Medical Scientist Training Program, University of Washington, Seattle, WA, USA

Alex J. DeGrave

Department of Dermatology, Stanford School of Medicine, Stanford, CA, USA

Jesutofunmi A. Omiye & Roxana Daneshjou

Department of Biomedical Data Science, Stanford School of Medicine, Stanford, CA, USA

Program for Clinical Research and Technology, Stanford University, Stanford, CA, USA

Zhuo Ran Cai

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Contributions

C.K., R.D. and S.-I.L. conceived the initial study. C.K., S.U.G., A.J.D. and J.A.O. performed the experiments. Z.R.C. and R.D. evaluated the training data, provided dermatological insights and clinical context in all steps of the analyses, and analyzed images from concept retrieval experiments. C.K., S.U.G., A.J.D., J.A.O., Z.R.C., R.D. and S.-I.L. wrote the paper. S.-I.L. secured funding. R.D. and S.-I.L. co-supervised the study.

Corresponding authors

Correspondence to Roxana Daneshjou or Su-In Lee .

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Competing interests.

R.D. reports fees from L’Oreal, Frazier Healthcare Partners, Pfizer, DWA and VisualDx for consulting, stock options from MDAcne and Revea for advisory board and research funding from UCB. The remaining authors declare no competing interests.

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Extended data

Extended data fig. 1 dermoscopic images with artifacts from the isic dataset as determined by high concept presence scores calculated using monet..

We show the top 30 images for each artifact. a , Purple pen. b , Orange sticker. c , Nail. d , Hair. e , Dermoscopic border. Figures adapted from ref. 11 , 12 with permission and from ref. 13 , 14 under CC-BY license.

Extended Data Fig. 2 Concept bottleneck models in the interinstitution model transfer setting.

a – d , We train models using images from Hospital Barcelona and test their performance using images from Med. U. Vienna. In each setting, we repeated the evaluations 20 times, using a different split of images from the training site into train and validation sets each time. a – b , Performance comparison of malignancy and melanoma prediction models. We measure the validation AUROC on a 25% validation set from Hospital Barcelona data. We measure the test AUROC on the entire Med. U. Vienna data. c – d , Coefficient of the linear model in MONET + CBM for malignancy and melanoma predictions. The error bars, obtained from n = 20 different runs, indicate the 95% confidence interval, extending from the mean. e – h , We train models using images from Med. U. Vienna and test their performance using images from Hospital Barcelona. e – f , Performance comparison of malignancy and melanoma prediction models. We measure the validation AUROC on a 25% validation set from Med. U. Vienna data. We measure the test AUROC on the entire Hospital Barcelona data. g – h , Coefficient of the linear model in MONET + CBM for malignancy and melanoma predictions. The error bars, obtained from n = 20 different runs, indicate the 95% confidence interval, extending from the mean.

Extended Data Fig. 3 Effect of concept sets on MONET + CBM’s performance.

We compare CBMs operating on our curated, task-relevant, concepts with those operating on SkinCon concepts. From each concept list, we sample subsets of concepts with varying sizes and train CBMs separately on these subsets, repeating this process 20 times for each subset size. For our 10 curated concepts, we use the subset size ranging from 1 to 10, and for SkinCon concepts, we use the subset size of interval 5, including 1 and the full set of 48 (that is, 1, 5, 10, …, 40, 45, 48). The center line indicates the mean across n = 20 runs, with the shaded area covering the 95% confidence interval. a , Performance of MONET + CBM for malignancy and melanoma predictions on clinical images with respect to the number of concepts. b , Performance of MONET + CBM for malignancy and melanoma predictions on dermoscopic images with respect to the number of concepts. c , Performance of MONET + CBM for malignancy and melanoma predictions on dermoscopic images in an interinstitution model transfer setting with respect to the number of concepts. We train models on Hospital Barcelona and test them on Med. U. Vienna. d , Performance of MONET + CBM for malignancy and melanoma predictions on dermoscopic images in an interinstitution model transfer setting with respect to the number of concepts. We train models on Med. U. Vienna and test them on Hospital Barcelona.

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Supplementary Methods, Discussion, Figs. 1–10 and Tables 1–8.

