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What are the benefits and drawbacks of case study research?

Posted by Mark Murphy | May 24, 2014 | Method , Research Students | 0

What are the benefits and drawbacks of case study research?

There should be no doubt that with case studies what you gain in depth you lose in breadth – this is the unavoidable compromise that needs to be understood from the beginning of the research process. So this is neither an advantage nor a disadvantage as one aspect cancels out the benefits/drawbacks of the other – there are other benefits and drawbacks that need attention however …

  • Their flexibility: case studies are popular for a number of reasons, one being that they can be conducted at various points in the research process. Researchers are known to favour them as a way to develop ideas for more extensive research in the future – pilot studies often take the form of case studies. They are also effective conduits for a broad range of research methods; in that sense they are non-prejudicial against any particular type of research – focus groups are just as welcome in case study research as are questionnaires or participant observation.
  • Capturing reality: One of their key benefits is their ability to capture what Hodkinson and Hodkinson call ‘lived reality’ (2001: 3). As they put it, case studies have the potential, when applied successfully, to ‘retain more of the “noise” of real life than many other types of research’ (Hodkinson and Hodkinson, 2001: 3). The importance of ‘noise’ and its place in research is especially important in contexts such as education, for example in schools where background noise is unavoidable. Educational contexts are always complex, and as a result it is difficult to exclude other unwanted variables, ‘some of which may only have real significance for one of their students’ (Hodkinson and Hodkinson, 2001, 4).
  • The challenge of generality: At the same time, given their specificity, care needs to be taken when attempting to generalise from the findings. While there’s no inherent flaw in case study design that precludes its broader application, it is preferable that researchers choose their case study sites carefully, while also basing their analysis within existing research findings that have been generated via other research designs. No design is infallible but so often has the claim against case studies been made, that some of the criticism (unwarranted and unfair in many cases) has stuck.
  • Suspicion of amateurism: Less partisan researchers might wonder whether the case study offers the time and finance-strapped researcher a convenient and pragmatic source of data, providing findings and recommendations that, given the nature of case studies, can neither be confirmed nor denied, in terms of utility or veracity. Who is to say that case studies offer anything more than a story to tell, and nothing more than that?
  • But alongside this suspicion is another more insiduous one – a notion that ‘stories’ are not what social science research is about. This can be a concern for those who favour  case study research, as the political consequences can be hard to ignore. That said, so much research is based either on peoples’ lives or the impact of other issues (poverty, institutional policy) on their lives, so the stories of what actually occurs in their lives or in professional environments tend to be an invaluable source of evidence. The fact is that stories (individual, collective, institutional) have a vital role to play in the world of research. And to play the specific v. general card against case study design suggests a tendency towards forms of research fundamentalism as opposed to any kind of rational and objective take on case study’s strengths and limitations.
  • Preciousness: Having said that, researchers should not fall into the trap (surprising how often this happens) of assuming that case study data speaks for itself – rarely is this ever the case, an assumption that is as patronising to research subjects as it is false. The role of the researcher is both to describe social phenomena and also to explain – i.e., interpret. Without interpretation the research findings lack meaningful presentation – they present themselves as fact when of course the reality of ‘facts’ is one of the reasons why such research is carried out.
  • Conflation of political/research objectives: Another trap that case study researchers sometimes fall into is presenting research findings as if they were self-evidently true, as if the stories were beyond criticism. This is often accompanied by a vague attachment to the notion that research is a political process – one that is performed as a form of liberation against for example policies that seek to ignore the stories of those who ‘suffer’ at the hands of overbearing political or economic imperatives. Case study design should not be viewed as a mechanism for providing a ‘local’ bulwark against the ‘global’ – bur rather as a mechanism for checking the veracity of universalist claims (at least one of its objectives). The valorisation of particularism can only get you so far in social research.

Reference: Hodkinson, P. and H. Hodkinson (2001). The strengths and limitations of case study research. Paper presented to the Learning and Skills Development Agency conference, Making an impact on policy and practice , Cambridge, 5-7 December 2001, downloaded from h ttp://education.exeter.ac.uk/tlc/docs/publications/LE_PH_PUB_05.12.01.rtf.26.01.2013

About The Author

Mark Murphy

Mark Murphy

Mark Murphy is a Reader in Education and Public Policy at the University of Glasgow. He previously worked as an academic at King’s College, London, University of Chester, University of Stirling, National University of Ireland, Maynooth, University College Dublin and Northern Illinois University. Mark is an active researcher in the fields of education and public policy. His research interests include educational sociology, critical theory, accountability in higher education, and public sector reform.

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Journal of Applied Social Theory Special Edition on Character Assassination

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Case study research for better evaluations of complex interventions: rationale and challenges

  • Sara Paparini   ORCID: orcid.org/0000-0002-1909-2481 1 ,
  • Judith Green 2 ,
  • Chrysanthi Papoutsi 1 ,
  • Jamie Murdoch 3 ,
  • Mark Petticrew 4 ,
  • Trish Greenhalgh 1 ,
  • Benjamin Hanckel 5 &
  • Sara Shaw 1  

BMC Medicine volume  18 , Article number:  301 ( 2020 ) Cite this article

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The need for better methods for evaluation in health research has been widely recognised. The ‘complexity turn’ has drawn attention to the limitations of relying on causal inference from randomised controlled trials alone for understanding whether, and under which conditions, interventions in complex systems improve health services or the public health, and what mechanisms might link interventions and outcomes. We argue that case study research—currently denigrated as poor evidence—is an under-utilised resource for not only providing evidence about context and transferability, but also for helping strengthen causal inferences when pathways between intervention and effects are likely to be non-linear.

Case study research, as an overall approach, is based on in-depth explorations of complex phenomena in their natural, or real-life, settings. Empirical case studies typically enable dynamic understanding of complex challenges and provide evidence about causal mechanisms and the necessary and sufficient conditions (contexts) for intervention implementation and effects. This is essential evidence not just for researchers concerned about internal and external validity, but also research users in policy and practice who need to know what the likely effects of complex programmes or interventions will be in their settings. The health sciences have much to learn from scholarship on case study methodology in the social sciences. However, there are multiple challenges in fully exploiting the potential learning from case study research. First are misconceptions that case study research can only provide exploratory or descriptive evidence. Second, there is little consensus about what a case study is, and considerable diversity in how empirical case studies are conducted and reported. Finally, as case study researchers typically (and appropriately) focus on thick description (that captures contextual detail), it can be challenging to identify the key messages related to intervention evaluation from case study reports.

Whilst the diversity of published case studies in health services and public health research is rich and productive, we recommend further clarity and specific methodological guidance for those reporting case study research for evaluation audiences.

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The need for methodological development to address the most urgent challenges in health research has been well-documented. Many of the most pressing questions for public health research, where the focus is on system-level determinants [ 1 , 2 ], and for health services research, where provisions typically vary across sites and are provided through interlocking networks of services [ 3 ], require methodological approaches that can attend to complexity. The need for methodological advance has arisen, in part, as a result of the diminishing returns from randomised controlled trials (RCTs) where they have been used to answer questions about the effects of interventions in complex systems [ 4 , 5 , 6 ]. In conditions of complexity, there is limited value in maintaining the current orientation to experimental trial designs in the health sciences as providing ‘gold standard’ evidence of effect.

There are increasing calls for methodological pluralism [ 7 , 8 ], with the recognition that complex intervention and context are not easily or usefully separated (as is often the situation when using trial design), and that system interruptions may have effects that are not reducible to linear causal pathways between intervention and outcome. These calls are reflected in a shifting and contested discourse of trial design, seen with the emergence of realist [ 9 ], adaptive and hybrid (types 1, 2 and 3) [ 10 , 11 ] trials that blend studies of effectiveness with a close consideration of the contexts of implementation. Similarly, process evaluation has now become a core component of complex healthcare intervention trials, reflected in MRC guidance on how to explore implementation, causal mechanisms and context [ 12 ].