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Kim, C., Gadgil, S.U., DeGrave, A.J. et al. Transparent medical image AI via an image–text foundation model grounded in medical literature. Nat Med (2024). https://doi.org/10.1038/s41591-024-02887-x

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Organizing Your Social Sciences Research Paper: Writing a Case Study

Purpose of Guide
Design Flaws to Avoid
Independent and Dependent Variables
Glossary of Research Terms
Narrowing a Topic Idea
Broadening a Topic Idea
Extending the Timeliness of a Topic Idea
Academic Writing Style
Choosing a Title
Making an Outline
Paragraph Development
Executive Summary
The C.A.R.S. Model
Background Information
The Research Problem/Question
Theoretical Framework
Citation Tracking
Content Alert Services
Evaluating Sources
Reading Research Effectively
Primary Sources
Secondary Sources
Tiertiary Sources
What Is Scholarly vs. Popular?
Qualitative Methods
Quantitative Methods
Using Non-Textual Elements
Limitations of the Study
Common Grammar Mistakes
Writing Concisely
Avoiding Plagiarism
Footnotes or Endnotes?
Further Readings
Annotated Bibliography
Dealing with Nervousness
Using Visual Aids
Grading Someone Else's Paper
Types of Structured Group Activities
Group Project Survival Skills
Multiple Book Review Essay
Reviewing Collected Essays
Writing a Case Study
About Informed Consent
Writing Field Notes
Writing a Policy Memo
Writing a Research Proposal
Bibliography

The term case study refers to both a method of analysis and a specific research design for examining a problem, both of which are used in most circumstances to generalize across populations. This tab focuses on the latter--how to design and organize a research paper in the social sciences that analyzes a specific case.

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

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

How to Approach Writing a Case Study Research Paper

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

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

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

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

Structure and Writing Style

The purpose of a paper in the social sciences designed around a case study is to thoroughly investigate a subject of analysis in order to reveal a new understanding about the research problem and, in so doing, contributing new knowledge to what is already known from previous studies. In applied social sciences disciplines [e.g., education, social work, public administration, etc.], case studies may also be used to reveal best practices, highlight key programs, or investigate interesting aspects of professional work. In general, the structure of a case study research paper is not all that different from a standard college-level research paper. However, there are subtle differences you should be aware of. Here are the key elements to organizing and writing a case study research paper.

I. Introduction

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

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

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

II. Literature Review

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

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

III. Method

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

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

If your subject of analysis is a person. Explain why you selected this particular individual to be studied and describe what experience he or she has had that provides an opportunity to advance new understandings about the research problem. Mention any background about this person which might help the reader understand the significance of his/her experiences that make them worthy of study. This includes describing the relationships this person has had with other people, institutions, and/or events that support using him or her as the subject for a case study research paper. It is particularly important to differentiate the person as the subject of analysis from others and to succinctly explain how the person relates to examining the research problem.

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

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

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

IV. Discussion

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

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

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

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

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

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

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

V. Conclusion

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

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

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

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

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

Problems to Avoid

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

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

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

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

Writing Tip

At Least Five Misconceptions about Case Study Research

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

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

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

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

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For Filmmakers, O.J. Simpson’s Trial Was a Powerful Case Study

In 2016, both an FX mini-series and an ESPN documentary re-examined the polarizing criminal accusations against Simpson and the nation’s divided conversation about race.

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In a movie screenshot, the actor playing O.J. Simpson shrugs while wearing black gloves on both hands in a courtroom scene.

By Emmanuel Morgan

More than 20 years after the O.J. Simpson trial, long after the headlines had faded and the news cycle had moved on to other scandals, the polarizing saga was thrust back into the national conversation thanks to two very different projects.

“ The People v. O.J. Simpson: American Crime Story ,” an FX mini-series directed by Ryan Murphy, won nine Emmys in 2016. That year’s “ O.J.: Made in America, ” a nearly eight-hour film for ESPN, won the Academy Award for best documentary feature.

“It was a story that combined everything that obsesses the American people,” the legal analyst Jeffrey Toobin said the day after Simpson died at 76 . Toobin’s 1996 book, “The Run of His Life: The People v. O.J. Simpson,” inspired the FX series.

Toobin said the Simpson odyssey captivated the country’s psyche. There was love, violence, sports and Hollywood. Even a fugitive on the run.

Simpson had been a star football player , winning the Heisman Trophy in college and the Most Valuable Player Award in the N.F.L. But for many people, his athletic highlights are overshadowed by a highway chase involving a white Ford Bronco and murder charges in the 1994 deaths of his ex-wife Nicole Brown Simpson and her friend Ronald L. Goldman.