Evidence about the context of an intervention is crucial for questions of external validity. As Woolcock [ 4 ] notes, even if RCT designs are accepted as robust for maximising internal validity, questions of transferability (how well the intervention works in different contexts) and generalisability (how well the intervention can be scaled up) remain unanswered [ 5 , 13 ]. For research evidence to have impact on policy and systems organisation, and thus to improve population and patient health, there is an urgent need for better methods for strengthening external validity, including a better understanding of the relationship between intervention and context [ 14 ].

Policymakers, healthcare commissioners and other research users require credible evidence of relevance to their settings and populations [ 15 ], to perform what Rosengarten and Savransky [ 16 ] call ‘careful abstraction’ to the locales that matter for them. They also require robust evidence for understanding complex causal pathways. Case study research, currently under-utilised in public health and health services evaluation, can offer considerable potential for strengthening faith in both external and internal validity. For example, in an empirical case study of how the policy of free bus travel had specific health effects in London, UK, a quasi-experimental evaluation (led by JG) identified how important aspects of context (a good public transport system) and intervention (that it was universal) were necessary conditions for the observed effects, thus providing useful, actionable evidence for decision-makers in other contexts [ 17 ].

The overall approach of case study research is based on the in-depth exploration of complex phenomena in their natural, or ‘real-life’, settings. Empirical case studies typically enable dynamic understanding of complex challenges rather than restricting the focus on narrow problem delineations and simple fixes. Case study research is a diverse and somewhat contested field, with multiple definitions and perspectives grounded in different ways of viewing the world, and involving different combinations of methods. In this paper, we raise awareness of such plurality and highlight the contribution that case study research can make to the evaluation of complex system-level interventions. We review some of the challenges in exploiting the current evidence base from empirical case studies and conclude by recommending that further guidance and minimum reporting criteria for evaluation using case studies, appropriate for audiences in the health sciences, can enhance the take-up of evidence from case study research.

Case study research offers evidence about context, causal inference in complex systems and implementation

Well-conducted and described empirical case studies provide evidence on context, complexity and mechanisms for understanding how, where and why interventions have their observed effects. Recognition of the importance of context for understanding the relationships between interventions and outcomes is hardly new. In 1943, Canguilhem berated an over-reliance on experimental designs for determining universal physiological laws: ‘As if one could determine a phenomenon’s essence apart from its conditions! As if conditions were a mask or frame which changed neither the face nor the picture!’ ([ 18 ] p126). More recently, a concern with context has been expressed in health systems and public health research as part of what has been called the ‘complexity turn’ [ 1 ]: a recognition that many of the most enduring challenges for developing an evidence base require a consideration of system-level effects [ 1 ] and the conceptualisation of interventions as interruptions in systems [ 19 ].

The case study approach is widely recognised as offering an invaluable resource for understanding the dynamic and evolving influence of context on complex, system-level interventions [ 20 , 21 , 22 , 23 ]. Empirically, case studies can directly inform assessments of where, when, how and for whom interventions might be successfully implemented, by helping to specify the necessary and sufficient conditions under which interventions might have effects and to consolidate learning on how interdependencies, emergence and unpredictability can be managed to achieve and sustain desired effects. Case study research has the potential to address four objectives for improving research and reporting of context recently set out by guidance on taking account of context in population health research [ 24 ], that is to (1) improve the appropriateness of intervention development for specific contexts, (2) improve understanding of ‘how’ interventions work, (3) better understand how and why impacts vary across contexts and (4) ensure reports of intervention studies are most useful for decision-makers and researchers.

However, evaluations of complex healthcare interventions have arguably not exploited the full potential of case study research and can learn much from other disciplines. For evaluative research, exploratory case studies have had a traditional role of providing data on ‘process’, or initial ‘hypothesis-generating’ scoping, but might also have an increasing salience for explanatory aims. Across the social and political sciences, different kinds of case studies are undertaken to meet diverse aims (description, exploration or explanation) and across different scales (from small N qualitative studies that aim to elucidate processes, or provide thick description, to more systematic techniques designed for medium-to-large N cases).

Case studies with explanatory aims vary in terms of their positioning within mixed-methods projects, with designs including (but not restricted to) (1) single N of 1 studies of interventions in specific contexts, where the overall design is a case study that may incorporate one or more (randomised or not) comparisons over time and between variables within the case; (2) a series of cases conducted or synthesised to provide explanation from variations between cases; and (3) case studies of particular settings within RCT or quasi-experimental designs to explore variation in effects or implementation.

Detailed qualitative research (typically done as ‘case studies’ within process evaluations) provides evidence for the plausibility of mechanisms [ 25 ], offering theoretical generalisations for how interventions may function under different conditions. Although RCT designs reduce many threats to internal validity, the mechanisms of effect remain opaque, particularly when the causal pathways between ‘intervention’ and ‘effect’ are long and potentially non-linear: case study research has a more fundamental role here, in providing detailed observational evidence for causal claims [ 26 ] as well as producing a rich, nuanced picture of tensions and multiple perspectives [ 8 ].

Longitudinal or cross-case analysis may be best suited for evidence generation in system-level evaluative research. Turner [ 27 ], for instance, reflecting on the complex processes in major system change, has argued for the need for methods that integrate learning across cases, to develop theoretical knowledge that would enable inferences beyond the single case, and to develop generalisable theory about organisational and structural change in health systems. Qualitative Comparative Analysis (QCA) [ 28 ] is one such formal method for deriving causal claims, using set theory mathematics to integrate data from empirical case studies to answer questions about the configurations of causal pathways linking conditions to outcomes [ 29 , 30 ].

Nonetheless, the single N case study, too, provides opportunities for theoretical development [ 31 ], and theoretical generalisation or analytical refinement [ 32 ]. How ‘the case’ and ‘context’ are conceptualised is crucial here. Findings from the single case may seem to be confined to its intrinsic particularities in a specific and distinct context [ 33 ]. However, if such context is viewed as exemplifying wider social and political forces, the single case can be ‘telling’, rather than ‘typical’, and offer insight into a wider issue [ 34 ]. Internal comparisons within the case can offer rich possibilities for logical inferences about causation [ 17 ]. Further, case studies of any size can be used for theory testing through refutation [ 22 ]. The potential lies, then, in utilising the strengths and plurality of case study to support theory-driven research within different methodological paradigms.

Evaluation research in health has much to learn from a range of social sciences where case study methodology has been used to develop various kinds of causal inference. For instance, Gerring [ 35 ] expands on the within-case variations utilised to make causal claims. For Gerring [ 35 ], case studies come into their own with regard to invariant or strong causal claims (such as X is a necessary and/or sufficient condition for Y) rather than for probabilistic causal claims. For the latter (where experimental methods might have an advantage in estimating effect sizes), case studies offer evidence on mechanisms: from observations of X affecting Y, from process tracing or from pattern matching. Case studies also support the study of emergent causation, that is, the multiple interacting properties that account for particular and unexpected outcomes in complex systems, such as in healthcare [ 8 ].

Finally, efficacy (or beliefs about efficacy) is not the only contributor to intervention uptake, with a range of organisational and policy contingencies affecting whether an intervention is likely to be rolled out in practice. Case study research is, therefore, invaluable for learning about contextual contingencies and identifying the conditions necessary for interventions to become normalised (i.e. implemented routinely) in practice [ 36 ].

The challenges in exploiting evidence from case study research

At present, there are significant challenges in exploiting the benefits of case study research in evaluative health research, which relate to status, definition and reporting. Case study research has been marginalised at the bottom of an evidence hierarchy, seen to offer little by way of explanatory power, if nonetheless useful for adding descriptive data on process or providing useful illustrations for policymakers [ 37 ]. This is an opportune moment to revisit this low status. As health researchers are increasingly charged with evaluating ‘natural experiments’—the use of face masks in the response to the COVID-19 pandemic being a recent example [ 38 ]—rather than interventions that take place in settings that can be controlled, research approaches using methods to strengthen causal inference that does not require randomisation become more relevant.

A second challenge for improving the use of case study evidence in evaluative health research is that, as we have seen, what is meant by ‘case study’ varies widely, not only across but also within disciplines. There is indeed little consensus amongst methodologists as to how to define ‘a case study’. Definitions focus, variously, on small sample size or lack of control over the intervention (e.g. [ 39 ] p194), on in-depth study and context [ 40 , 41 ], on the logic of inference used [ 35 ] or on distinct research strategies which incorporate a number of methods to address questions of ‘how’ and ‘why’ [ 42 ]. Moreover, definitions developed for specific disciplines do not capture the range of ways in which case study research is carried out across disciplines. Multiple definitions of case study reflect the richness and diversity of the approach. However, evidence suggests that a lack of consensus across methodologists results in some of the limitations of published reports of empirical case studies [ 43 , 44 ]. Hyett and colleagues [ 43 ], for instance, reviewing reports in qualitative journals, found little match between methodological definitions of case study research and how authors used the term.

This raises the third challenge we identify that case study reports are typically not written in ways that are accessible or useful for the evaluation research community and policymakers. Case studies may not appear in journals widely read by those in the health sciences, either because space constraints preclude the reporting of rich, thick descriptions, or because of the reported lack of willingness of some biomedical journals to publish research that uses qualitative methods [ 45 ], signalling the persistence of the aforementioned evidence hierarchy. Where they do, however, the term ‘case study’ is used to indicate, interchangeably, a qualitative study, an N of 1 sample, or a multi-method, in-depth analysis of one example from a population of phenomena. Definitions of what constitutes the ‘case’ are frequently lacking and appear to be used as a synonym for the settings in which the research is conducted. Despite offering insights for evaluation, the primary aims may not have been evaluative, so the implications may not be explicitly drawn out. Indeed, some case study reports might properly be aiming for thick description without necessarily seeking to inform about context or causality.

Acknowledging plurality and developing guidance

We recognise that definitional and methodological plurality is not only inevitable, but also a necessary and creative reflection of the very different epistemological and disciplinary origins of health researchers, and the aims they have in doing and reporting case study research. Indeed, to provide some clarity, Thomas [ 46 ] has suggested a typology of subject/purpose/approach/process for classifying aims (e.g. evaluative or exploratory), sample rationale and selection and methods for data generation of case studies. We also recognise that the diversity of methods used in case study research, and the necessary focus on narrative reporting, does not lend itself to straightforward development of formal quality or reporting criteria.

Existing checklists for reporting case study research from the social sciences—for example Lincoln and Guba’s [ 47 ] and Stake’s [ 33 ]—are primarily orientated to the quality of narrative produced, and the extent to which they encapsulate thick description, rather than the more pragmatic issues of implications for intervention effects. Those designed for clinical settings, such as the CARE (CAse REports) guidelines, provide specific reporting guidelines for medical case reports about single, or small groups of patients [ 48 ], not for case study research.

The Design of Case Study Research in Health Care (DESCARTE) model [ 44 ] suggests a series of questions to be asked of a case study researcher (including clarity about the philosophy underpinning their research), study design (with a focus on case definition) and analysis (to improve process). The model resembles toolkits for enhancing the quality and robustness of qualitative and mixed-methods research reporting, and it is usefully open-ended and non-prescriptive. However, even if it does include some reflections on context, the model does not fully address aspects of context, logic and causal inference that are perhaps most relevant for evaluative research in health.

Hence, for evaluative research where the aim is to report empirical findings in ways that are intended to be pragmatically useful for health policy and practice, this may be an opportune time to consider how to best navigate plurality around what is (minimally) important to report when publishing empirical case studies, especially with regards to the complex relationships between context and interventions, information that case study research is well placed to provide.

The conventional scientific quest for certainty, predictability and linear causality (maximised in RCT designs) has to be augmented by the study of uncertainty, unpredictability and emergent causality [ 8 ] in complex systems. This will require methodological pluralism, and openness to broadening the evidence base to better understand both causality in and the transferability of system change intervention [ 14 , 20 , 23 , 25 ]. Case study research evidence is essential, yet is currently under exploited in the health sciences. If evaluative health research is to move beyond the current impasse on methods for understanding interventions as interruptions in complex systems, we need to consider in more detail how researchers can conduct and report empirical case studies which do aim to elucidate the contextual factors which interact with interventions to produce particular effects. To this end, supported by the UK’s Medical Research Council, we are embracing the challenge to develop guidance for case study researchers studying complex interventions. Following a meta-narrative review of the literature, we are planning a Delphi study to inform guidance that will, at minimum, cover the value of case study research for evaluating the interrelationship between context and complex system-level interventions; for situating and defining ‘the case’, and generalising from case studies; as well as provide specific guidance on conducting, analysing and reporting case study research. Our hope is that such guidance can support researchers evaluating interventions in complex systems to better exploit the diversity and richness of case study research.

Availability of data and materials

Not applicable (article based on existing available academic publications)

Abbreviations

Qualitative comparative analysis

Quasi-experimental design

Randomised controlled trial

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This work was funded by the Medical Research Council - MRC Award MR/S014632/1 HCS: Case study, Context and Complex interventions (TRIPLE C). SP was additionally funded by the University of Oxford's Higher Education Innovation Fund (HEIF).

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Sara Paparini, Chrysanthi Papoutsi, Trish Greenhalgh & Sara Shaw

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Judith Green

School of Health Sciences, University of East Anglia, Norwich, UK

Jamie Murdoch

Public Health, Environments and Society, London School of Hygiene & Tropical Medicin, London, UK

Mark Petticrew

Institute for Culture and Society, Western Sydney University, Penrith, Australia

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JG, MP, SP, JM, TG, CP and SS drafted the initial paper; all authors contributed to the drafting of the final version, and read and approved the final manuscript.

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Paparini, S., Green, J., Papoutsi, C. et al. Case study research for better evaluations of complex interventions: rationale and challenges. BMC Med 18 , 301 (2020). https://doi.org/10.1186/s12916-020-01777-6

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

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

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What is it?

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

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

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

Benefits and limitations of case studies

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

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

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

Examples of case studies

Example 1: nurses’ paediatric pain management practices.

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

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

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

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

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

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

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

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

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

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

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

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

  • Gustafsson J
  • Calanzaro M
  • Sandelowski M

Competing interests None declared.

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

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

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

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

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

Table of contents

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Research bias

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

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benefits of case studies in research

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

benefits of case studies in research

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

Research question

  • Conceptual framework
  • Conceptual vs. theoretical framework

Data collection

  • Qualitative research methods
  • Focus groups
  • Observational research

What is a case study?

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

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

Case studies

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

benefits of case studies in research

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

Definition of a case study

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

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

Characteristics of case studies

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

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

The role of case studies in research

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

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

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

What is the purpose of a case study?

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

Why use case studies in qualitative research?

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

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

The explanatory, exploratory, and descriptive roles of case studies

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

The impact of case studies on knowledge development

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

benefits of case studies in research

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

Types of case studies

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

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

Exploratory case studies

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

Descriptive case studies

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

Explanatory case studies

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

benefits of case studies in research

Intrinsic, instrumental, and collective case studies

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

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

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

Critical information systems research

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

Health research

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

benefits of case studies in research

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

Asthma research studies

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

Other fields

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

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

benefits of case studies in research

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

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

Propositions

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

Units of analysis

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

Argumentation

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

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

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

Defining the research question

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

Selecting and defining the case

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

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

Developing a detailed case study protocol

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

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

Collecting data

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

Analyzing and interpreting data

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

Writing the case study report

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

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

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

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

Observations

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

Documents and artifacts

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

benefits of case studies in research

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

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

Ensuring the quality of data collection

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

Data analysis

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

Organizing the data

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

Categorizing and coding the data

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

Identifying patterns and themes

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

Interpreting the data

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

Verification of the data

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

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

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

Benefits include the following:

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

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

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

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

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Case Study – Methods, Examples and Guide

Table of Contents

Case Study Research

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

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

Types of Case Study

Types and Methods of Case Study are as follows:

Single-Case Study

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

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

Multiple-Case Study

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

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

Exploratory Case Study

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

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

Descriptive Case Study

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

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

Instrumental Case Study

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

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

Case Study Data Collection Methods

Here are some common data collection methods for case studies:

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

Observations

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

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

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

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

How to conduct Case Study Research

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

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

Examples of Case Study

Here are some examples of case study research:

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

Application of Case Study

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

Business and Management

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

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

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

Social Sciences

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

Law and Ethics

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

Purpose of Case Study

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

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

Case studies can also serve other purposes, including:

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

Advantages of Case Study Research

There are several advantages of case study research, including:

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

Limitations of Case Study Research

There are several limitations of case study research, including:

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

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What the Case Study Method Really Teaches

  • Nitin Nohria

benefits of case studies in research

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

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

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

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

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10 Case Study Advantages and Disadvantages

case study advantages and disadvantages, explained below

A case study in academic research is a detailed and in-depth examination of a specific instance or event, generally conducted through a qualitative approach to data.