As Americans followed the nine-month trial, their perception of the criminal case against Simpson, a prominent Black athlete who became an actor and a pitchman , was often split along racial lines. Simpson was acquitted in the criminal case and was later found liable for the deaths in a civil trial .

“I think the reason it still feels so raw is that it still feels like it’s today,” said Larry Karaszewski, a screenwriter for the FX mini-series. “A lot of times people think we’re at this post-racial moment, but it keeps coming back.”

Karaszewski said that like during Simpson’s trial, race was at the forefront of the national conversation when “The People v. O.J. Simpson” was being produced, during the rise of the Black Lives Matter movement after the fatal shooting of Trayvon Martin by a neighborhood watchman in 2012.

The mini-series focused on the Simpson trial, treating him as a secondary character while highlighting other key players in the courtroom , like Marcia Clark, the lead prosecutor, and Johnnie Cochran, one of Simpson’s prominent defense lawyers.

In contrast, ESPN’s documentary, an installment of the sports network’s “30 for 30” series, traced Simpson’s biography and contextualized it through the sports and socioeconomic history of the Los Angeles region. Its director, Ezra Edelman, has said he thought it was important to take that wider view.

“I was interested in the 30 years before the murders, the city, race and identity, and the juxtaposition with O.J.’s story,” he told The New York Times in 2016 . “This is a big American studies paper. This touches on everything in our culture.”

Through an ESPN spokeswoman, Edelman declined to comment after Simpson’s death. Several of the documentary’s producers did not respond to requests for comment.

Karaszewski said the distance from the trial allowed viewers of the FX series to watch the case with fresh eyes, without the emotional response to the verdict. And he and Toobin agreed that it also presented the saga and its characters — including Robert Kardashian, a defense lawyer whose family’s fame grew after the case — to new audiences.

“For those of us who lived through it, it brought it back up,” Toobin said, “but it introduced a whole generation of people who had no firsthand experience with the story.”

Emmanuel Morgan reports on sports, pop culture and entertainment. More about Emmanuel Morgan

Open access
Published: 13 April 2024

Associations between transport modes and site-specific cancers: a systematic review and meta-analysis

Win Thu 1 ,
Alistair Woodward 1 ,
Alana Cavadino 1 &
Sandar Tin Tin 1 , 2

Environmental Health volume 23 , Article number: 39 ( 2024 ) Cite this article

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Physical inactivity is a global public health problem. A practical solution would be to build physical activity into the daily routine by using active modes of transport. Choice of transport mode can influence cancer risk through their effects on levels of physical activity, sedentary time, and environmental pollution. This review synthesizes existing evidence on the associations of specific transport modes with risks of site-specific cancers.

Relevant literature was searched in PubMed, Embase, and Scopus from 1914 to 17th February 2023. For cancer sites with effect measures available for a specific transport mode from two or more studies, random effects meta-analyses were performed to pool relative risks (RR) comparing the highest vs. lowest activity group as well as per 10 Metabolic Equivalent of Task (MET) hour increment in transport-related physical activity per week ( ∼ 150 min of walking or 90 min of cycling).

27 eligible studies (11 cohort, 15 case-control, and 1 case-cohort) were identified, which reported the associations of transport modes with 10 site-specific cancers. In the meta-analysis, 10 MET hour increment in transport-related physical activity per week was associated with a reduction in risk for endometrial cancer (RR: 0.91, 95% CI: 0.83–0.997), colorectal cancer (RR: 0.95, 95% CI: 0.91–0.99) and breast cancer (RR: 0.99, 95% CI: 0.89–0.996). The highest level of walking only or walking and cycling combined modes, compared to the lowest level, were significantly associated with a 12% and 30% reduced risk of breast and endometrial cancers respectively. Cycling, compared to motorized modes, was associated with a lower risk of overall cancer incidence and mortality.

Active transport appears to reduce cancer risk, but evidence for cancer sites other than colorectum, breast, and endometrium is currently limited.

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Introduction

Physical inactivity is a global public health problem, contributing to substantial disease and economic burden worldwide [ 1 , 2 ]. With rapid changes in technology, lifestyle, and habitual environment, people have been less active and more sedentary over the past few decades. Globally, about 1 in 4 adults were not active, i.e., did not meet the World Health Organization (WHO) recommendation of engaging at least 150–300 min of moderate-intensity or 75–150 min of vigorous-intensity aerobic physical activity per week [ 3 ], but the prevalence varied widely within and across countries [ 4 ]. If the current trends continue, it is unlikely that the WHO’s target to reduce physical inactivity by 10% in 2025 will be met.