The most common case study definition that I come across is is Robert K. Yin’s (2003, p. 13) quote provided below:

“An empirical inquiry that investigates a contemporary phenomenon within its real-life context, especially when the boundaries between phenomenon and context are not clearly evident.”

Researchers conduct case studies for a number of reasons, such as to explore complex phenomena within their real-life context, to look at a particularly interesting instance of a situation, or to dig deeper into something of interest identified in a wider-scale project.

While case studies render extremely interesting data, they have many limitations and are not suitable for all studies. One key limitation is that a case study’s findings are not usually generalizable to broader populations because one instance cannot be used to infer trends across populations.

Case Study Advantages and Disadvantages

1. in-depth analysis of complex phenomena.

Case study design allows researchers to delve deeply into intricate issues and situations.

By focusing on a specific instance or event, researchers can uncover nuanced details and layers of understanding that might be missed with other research methods, especially large-scale survey studies.

As Lee and Saunders (2017) argue,

“It allows that particular event to be studies in detail so that its unique qualities may be identified.”

This depth of analysis can provide rich insights into the underlying factors and dynamics of the studied phenomenon.

2. Holistic Understanding

Building on the above point, case studies can help us to understand a topic holistically and from multiple angles.

This means the researcher isn’t restricted to just examining a topic by using a pre-determined set of questions, as with questionnaires. Instead, researchers can use qualitative methods to delve into the many different angles, perspectives, and contextual factors related to the case study.

We can turn to Lee and Saunders (2017) again, who notes that case study researchers “develop a deep, holistic understanding of a particular phenomenon” with the intent of deeply understanding the phenomenon.

3. Examination of rare and Unusual Phenomena

We need to use case study methods when we stumble upon “rare and unusual” (Lee & Saunders, 2017) phenomena that would tend to be seen as mere outliers in population studies.

Take, for example, a child genius. A population study of all children of that child’s age would merely see this child as an outlier in the dataset, and this child may even be removed in order to predict overall trends.

So, to truly come to an understanding of this child and get insights into the environmental conditions that led to this child’s remarkable cognitive development, we need to do an in-depth study of this child specifically – so, we’d use a case study.

4. Helps Reveal the Experiences of Marginalzied Groups

Just as rare and unsual cases can be overlooked in population studies, so too can the experiences, beliefs, and perspectives of marginalized groups.

As Lee and Saunders (2017) argue, “case studies are also extremely useful in helping the expression of the voices of people whose interests are often ignored.”

Take, for example, the experiences of minority populations as they navigate healthcare systems. This was for many years a “hidden” phenomenon, not examined by researchers. It took case study designs to truly reveal this phenomenon, which helped to raise practitioners’ awareness of the importance of cultural sensitivity in medicine.

5. Ideal in Situations where Researchers cannot Control the Variables

Experimental designs – where a study takes place in a lab or controlled environment – are excellent for determining cause and effect . But not all studies can take place in controlled environments (Tetnowski, 2015).

When we’re out in the field doing observational studies or similar fieldwork, we don’t have the freedom to isolate dependent and independent variables. We need to use alternate methods.

Case studies are ideal in such situations.

A case study design will allow researchers to deeply immerse themselves in a setting (potentially combining it with methods such as ethnography or researcher observation) in order to see how phenomena take place in real-life settings.

6. Supports the generation of new theories or hypotheses

While large-scale quantitative studies such as cross-sectional designs and population surveys are excellent at testing theories and hypotheses on a large scale, they need a hypothesis to start off with!

This is where case studies – in the form of grounded research – come in. Often, a case study doesn’t start with a hypothesis. Instead, it ends with a hypothesis based upon the findings within a singular setting.

The deep analysis allows for hypotheses to emerge, which can then be taken to larger-scale studies in order to conduct further, more generalizable, testing of the hypothesis or theory.

7. Reveals the Unexpected

When a largescale quantitative research project has a clear hypothesis that it will test, it often becomes very rigid and has tunnel-vision on just exploring the hypothesis.

Of course, a structured scientific examination of the effects of specific interventions targeted at specific variables is extermely valuable.

But narrowly-focused studies often fail to shine a spotlight on unexpected and emergent data. Here, case studies come in very useful. Oftentimes, researchers set their eyes on a phenomenon and, when examining it closely with case studies, identify data and come to conclusions that are unprecedented, unforeseen, and outright surprising.

As Lars Meier (2009, p. 975) marvels, “where else can we become a part of foreign social worlds and have the chance to become aware of the unexpected?”

Disadvantages

1. not usually generalizable.

Case studies are not generalizable because they tend not to look at a broad enough corpus of data to be able to infer that there is a trend across a population.

As Yang (2022) argues, “by definition, case studies can make no claims to be typical.”

Case studies focus on one specific instance of a phenomenon. They explore the context, nuances, and situational factors that have come to bear on the case study. This is really useful for bringing to light important, new, and surprising information, as I’ve already covered.

But , it’s not often useful for generating data that has validity beyond the specific case study being examined.

2. Subjectivity in interpretation

Case studies usually (but not always) use qualitative data which helps to get deep into a topic and explain it in human terms, finding insights unattainable by quantitative data.

But qualitative data in case studies relies heavily on researcher interpretation. While researchers can be trained and work hard to focus on minimizing subjectivity (through methods like triangulation), it often emerges – some might argue it’s innevitable in qualitative studies.

So, a criticism of case studies could be that they’re more prone to subjectivity – and researchers need to take strides to address this in their studies.

3. Difficulty in replicating results

Case study research is often non-replicable because the study takes place in complex real-world settings where variables are not controlled.

So, when returning to a setting to re-do or attempt to replicate a study, we often find that the variables have changed to such an extent that replication is difficult. Furthermore, new researchers (with new subjective eyes) may catch things that the other readers overlooked.

Replication is even harder when researchers attempt to replicate a case study design in a new setting or with different participants.

Comprehension Quiz for Students

Question 1: What benefit do case studies offer when exploring the experiences of marginalized groups?

a) They provide generalizable data. b) They help express the voices of often-ignored individuals. c) They control all variables for the study. d) They always start with a clear hypothesis.

Question 2: Why might case studies be considered ideal for situations where researchers cannot control all variables?

a) They provide a structured scientific examination. b) They allow for generalizability across populations. c) They focus on one specific instance of a phenomenon. d) They allow for deep immersion in real-life settings.

Question 3: What is a primary disadvantage of case studies in terms of data applicability?

a) They always focus on the unexpected. b) They are not usually generalizable. c) They support the generation of new theories. d) They provide a holistic understanding.

Question 4: Why might case studies be considered more prone to subjectivity?

a) They always use quantitative data. b) They heavily rely on researcher interpretation, especially with qualitative data. c) They are always replicable. d) They look at a broad corpus of data.

Question 5: In what situations are experimental designs, such as those conducted in labs, most valuable?

a) When there’s a need to study rare and unusual phenomena. b) When a holistic understanding is required. c) When determining cause-and-effect relationships. d) When the study focuses on marginalized groups.

Question 6: Why is replication challenging in case study research?

a) Because they always use qualitative data. b) Because they tend to focus on a broad corpus of data. c) Due to the changing variables in complex real-world settings. d) Because they always start with a hypothesis.

Lee, B., & Saunders, M. N. K. (2017). Conducting Case Study Research for Business and Management Students. SAGE Publications.

Meir, L. (2009). Feasting on the Benefits of Case Study Research. In Mills, A. J., Wiebe, E., & Durepos, G. (Eds.). Encyclopedia of Case Study Research (Vol. 2). London: SAGE Publications.

Tetnowski, J. (2015). Qualitative case study research design.  Perspectives on fluency and fluency disorders ,  25 (1), 39-45. ( Source )

Yang, S. L. (2022). The War on Corruption in China: Local Reform and Innovation . Taylor & Francis.

Yin, R. (2003). Case Study research. Thousand Oaks, CA: Sage.

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Dr. Chris Drew is the founder of the Helpful Professor. He holds a PhD in education and has published over 20 articles in scholarly journals. He is the former editor of the Journal of Learning Development in Higher Education. [Image Descriptor: Photo of Chris]

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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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benefits of case studies in research

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Case Study Research Method | Benefits, Limitations

benefits of case studies in research

Case study research is a type of qualitative research that helps understand an individual case or a specific situation in detail.

Case study researchers focus on an in-depth understanding of the research topic by exploring an individual case or a specific situation in detail. Researchers document findings as case studies and present them with the help of visuals such as screenshots, images, and tables.

A case study can be written as a final report or it can be presented as an article in a journal or conference proceedings. Before you begin your next case study, you must know about its scope and limitations.

This article will help you get started with your next case study project by providing useful tips and information about this type of qualitative research .

  • Table of Contents

What is a Case Study?

A case study is a type of qualitative research that examines one particular case (or several cases) in-depth.

Case studies concentrate on gathering data about a particular object, event, or activity, like a certain business unit or organization. The person, group, organization, event, or circumstance that the researcher is interested in is the case in a case study.

A case study is designed to demonstrate how different angles and points of view can be used to evaluate a real-world event in order to gain a clear understanding of an issue. In keeping with this, a case study may be defined as a research strategy that entails an empirical investigation of a specific current event within its real-life setting employing a variety of data gathering techniques.

It is often used for exploring a single phenomenon such as:

  • Successful marketing campaign

Most importantly, a case study helps you understand the reasons for the occurrence or failure of a specific event. Case studies are common in business and management research . They can be qualitative or quantitative in nature. Researchers explore a single case, typically a business-related event or experiment.

They collect data through a variety of methods, such as

  • Document analysis
  • Observation

Case studies may offer both qualitative and quantitative data for analysis and interpretation. Hypotheses can be developed in case studies just like in experimental research . However, no support can be demonstrated for the alternative hypothesis developed if a specific hypothesis has not been supported in even one more case study.

Researchers document findings as case studies and present them with the help of visuals such as

  • Screenshots

A case study can be written as a final report or it can be presented as an article in a journal or conference proceedings.

Case Study- Example

How can teachers employ active learning practices in classrooms with mixed ability levels can be our research question.

This might be stated as a case study of a nearby school that encourages active learning.

When to do a case study?

  • In a thesis or dissertation, case studies are frequently a wise choice.
  • When you don’t have the time or resources to conduct extensive research , they help keep your project focused and manageable.
  • To compare and shed light on various facets of your research problem , you might perform several case studies or just one complicated case study where you thoroughly examine a single subject.

Step by step guide for conducting case study research

Define the problem.

Select a research topic and problem statement that you wish to solve using a case study.

Create a research plan

Before you begin with your case study, make sure you have a research plan. A research plan will help you outline your case study and make sure you don’t miss any important steps.

Conduct field research

Once you have a research plan, start your field research . You can use a variety of methods to conduct field research in a case study. You can use observation, interviews, or document analysis to collect data related to your case study.

Analyze data

Once you have collected data for your case study, it’s time to analyze it and make sense of it. You can use qualitative analysis methods to transform data into meaningful insights.

Organize data

Once you have analyzed data and made sense of it, it’s time to organize it into something more readable and understandable. You can use graphs, diagrams, or tables to summarize data and make it easy to understand.

Present case findings

Once you have organized data and summarized it, it’s time to present your case findings. You can write a case study report or present it in the form of an article in a journal or conference proceedings.

Benefits of Case Study Research

  • A single-case study is necessary to fully understand a single occurrence and would entail gathering a variety of data kinds if a researcher wanted to investigate a specific phenomenon resulting from a distinct entity.

By comparing the similarities and differences of the individual examples, a multiple-case research study enables a deeper knowledge of the cases as a whole.

Multiple case studies are frequently more robust and trustworthy than single case studies. Studies with multiple cases enable the formation of theories and a more thorough investigation of research problems .

Here are the benefits of case study research

  • A case study provides detailed information about the situation and the context in which it occurred.
  • A case study allows you to explore the causes of particular events.
  • It helps you explore different points of view of people associated with the case study.
  • It helps you understand problems that people in your target audience face on a daily basis.
  • It allows you to make inferences about the wider population from studying one case in detail.
  • It helps you explore real-world problems and come up with practical solutions for them.

Limitations of Case Study Research

  • A case study is not an appropriate research method when trying to generalize from one specific case to a wider population.
  • It is difficult to generalize findings from a case study since every case is different.
  • You can’t apply the insights from a single case study to other contexts.
  • You can’t use the insights from a case study to make predictions about the future.
  • You will have to be careful about using causal language in your case study report.
  • You can’t make causal claims based on a single case study.
  • You can’t draw generalized conclusions from a case study.
  • Case study research is not appropriate when studying an extremely rare event.
  • Since there is a lot of data to arrange, integration and data analysis methodologies should be carefully considered.
  • Reporting results from multiple-case research studies can occasionally be difficult, especially given the word limits for some journal papers.

Bottom line

A case study is a type of qualitative research that examines one particular case (or several cases) in-depth. It is often used for exploring a single phenomenon or event, such as a successful marketing campaign, a product, or a service.

Case study researchers collect data through a variety of methods, such as interviews, document analysis, and observation. They then analyze this data, organize it, and present their findings in a case study report or article.

Other articles

Please read through some of our other articles with examples and explanations if you’d like to learn more about research methodology.

  • PLS-SEM model
  • Principal Components Analysis
  • Multivariate Analysis
  • Friedman Test
  • Chi-Square Test (Χ²)
  • Effect Size

 Methodology

  • Research Methods
  • Quantitative Research
  • Qualitative Research
  • Case Study Research
  • Survey Research
  • Conclusive Research
  • Descriptive Research
  • Cross-Sectional Research
  • Theoretical Framework
  • Conceptual Framework
  • Triangulation
  • Grounded Theory
  • Quasi-Experimental Design
  • Mixed Method
  • Correlational Research
  • Randomized Controlled Trial
  • Stratified Sampling
  • Ethnography
  • Ghost Authorship
  • Secondary Data Collection
  • Primary Data Collection
  • Ex-Post-Facto
  •   Dissertation Topic
  • Thesis Statement
  • Research Proposal
  • Research Questions
  • Research Problem
  • Research Gap
  • Types of Research Gaps
  • Operationalization of Variables
  • Literature Review
  • Research Hypothesis
  • Questionnaire
  • Reliability
  • Measurement of Scale
  • Sampling Techniques
  • Acknowledgements

benefits of case studies in research

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The clinical case report: a review of its merits and limitations

Trygve nissen.

1 Department of Clinical Medicine, University of Tromsø, N-9038 Tromsø, Norway

2 Division of General Psychiatry, University Hospital of North Norway, N-9291 Tromsø, Norway

3 Division of Addictions and Specialized Psychiatry, University Hospital of North Norway, N-9291 Tromsø, Norway

The clinical case report has a long-standing tradition in the medical literature. While its scientific significance has become smaller as more advanced research methods have gained ground, case reports are still presented in many medical journals. Some scholars point to its limited value for medical progress, while others assert that the genre is undervalued. We aimed to present the various points of view regarding the merits and limitations of the case report genre. We searched Google Scholar, PubMed and select textbooks on epidemiology and medical research for articles and book-chapters discussing the merits and limitations of clinical case reports and case series.

The major merits of case reporting were these: Detecting novelties, generating hypotheses, pharmacovigilance, high applicability when other research designs are not possible to carry out, allowing emphasis on the narrative aspect (in-depth understanding), and educational value. The major limitations were: Lack of ability to generalize, no possibility to establish cause-effect relationship, danger of over-interpretation, publication bias, retrospective design, and distraction of reader when focusing on the unusual.