One practical solution would be to build physical activity into the daily routine by using active modes of transport [ 5 ]. Walking and cycling have been shown to improve health (mainly all-cause mortality, cardiovascular disease, diabetes, and cancer) [ 6 ] and also provide social, economic and environmental benefits [ 7 , 8 ]. Car use, on the other hand, contributes to a significant proportion of daily sedentary time, and the situation is worsening with increasing traffic congestion/delays [ 9 ]; it has been associated with an increased risk of obesity and related outcomes [ 10 ]. Further, exposure to environmental pollutants such as nitrogen dioxide and/or particulate matter could differ across different road users [ 11 ], while it has been shown to increase the risk of certain cancers, particularly lung cancer [ 12 ].

While there is ample evidence linking leisure time physical activity or physical activity in general with a reduced risk for a number of cancer sites [ 13 , 14 ], and sedentary behavior in general with an increased risk [ 15 ], the findings may not be directly applicable to transport-related activity because the context and correlates of activity as well as its frequency, duration and intensity are likely to be different across different domains. We therefore reviewed the existing literature that reported the associations between transport modes and risks of site-specific cancers.

A systematic literature review and meta-analysis was conducted and reported according to the PRISMA guideline (Supplementary file S1 ). The review was not registered.

Search strategy and study selection

Relevant literature was searched from 1914 to 17th February 2023 in PubMed, Scopus, and Embase databases using the relevant search terms such as walking, cycling, car, public transport, commute and cancers. Site-specific cancers known to be associated with physical activity and body weight such as breast, colon, liver, esophageal adenocarcinoma and those associated with environmental factor such as lung and melanoma of skin were also searched (Supplementary file S2 ). The reference lists of systematic reviews on physical activity and cancers were also reviewed. Studies were included if they (1) used cohort, case-control, case-cohort or experimental design, (2) assessed transport modes such as walking, cycling, public transport or car use as the exposures of interest, (3) investigated one or more site-specific cancers, overall cancer incidence and/or mortality as the outcome(s), (4) reported effect measures associated with transport modes, and (5) published the full article in English. Studies that used cross-sectional design or mathematical modeling to estimate health impacts at the population level were excluded. Details of excluded studies after full text review, together with the reasons for exclusion, were provided in the Supplementary file S3 . WT conducted the search and selection, and STT oversaw the process.

Data extraction and study quality assessment

Information about title, first author, year of publication, study name (if available), country, study design, sample size, age range of the participants, follow-up duration (for cohort and case-cohort studies), data collection tool, measurement units for exposure(s), data sources for outcome(s), site-specific cancer assessed, effect measures, and confounders adjusted were extracted in a standardized data collection spreadsheet. The study quality was evaluated using the Newcastle-Ottawa Scale (NOS) [ 16 ], which scores the cohort and case-control studies based on three domains: selection of study groups, comparability of the groups and ascertainment of exposure (case-control studies) or outcome (cohort studies). For the second domain, a point was awarded for adjustment of Body Mass Index (BMI) - to evaluate the direct vs. indirect (through BMI) effect of physical activity on cancer risk, and another point for adjustment of physical activities from other domains - to isolate the effects of transport-related physical activity from other activities. A maximum of nine points were awarded, with a higher score indicating better quality [ 16 ]. For case-cohort studies, the NOS scale for cohort studies was used. WT conducted the data extraction and quality assessment, and STT oversaw the process.

Data analysis

For cancer sites with effect measures available for a specific transport mode from two or more studies, meta-analyses were performed using random effects models. The analyses compared the highest level of active transport such as walking, cycling or mixed mode with the lowest level as reported in the individual studies. Where necessary, the reference category for exposure was changed to the lowest group to facilitate pooling of the risks [ 17 ]. The pooled relative risks (RRs) and 95% CI were presented for breast, endometrial, colorectal and testicular cancers, and overall cancer mortality.

For studies that reported time or MET as measurement units, the dose-response effects were estimated using the trend estimation method proposed by Greenland and Longnecker [ 18 ]. The reported time spent for each mode/category was converted to MET hours (see Supplementary file S4 for conversion values and formulas used). For studies that only reported estimates for categorical exposures, study-specific slopes were calculated from the natural logs of the reported risk estimates across categories and risk estimates per unit change were then estimated. The pooled results were presented per 10 Metabolic Equivalent of Task (MET) hour increment in transport-related physical activity per week ( ∼ 150 min of walking or 90 min of cycling) to align with the WHO’s physical activity recommendation [ 3 ]. This approach enabled us to pool risk estimates from a large number of studies irrespective of how the exposures were assessed (e.g., walking and cycling separately or combined) or categorised. The results were presented for breast, endometrial, colorectal, prostate cancers, and overall cancer mortality.