Conclusions

Despite having lost its central role in medical literature in the 20th century, the genre still appears popular. It is a valuable part of the various research methods, especially since it complements other approaches. Furthermore, it also contributes in areas of medicine that are not specifically research-related, e.g. as an educational tool. Revision of the case report genre has been attempted in order to integrate the biomedical model with the narrative approach, but without significant success. The future prospects of the case report could possibly be in new applications of the genre, i.e. exclusive case report databases available online, and open access for clinicians and researchers.

Throughout history the clinical case report and case report series have been integral components of medical literature [ 1 ]. The case report genre held a strong position until it was sidelined in the second half of the 20 th century [ 2 , 3 ]. New methodologies for research articles paved the way for evidence-based medicine. Editors had to make space for these research articles and at the same time signaled less enthusiasm for publishing case reports [ 4 ]. This spurred some heated debates in medical journals as readers were worried that the traditional case report was in jeopardy [ 5 , 6 ]. Those who welcomed the new trend with fewer case reports being published pointed mainly to their low quality and inclination to emphasize mere curiosa [ 7 - 9 ]. Some of the proponents of the genre claimed that the case report had been and still was indispensible for furthering medical knowledge and that it was unique in taking care of the detailed study of the individual patient as opposed to the new research methods with their “…nomothetic approach [taking] precedence…” [ 5 ]. Still, the case report got a low ranking on the evidence hierarchy. After a decline in popularity a new interest for the case report emerged, probably beginning in the late 1990s [ 2 ]. A peer-reviewed ‘Case reports’ section was introduced in the Lancet in 1995 [ 10 ]. In 2007, the first international, Pubmed-listed medical journal publishing only case reports was established [ 11 , 12 ]. In the following years, several similar journals, for the most part online and open-access, have been launched.

The present debate is not so much focused on whether case reporting is obsolete or not. Some of the discussions after the turn of the century have been about adapting the case report genre to new challenges. One example is the suggestion of incorporating the narrative, i.e. “… stressing the patient’s story”, in the case report [ 13 ]. The authors termed their initiative “The storied case report”. Their endeavor was not met with success. In analyzing the causes for this, they wondered if “… junior trainees find it too hard to determine what is relevant and senior trainees find it too hard to change their habits” [ 13 ]. A similar attempt was done when the editors of the Journal of Medical Case Reports in 2012 encouraged authors to include the patients’ perspectives by letting patients describe their own experiences [ 14 ].

Notwithstanding, we feel there is much to be gained from having an ongoing discussion highlighting the indications and contraindications for producing case reports. This can to some degree be facilitated by getting an understanding of the merits and limitations of the genre. The objective of this article is to present the merits and limitations of case reports and case series reports.

We adopted Taber’s Cyclopedic Medical Dictionary’s definition of the case report : “A formal summary of a unique patient and his or her illness, including the presenting signs and symptoms, diagnostic studies, treatment course and outcome” [ 15 ]. A case report consists of one or two cases, most often only one. The case series or case series report usually consists of three to ten cases [ 16 ]. (In the following we use the term case report to denote both case reports and case series report). Case reports are most often naturalistic and descriptive. Sometimes, however, they can be prospective and experimental.

As literature specifically dealing with the case report genre seemed harder to elicit from the databases than the vast amount of particular case reports, we performed iterative searches. We searched Google Scholar and PubMed using the search terms ‘case report(s)’, ‘case series’, ‘case series report(s)’, ‘case reporting’ in various combinations with ‘clinical’, ‘medical’, ‘anecdotal’, ‘methodology’, ‘review’, ‘overview’, ‘strengths’, ‘weaknesses’, ‘merits’, and ‘limitations’. Further references were identified by examining the literature found in the electronic searches. We also consulted major textbooks on epidemiology [ 17 , 18 ], some scholars of medical genres [ 19 , 20 ] and a monograph on case reporting by the epidemiologist M. Jenicek [ 16 ]. We delimited our review to the retrospective, naturalistic, and descriptive case report, also labeled the “traditional” or “classic” case report, and case series including such reports. Thus we excluded other types, such as the planned, qualitative case study approach [ 21 ] and simulated cases [ 22 - 24 ]. Finally, we extracted the relevant data and grouped the merits and limitations items in rank order with the items we judged to be the most important first.

New observations

The major advantage of case reporting is probably its ability to detect novelties [ 16 ]. It is the only way to present unusual, uncontrolled observations regarding symptoms, clinical findings, course of illness, complications of interventions, associations of diseases, side effects of drugs, etc. In short, anything that is rare or has never been observed previously might be important for the medical community and ought to be published. A case report might sensitize readers and thus facilitate detection of similar or identical cases.

Generating hypotheses

From a single, or preferably several single case reports or a case series, new hypotheses could be formulated. These could then be tested with formal research methods that are designed to refute or confirm the hypotheses, i.e. comparative (observational and experimental) studies.

There are numerous examples of new discoveries or major advancements in medicine that started with a case report or, in some cases, as humbly as a letter to the editor. The first concern from the medical community about the devastating side effect of thalidomide, i.e. the congenital abnormalities, appeared as a letter to the editor in the Lancet in 1961 [ 25 ]. Soon thereafter, several case reports and case series reports were published in various journals. Case reporting is thus indispensable in drug safety surveillance (pharmacovigilance) [ 26 ].

Sometimes significant advancements in knowledge have come not from what researchers were pursuing, but from “accidental discoveries”, i.e. by serendipity. The story of Alexander Fleming’s discovery of penicillin in 1928 is well known in the medical field [ 27 ]. Psychiatry has profited to a large degree from this mode of advancing medical science as many of the drugs used for mental disorders have been discovered serendipitously [ 27 ]. One notable example is the discovery of the effect of lithium on manic episodes in patients with manic-depressive disorder [ 28 ]. A more recent discovery is the successful treatment of infantile hemangiomas with systemic propranolol. This discovery was published, as a case series report, in the correspondence section in New England Journal of Medicine [ 29 ]. However, the evidence for the effect of this treatment is still preliminary, and several randomized trials are under way [ 30 , 31 ].

Clear and operational entities are prerequisites for doing medical research. Descriptions must come before understanding. Clinical observations that lead to new disorders being described are well suited for case reporting. The medical literature is replete with case-based articles describing new diseases and syndromes. One notable example is the first description of neurasthenia by G. Beard in Boston Medical and Surgical Journal in 1869 [ 32 ].

Researching rare disorders

For rare disorders randomized controlled trials (RCTs) can be impossible to run due to lack of patients to be enrolled. Research on drug treatment and other kinds of interventions must therefore be based on less rigorous methodologies, among them case series and case reports. This would be in accordance with the European Commission’s recommendation to its members to improve health care for those with rare disorders [ 33 ].

Solving ethical constraints

Case reporting can be valuable when ethical constraints prohibit experimental research. Take as an example the challenge of how to manage the side effects of accidental extravasation of cytotoxic drugs. As RCTs on humans seem unethical in this clinical situation the current guidelines rest on small observational studies, case reports and animal studies [ 34 ]. Or another example: Physical restraint is sometimes associated with sudden, unexpected death. The cause or causes for this are to some degree enigmatic, and it is hard to conceive of a controlled study that could be ethical [ 35 , 36 ]. Case reports and case series being “natural experiments” might be the only evidence available for guiding clinical practice.

In-depth narrative case studies

Case reporting can be a way of presenting research with an idiographic emphasis. As contrasted to nomothetic research, an idiographic approach aims at in-depth understanding of human phenomena, especially in the field of psychology and psychiatry. The objective is not generalizable knowledge, but an understanding of meaning and intentionality for an individual or individuals. Sigmund Freud’s case studies are relevant examples. This usage of case reports borders on qualitative research. Qualitative studies, although developed in the social sciences, have become a welcome contribution within health sciences in the last two decades.

Educational value

Clinical medical learning is to a large degree case-based. Typical case histories and vignettes are often presented in textbooks, in lectures, etc. Unusual observations presented as published case reports are important as part of doctors’ continuing medical education, especially as they demonstrate the diversity of manifestations both within and between medical diseases and syndromes [ 37 , 38 ]. Among the various medical texts, the case report is the only one that presents day-to-day clinical practice, clinicians’ diagnostic reasoning, disease management, and follow-up. We believe that some case reports that are written with the aim of contributing to medical knowledge turn out to be of most value educationally because the phenomena have already been described elsewhere. Other case reports are clearly primarily written for educational value [ 37 ]. Some journals have regular sections dedicated to educational case reports, e.g. The Case Records of the Massachusetts General Hospital in the New England Journal of Medicine and the Clinical Case Conference found in the American Journal of Psychiatry.

The cost of doing a case report is low compared to planned, formal studies. Most often the necessary work is probably done in the clinical setting without specific funding. Larger studies, for instance RCTs, will usually need an academic setting.

Fast publication

The time span from observation to publication can be much shorter than for other kinds of studies. This is obviously a great advantage as a case report can be an important alert to the medical community about a serious event. The unexpected side effects of the sedative-antinauseant thalidomide on newborn babies is a telling story. The drug had been prescribed during pregnancy to the babies’ mothers. After the first published observation of severe abnormalities in babies appeared as a letter to the editor of the Lancet in December 16 th , 1961 [ 25 ], several case reports and series followed [ 39 , 40 ]. It should be mentioned though that the drug company had announced on December 2 nd , 1961, i.e. two weeks before the letter from McBride [ 25 ], that it would withdraw the drug form the market immediately [ 41 ].

Flexible structure

Riaz Agha, editor of the International Journal of Surgery Case Reports suggests that the case report, with its less rigid structure is useful as it “… allows the surgeon(s) to discuss their diagnostic approach, the context, background, decision-making, reasoning and outcomes” [ 42 ]. Although the editor is commenting on the surgical case report, the argument can be applied for the whole field of clinical medicine. It should be mentioned though, that other commentators have argued for a more standardized, in effect more rigid, structure [ 43 ].

Clinical practice can be changed

Case reporting can lead to or contribute to a change in clinical practice. A drug might be withdrawn from the market. Or a relabeling might change the attitude to and treatment of a condition. During Word War I the shell shock syndrome was labeled and described thoroughly in several articles in the Lancet , the first of them appearing in February 1915 [ 44 ]. The author was the British captain and military doctor Charles S. Myers. Before his efforts to bring good care and treatment to afflicted soldiers there had been a common misconception that many of these dysfunctional soldiers were malingerers or cowards.

Exercise for novice researchers

The case report format is well suited for young doctors not yet trained as researchers. It can be an opportunity for a first exercise in authoring an article and a preparation for a scientific career [ 37 , 45 , 46 ].

Communication between the clinical and academic fields

Articles authored by clinicians can promote communication between practicing clinicians and academic researchers. Observations published can generate ideas and be a trigger for further studies. For instance, a case series consisting of several similar cases in a short period can make up the case-group for a case–control study [ 47 ]. Clinicians could do the observation and publish the case series while the case–control study could be left to the academics.

Entertainment

Some commentators find reading case reports fun. Although a rather weak argument in favor of case reporting, the value of being entertained should not be dismissed altogether. It might inspire physicians to spend more time browsing and reading scientific literature [ 48 ].

Studying the history of medicine

Finally, we present a note on a different and unintended aspect of the genre. The accumulated case reports from past eras are a rich resource for researching and understanding medical history [ 49 , 50 ]. A close study of old case reports can provide valuable information about how medicine has been practiced through the centuries [ 50 , 51 ].

Limitations

No epidemiological quantities.

As case reports are not chosen from representative population samples they cannot generate information on rates, ratios, incidences or prevalences. The case or cases being the numerator in the equation, has no denominator. However, if a case series report consists of a cluster of cases, it can signal an important and possibly causal association, e.g. an epidemic or a side effect of a newly marketed drug.

Causal inference not possible

Causality cannot be inferred from an uncontrolled observation. An association does not imply a cause-effect relationship. The observation or event in question could be a mere coincidence. This is a limitation shared by all the descriptive studies [ 47 ]. Take the thalidomide tragedy already mentioned as an example; Unusual events such as congenital malformations in some of the children born to mothers having taken a specific drug during pregnancy does not prove that the drug is the culprit. It is a mere hypothesis until further studies have either rejected or confirmed it. Cause-effect relationships require planned studies including control groups that to the extent possible control for chance, bias and confounders [ 52 ].

Generalization not possible

From the argument above, it follows that findings from case reports cannot be generalized. In order to generalize we need both a cause-effect relationship and a representative population for which the findings are valid. A single case report has neither. A case series, on the other hand, e.g. many “thalidomide babies” in a short time period, could strengthen the suspicion of a causal relationship, demanding further surveillance and research.

Publication bias could be a limiting factor. Journals in general favor positive-outcome findings [ 53 ]. One group of investigators studying case reports published in the Lancet found that only 5% of case reports and 10% of case series reported treatment failures [ 54 ]. A study of 435 case reports from the field of dentistry found that in 99.1%, the reports “…clearly [had] a positive outcome and the intervention was considered and described as successful by the authors” [ 55 ].

Overinterpretation

Overinterpretation or misinterpretation is the tendency or temptation to generalize when there is no justification for it. It has also been labeled “the anecdotal fallacy” [ 56 ]. This is not a shortcoming intrinsic to the method itself. Overinterpretation may be due to the phenomenon of case reports often having an emotional appeal on readers. The story implicitly makes a claim to truth. The reader might conclude prematurely that there is a causal connection. The phenomenon might be more clearly illustrated by the impact of the clinician’s load of personal cases on his or her practice. Here exemplified by a young doctor’s confession: “I often tell residents and medical students, ‘The only thing that actually changes practice is adverse anecdote.’” [ 57 ].

Emphasis on the rare

As case reporting often deals with the rare and atypical, it might divert the readers’ attention from common diseases and problems [ 58 ].

Confidentiality

Journals today require written informed consent from patients before publishing case reports. Both authors and publishers are responsible for securing confidentiality. A guarantee for full confidentiality is not always possible. Despite all possible measures taken to preserve confidentiality, sometimes the patient will be recognized by someone. This information should be given to the patient. An adequately informed patient might not consent to publication. In 1995 in an Editorial in the British Journal of Psychiatry one commentator, Isaac Marks, feared that written consent would discourage case reports being written [ 59 ]. Fortunately, judged form the large number of reports being published today, it seems unlikely that the demand for consent has impeded their publication.

Other methodological limitations

Case reports and series are written after the relevant event, i.e. the observation. Thus, the reports are produced retrospectively. The medical record might not contain all relevant data. Recall bias might prevent us from getting the necessary information from the patient or other informants such as family members and health professionals.

It has also been held against case reporting that it is subjective. The observer’s subjectivity might bias the quality and interpretation of the observation (i.e. information bias).

Finally, the falsification criterion within science, which is tested by repeating an experiment, cannot be applied for case reports. We cannot design another identical and uncontrolled observation. However, unplanned similar “experiments” of nature can be repeated. Several such observations can constitute a case series that represents stronger indicative evidence than the single case report.

The major advantages of case reporting are the ability to make new observations, generate hypotheses, accumulate scientific data about rare disorders, do in-depth narrative studies, and serve as a major educational tool. The method is deficient mainly in being unable to deliver quantitative data. Nor can it prove cause-effect relationship or allow generalizations. Furthermore, there is a risk of overinterpretation and publication bias.

The traditional case report does not fit easily into the qualitative-quantitative dichotomy of research methods. It certainly shares some characteristics with qualitative research [ 16 ], especially with regard to the idiographic, narrative perspective – the patient’s “interior world” [ 60 ] – that sometimes is attended to. Apart from “The storied case report” mentioned in the Background-section, other innovative modifications of the traditional case report have been tried: the “evidence-based case report” [ 61 ], the “interactive case report” [ 62 ] and the “integrated narrative and evidence based case report” [ 63 ]. These modifications of the format have not made a lasting impact on the way case reports in general are written today.