Meta-analysis was not conducted for the studies that compared active and non-active modes in relation to overall cancer incidence and mortality due to the potential overlap of the study samples.

For meta-analyses involving four or more studies, publication bias was assessed through the visual inspection of funnel plots, Begg’s rank correlation test, and Egger’s regression test for asymmetry. If significant associations were observed, sensitivity analyses were conducted by removing one study at a time from the initial meta-analysis to test the robustness of the results. Where possible, sub-group analyses were performed to assess variability of summary effects across population groups (Western vs. Asian), study design (cohort vs. case-control), measurement units (time vs. MET) and adjustment for BMI (yes vs. no). Metafor [ 19 ] and dosresmeta [ 20 ] R packages were used for meta-analysis and trend estimation. All authors have access to the data.

Of the 11,829 records identified, 27 unique studies (total 34 publications) were included, of which 22 studies (28 records) contributed to the meta-analyses (Fig. 1 ). There were four publications from the Netherlands Cohort Study which reported endometrial [ 21 ], ovarian [ 22 ], prostate [ 23 ], and colorectal [ 24 ] cancers, three publications from United Kingdom Biobank which reported lung [ 25 ], breast and colon [ 26 ], and overall cancer incidence and mortality [ 27 ], two publications from Shanghai Women’s Health Study which reported breast [ 28 ] and overall cancer mortality [ 29 ], and two publications from National Institutes of Health - American Association of Retired Persons Diet and Health Study which reported breast [ 30 ] and endometrial [ 31 ] cancers. Of the included studies, 20 compared the risks between the highest and lowest levels of active transport (e.g., walking, cycling, walking and cycling) and two compared the risk between active and non-active commuting modes. The majority used case-control design ( n = 15), followed by cohort ( n = 11) and case-cohort ( n = 1) designs. Most of the studies were conducted in North America, mainly in the United States (US) ( n = 7), followed by Europe ( n = 5), China ( n = 5), United Kingdom ( n = 4), Australia ( n = 2) and the remaining four studies were from India, Iran, Brazil and Nigeria. (Table 1 )

Almost half of the studies assessed walking and cycling combined, i.e., did not provide the risk estimates for each mode ( n = 13), while others assessed walking and cycling separately ( n = 8), or assessed only one mode (walking: n = 3 and cycling: n = 3). Most studies quantified active transport in terms of time spent (e.g., minutes per day, hours per week) ( n = 14) or MET ( n = 7), but others assessed it in terms of activity status (e.g., yes, no) ( n = 3), or in comparison to car or motorized mode ( n = 2), and distance ( n = 1) (Supplementary file S5 ). The studies reported the risks associated with ten site-specific cancers, most commonly breast ( n = 12), endometrial ( n = 5), and colorectal ( n = 4) cancers (Fig. 2 ). Cancer cases were identified through cancer registries, death registries, pathological reports, or hospital or medical records (Supplementary file S5 ). The NOS score for cohort studies ranged from 5 to 9, with an average score of 6.5, and the score for case-control studies ranged from 4 to 7, with an average score of 5.6 (Table 1 , detailed scoring in Supplementary file S6 , S7 ).

Flow diagram for study selection

Cancers reported in the studies

Active transport studies

The pooled results were presented for breast, endometrial, colorectal, testicular and prostate cancers, and overall cancer mortality (Fig. 3 ). For other cancers where only one study was identified, the results from the individual study were presented.

Breast cancer

In the meta-analysis of six studies comparing the highest vs. lowest activity group, an inverse association was observed for walking (RR: 0.88, 95% CI: 0.78–0.98), a borderline inverse association for cycling (RR: 0.90, 95% CI: 0.77–1.05) and no significant association for walking and cycling combined (RR: 0.97, 95% CI: 0.84–1.12). 10 MET hour increment in transport-related physical activity per week ( ∼ 150 min of walking or 90 min of cycling) was associated with a marginally reduced risk (RR: 0.99, 95% CI: 0.97–0.996). (Fig. 3 , detailed forest plots in the supplementary file S9 )

Endometrial cancer

The meta-analysis of four studies indicated that walking and cycling combined was associated with a reduced risk of endometrial cancer (RR comparing highest vs. lowest: 0.70, 95% CI: 0.56–0.87; RR per 10 MET hour increment in activity per week: 0.91, 95% CI: 0.83–0.997). (Fig. 3 , detailed forest plots in S9 )

Colorectal cancer

In the meta-analysis of two studies, walking and cycling combined was associated with a reduced risk of colorectal cancer (RR comparing highest vs. lowest: 0.89, 95% CI: 0.78–1.01; RR per 10 MET hour increment in activity per week: 0.95, 95% CI: 0.91–0.99) (Fig. 3 , detailed forest plot in S9 ).

Testicular cancer

In the meta-analysis of two studies, there was no significant association between cycle commuting in adolescence and testicular germ cell cancer (RR comparing highest vs. lowest: 1.23, 95% CI: 0.71–2.13). (Fig. 3 , detailed forest plot in S9 )

Prostate cancer

10 MET hour increment per week for transport related physical activity was associated with a reduced risk of prostate cancer (RR: 0.96, 95% CI: 0.88–1.04) (Fig. 3 , detailed forest plot in S9 ).

Ovarian cancer

Only a case-cohort study assessed the relationship of walking and cycling combined mode with ovarian cancer risk, and reported no significant association (Supplementary file S5 ) [ 22 ].

Liver, gallbladder and biliary tract cancers

A cohort study reported a significant association of commuting physical activity with a reduced risk of gallbladder and biliary tract cancers in women (HR: 0.51, 95% CI: 0.28–0.94) but not in men (HR: 0.92, 95% CI: 0.61–1.37); there was no significant association with liver cancer in both sexes (supplementary file S5 ) [ 49 ].

Renal cancer

A case-control study assessed the association of walking and cycling with risk of renal cell carcinoma in white and black participants in the ages of 20s and 50s, and reported a significant association in the white participants in their 20s (OR comparing lowest vs. highest: 1.42, 95% CI: 1.10–1.83) but not in the black counterparts; the associations were also not significant in both groups in their 50s. (Supplementary file S5 ) [ 50 ].

Overall cancer mortality

In the meta-analyses of two studies, there was an inverse association for cycling only (RR comparing highest vs. lowest: 0.60, 95% CI: 0.34–1.04) and walking and cycling combined (RR: 0.98, 95% CI: 0.86–1.12), and also per 10 MET hour increment in activity per week (RR: 0.97, 95% CI: 0.92–1.01). (Fig. 3 , detailed forest plots in S9 )

In sub-group analyses, similar associations were observed between walking and breast cancer risk in terms of study design (cohort, case-control), population (western vs. Asian), measurement unit (time vs. MET), menopausal status (premenopausal and postmenopausal) and adjustment of BMI (yes vs. no); however, the associations were stronger in studies that adjusted for physical activity from other domains (Supplementary file S10 ). In the leave-one-out analyses assessing walking and breast cancer risk, the results were sensitive to effect sizes from some studies, but this was not the case for walking and cycling combined mode and endometrial cancer (Supplementary file S11 ). There was no evidence for funnel plot asymmetry; Egger’s regression tests and Begg’s ranks correlation tests were not significant (Supplementary file S12 ).

Results of meta-analysis for active transport studies. RE = a random-effects model, MET = Metabolic Equivalent of Task, I 2 = I 2 statistics for heterogeneity, RR = Summary relative risk

Studies comparing active vs. non-active modes for commuting

Four eligible publications were identified, of which three used the data from UK Biobank [ 25 , 26 , 27 ], one used the UK census data [ 51 ]. Three reported the associations for overall cancer incidence and mortality, and one reported the risk associated with lung cancer (Fig. 4 ). In the study that assessed lung cancer using the data from UK Biobank, when compared to automobile only mode, active modes did not show a significant association whereas frequent use of public transport (≥ 5 trips per week) was associated with an increased risk of lung cancer (HR: 1.58, 95% CI: 1.08–2.33) [ 25 ] (Fig. 4 ). In another UK Biobank study, no significant associations were observed for breast and colon cancers, and overall cancer incidence and mortality when more active patterns of commuting (walking, cycling, public transport, either alone or in combination with car) were compared to car only mode [ 26 ].

The results of two studies [ 27 , 51 ] that assessed overall cancer incidence and mortality were not combined as the outcome data was extracted from the same national cancer registry with an overlapped time frame (1991–2011 and 2007–2014), although the exposure information came from different sources (census and UK Biobank). In these studies, compared to private motorized mode or non-active mode, cycling was inversely associated with overall cancer incidence and mortality. Walking and public transport were also inversely associated with overall cancer incidence in the study that used the census data [ 51 ].

Results of the individual studies comparing active vs. non-active modes for commuting. Private motorized mode = car or motorcycle, Non-active = car or public transport, Active patterns of commuting = any other patterns including walking, cycling, public transport, either alone or in combination with car, HR = Hazard Ratio, regular:1–4, often: ≥5 work-bound trips/week

This review identified 27 studies (34 publications) that reported the associations of specific transport modes, mainly active transport modes, with risks of ten site-specific cancers along with overall cancer incidence and mortality. The most frequently studied cancer sites were breast, endometrium, and colorectum; our meta-analysis showed a reduction in risk of these cancers (1%, 9% and 5%, respectively) per 10 MET hour per week increment in transport-related physical activity ( ∼ 150 min of walking or 90 min of cycling).

We found an inverse association between active transport and risks of breast and endometrial cancers, with similar magnitude of risk reduction observed in previous systematic reviews on physical activity in general [ 55 , 56 ]. While obesity is known to increase post-menopausal but not pre-menopausal breast cancer risk [ 57 ], we found similar results by menopausal status. In contrast, an earlier review did not find any significant association between walking in general and risk of pre- or post-menopausal breast cancer [ 58 ], possibly because compared to walking for transport, walking for leisure or at home generally uses lower energy [ 59 ], and therefore may have less effect on body weight.

The inverse association of active transport with colorectal cancer risk observed in this review is also consistent with the findings from existing reviews on transport-related physical activity [ 60 ] as well as physical activity in general [ 61 ]. While physical activity in general or for leisure has also been associated with a reduced risk of many other cancer sites including liver, gastric, renal and lung [ 13 , 14 ], the evidence related to transport-related physical activity is currently limited.

Mechanisms linking physical activity with specific cancer sites have been proposed, including its effects on sex hormones (breast, endometrial and prostate cancers), insulin sensitivity, glucose metabolism and adipokines (obesity-related cancers), and inflammation and immune function (most cancers) [ 62 ]. For colorectal cancer, another potential mechanism is reduced contact time between carcinogens and bowel mucosa cells due to exercise-induced intestinal mobility [ 63 ].

The overall quality of the included studies, evaluated by NOS score, ranged from 4 to 9, and in general, cohort studies tend to have higher scores compared to case-control studies. The common criteria the studies did not meet include: inadequate exposure assessment, loss to follow-up (cohort studies) and low response rates (case-control studies). While we were not able to undertake subgroup analyses by NOS score due to the limited number of studies available, our subgroup analyses by study design showed similar associations between walking and breast cancer in cohort vs. case-control studies.

To our knowledge, this review represents the first systematic attempt to synthesize the existing evidence on specific transport modes and site-specific cancers. We provided mode-specific summary effects where possible and calculated the dose-response effects for transport-related physical activity, in line with WHO physical activity recommendation. When interpreting the findings, some limitations need to be considered. First, the review may not have included some eligible studies published in languages other than English. Second, due to the limited number of available studies, we were not able to pool the results separately for cohort and case-control studies; however, we conducted sub-group analyses by study design where possible. We were not able to evaluate the non-linear relationship between transport-related physical activity and the risks of site-specific cancers. While a recent systematic review on breast and colon cancers reported a linear relationship with physical activity [ 64 ], others suggested a non-linear relationship between physical activity and cancer risk [ 65 , 66 ]. Further, variations in measurement and categorization of the exposure across the studies make direct comparison of the results between different modes (e.g., walking vs. cycling) difficult. Finally, the majority of the studies included were conducted in high income countries in Europe, UK, and North America, limiting the generalizability of the findings to other populations and low and middle income countries where urbanization and motorization are mainly taking place [ 67 ].

Our findings suggest that transport choices may influence cancer risk, particularly of obesity-related cancers such as breast, colon and endometrial cancers. Breast cancer is the most common cancer in women globally, with an estimated over 2 million new cases (11.7% of all new cases) in 2020, while colon cancer stood at fourth place (over 1 million cases, 6% of total cases) [ 68 ]. The incidence of endometrial cancer also seems to be increasing in many countries particularly in younger women. Our findings indicate that the risks of these cancers can be reduced by meeting the WHO physical activity recommendation through active commuting ( ∼ 150 min of walking or 90 min of cycling per week). Yet, the current evidence is limited in relation to other cancer sites, underlying mechanisms, and potential environmental influences, requiring further exploration.

Given heterogeneity in exposure measurements in the existing studies, harmonizing choice of the assessment tool (e.g., using International Physical Activity Questionnaires that can capture information about all four physical activity domains including transport modes), and reporting the dose-response estimates for each transport mode such as walking and cycling separately rather than a combined mode would enhance comparability of results and provide mode-specific effects. Repeated or regular assessments of exposures/transport modes used throughout the study duration would capture changes and their potential impact on outcomes in cohort studies. Importantly, more research is needed in low and middle-income settings to generate context-specific evidence.

In conclusion, active transport modes appear to reduce cancer risk, but evidence for cancer sites other than colorectum, breast and endometrium is currently limited.

Data availability

No datasets were generated or analysed during the current study.

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Acknowledgements

STT is supported by Sir Charles Hercus Health Research Fellowship from the Health Research Council of New Zealand (Ref: 23/051).

STT is supported by Sir Charles Hercus Health Research Fellowship from the Health Research Council of New Zealand (Ref: 23/051). The funder had no role in the study design, data collection, data analysis, data interpretation, writing of the report, approval of the manuscript, or decision to submit the manuscript for publication.

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STT, AW, WT designed the study. STT supervised the study. WT conducted literature search, data analysis and wrote the original draft with critical inputs from STT, AC, and AW. All authors had full access to all the data in the study and had final responsibility for the decision to submit for publication. More than one author has directly accessed and verified the underlying data reported in the manuscript.

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: Supplementary file S1 PRISMA checklist. Supplementary file S2 Literature search strategy. Supplementary file S3 List of excluded full texts with reasons. Supplementary file S4 Metabolic Equivalent of Task (MET) values used and MET hour per week conversion formulas. Supplementary file S5 Measurement units, effect measures and covariates included in the studies. Supplementary file S6 Newcastle-Ottawa Score of the studies (cohort studies). Supplementary file S7 Newcastle-Ottawa Score of the studies (case control studies). Supplementary file S8 Risks estimates used in the meta-analyses (separate excel sheet). Supplementary file S9 Forest plots. Supplementary file S10 Sub-group and covariates adjustment analyses. Supplementary file S11 Sensitivity analysis. Supplementary file S12 Funnel plots

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Thu, W., Woodward, A., Cavadino, A. et al. Associations between transport modes and site-specific cancers: a systematic review and meta-analysis. Environ Health 23 , 39 (2024). https://doi.org/10.1186/s12940-024-01081-3

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The study quality was evaluated using the Newcastle-Ottawa Scale (NOS) , which scores the cohort and case-control studies based on three domains: selection of study groups, comparability of the groups and ascertainment of exposure (case-control studies) or outcome (cohort studies). For the second domain, a point was awarded for adjustment of ...

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

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Case Study | Definition, Examples & Methods

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Research Writing and Analysis

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A Quick Guide to Case Study with Examples

When to Use Case Study?

What are the Aims of the Case Study?

Types of Case Studies

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How to Conduct a Case Study?

Step1: Select the Case to Investigate

Step2: Formulate the Research Question

Step 3: Review of Literature

Step 4: Choose the Precise Case to Use in your Study

Step 5: Select Data Collection and Analysis Techniques

Step 6: Collect the Data

Step 7: Analyse the Data

Step 8: Prepare the Report

Advantages and Disadvantages of Case Study

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Literature as a Foundation for Research: Case Studies and Examples

The Importance of Literature in Research

Case Study: Literature Review in a Scientific Research Paper

Examples of Literature-Based Research

1. Social Sciences

2. Literature and Humanities

3. Education

Q1: What is a literature review in research?

Q2: Why is literature important in research?

Q3: How can literature-based research be applied in natural sciences?

Q4: Can literature-based research lead to original contributions?

Q5: How should one approach conducting a literature review?

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The case study approach

Introduction

What is a case study?

What are case studies used for?

How are case studies conducted?

Defining the case

Selecting the case(s)

Collecting the data

Analysing, interpreting and reporting case studies

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

Conclusions

Pre-publication history

Acknowledgements

Author information

Corresponding author

Additional information

Authors' contributions

Rights and permissions

About this article

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BMC Medical Research Methodology

CC0006 Basics of Report Writing

Content s Page

Introduction

Literature Review

Methodology