The method of case reporting is briefly dealt with in some textbooks on epidemiology [ 17 , 18 ]. Journals that welcome case reports often put more emphasis on style and design than on content in their ‘instruction to authors’ section [ 64 ]. As a consequence, Sorinola and coworkers argue for more consensus and more consistent guidance on writing case reports [ 64 ]. We feel that a satisfactory amount of guidance concerning both style and content now exists [ 12 , 16 , 65 , 66 ]. The latest contribution, “The CARE guidelines”, is an ambitious endeavor to improve completeness and transparency of reports [ 66 ]. These guidelines have included the “Patient perspective” as an item, apparently a bit half-heartedly as this item is placed after the Discussion section, thus not allowing this perspective to influence the Discussion and/or Conclusion section. We assume this is symptomatic of medicine’s problem with integrating the biomedical model with “narrative-based medicine”.

In recent years the medical community has taken an increased interest in case reports [ 2 ], especially after the surge of online, exclusive case report journals started in 2007 with the Journal of Medical Case Reports (which was the first international, Pubmed-listed medical journal publishing only case reports) as the first of this new brand. The climate of skepticism has been replaced by enthusiasm and demand for more case reports. A registry for case reports, Cases Database, was founded in 2012 [ 67 ]. On the condition that it succeeds in becoming a large, international database it could serve as a register being useful for clinicians at work as well as for medical research on various clinical issues. Assuming Pamela P. Powell’s assertion that “[a]lmost all practicing physicians eventually will encounter a case worthy of being reported” [ 60 ] is valid, there should be no shortage of potential cases waiting to be reported and filed in various databases, preferably online and open access.

Limitations of this review

There are several limitations to this study. It is a weakness that we have not been able to review all the relevant literature. The number of publications in some way related to case reports and case report series is enormous, and although we have attempted to identify those publications relevant for our purpose (i.e. those that describe the merits and limitations of the case report genre), we might have missed some. It was difficult to find good search terms for our objective. Still, after repeated electronic searches supplemented with manual searches in reference lists, we had a corpus of literature where essentially no new merits or limitations emerged.

As we point out above, the ranking of merits and limitations represents our subjective opinion and we acknowledge that others might rank the importance of the items differently.

The perspective on merits and limitations of case reporting has been strictly medical. As a consequence we have not analyzed or discussed the various non-medical factors affecting the publication of case reports in different medical journals [ 2 ]. For instance, case reports are cited less often than other kinds of medical research articles [ 68 ]. Thus they can lower a journal’s impact factor, potentially making the journal less attractive. This might lead some high-impact journals to publish few or no case reports, while other journals have chosen to specialize in this genre.

Before deciding on producing a case report or case series based on a particular patient or patients at hand, the observant clinician has to determine if the case report method is the appropriate article type. This review could hopefully assist in that judgment and perhaps be a stimulus to the continuing debate in the medical community on the value of case reporting.

Competing interests

The authors declare that there are no competing interests.

Authors’ contributions

TN contributed to the conception, drafting, and revision of the article. RW contributed to the conception, drafting, and revision of the article. Both authors approved the final manuscript.

Acknowledgements

There was no specific funding for this study.

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Green Garage

Case Study Method – 18 Advantages and Disadvantages

The case study method uses investigatory research as a way to collect data about specific demographics. This approach can apply to individuals, businesses, groups, or events. Each participant receives an equal amount of participation, offering information for collection that can then find new insights into specific trends, ideas, of hypotheses.

Interviews and research observation are the two standard methods of data collection used when following the case study method.

Researchers initially developed the case study method to develop and support hypotheses in clinical medicine. The benefits found in these efforts led the approach to transition to other industries, allowing for the examination of results through proposed decisions, processes, or outcomes. Its unique approach to information makes it possible for others to glean specific points of wisdom that encourage growth.

Several case study method advantages and disadvantages can appear when researchers take this approach.

List of the Advantages of the Case Study Method

1. It requires an intensive study of a specific unit. Researchers must document verifiable data from direct observations when using the case study method. This work offers information about the input processes that go into the hypothesis under consideration. A casual approach to data-gathering work is not effective if a definitive outcome is desired. Each behavior, choice, or comment is a critical component that can verify or dispute the ideas being considered.

Intensive programs can require a significant amount of work for researchers, but it can also promote an improvement in the data collected. That means a hypothesis can receive immediate verification in some situations.

2. No sampling is required when following the case study method. This research method studies social units in their entire perspective instead of pulling individual data points out to analyze them. That means there is no sampling work required when using the case study method. The hypothesis under consideration receives support because it works to turn opinions into facts, verifying or denying the proposals that outside observers can use in the future.

Although researchers might pay attention to specific incidents or outcomes based on generalized behaviors or ideas, the study itself won’t sample those situations. It takes a look at the “bigger vision” instead.

3. This method offers a continuous analysis of the facts. The case study method will look at the facts continuously for the social group being studied by researchers. That means there aren’t interruptions in the process that could limit the validity of the data being collected through this work. This advantage reduces the need to use assumptions when drawing conclusions from the information, adding validity to the outcome of the study over time. That means the outcome becomes relevant to both sides of the equation as it can prove specific suppositions or invalidate a hypothesis under consideration.

This advantage can lead to inefficiencies because of the amount of data being studied by researchers. It is up to the individuals involved in the process to sort out what is useful and meaningful and what is not.

4. It is a useful approach to take when formulating a hypothesis. Researchers will use the case study method advantages to verify a hypothesis under consideration. It is not unusual for the collected data to lead people toward the formulation of new ideas after completing this work. This process encourages further study because it allows concepts to evolve as people do in social or physical environments. That means a complete data set can be gathered based on the skills of the researcher and the honesty of the individuals involved in the study itself.

Although this approach won’t develop a societal-level evaluation of a hypothesis, it can look at how specific groups will react in various circumstances. That information can lead to a better decision-making process in the future for everyone involved.

5. It provides an increase in knowledge. The case study method provides everyone with analytical power to increase knowledge. This advantage is possible because it uses a variety of methodologies to collect information while evaluating a hypothesis. Researchers prefer to use direct observation and interviews to complete their work, but it can also advantage through the use of questionnaires. Participants might need to fill out a journal or diary about their experiences that can be used to study behaviors or choices.

Some researchers incorporate memory tests and experimental tasks to determine how social groups will interact or respond in specific situations. All of this data then works to verify the possibilities that a hypothesis proposes.

6. The case study method allows for comparisons. The human experience is one that is built on individual observations from group situations. Specific demographics might think, act, or respond in particular ways to stimuli, but each person in that group will also contribute a small part to the whole. You could say that people are sponges that collect data from one another every day to create individual outcomes.

The case study method allows researchers to take the information from each demographic for comparison purposes. This information can then lead to proposals that support a hypothesis or lead to its disruption.

7. Data generalization is possible using the case study method. The case study method provides a foundation for data generalization, allowing researches to illustrate their statistical findings in meaningful ways. It puts the information into a usable format that almost anyone can use if they have the need to evaluate the hypothesis under consideration. This process makes it easier to discover unusual features, unique outcomes, or find conclusions that wouldn’t be available without this method. It does an excellent job of identifying specific concepts that relate to the proposed ideas that researchers were verifying through their work.

Generalization does not apply to a larger population group with the case study method. What researchers can do with this information is to suggest a predictable outcome when similar groups are placed in an equal situation.

8. It offers a comprehensive approach to research. Nothing gets ignored when using the case study method to collect information. Every person, place, or thing involved in the research receives the complete attention of those seeking data. The interactions are equal, which means the data is comprehensive and directly reflective of the group being observed.

This advantage means that there are fewer outliers to worry about when researching an idea, leading to a higher level of accuracy in the conclusions drawn by the researchers.

9. The identification of deviant cases is possible with this method. The case study method of research makes it easier to identify deviant cases that occur in each social group. These incidents are units (people) that behave in ways that go against the hypothesis under consideration. Instead of ignoring them like other options do when collecting data, this approach incorporates the “rogue” behavior to understand why it exists in the first place.

This advantage makes the eventual data and conclusions gathered more reliable because it incorporates the “alternative opinion” that exists. One might say that the case study method places as much emphasis on the yin as it does the yang so that the whole picture becomes available to the outside observer.

10. Questionnaire development is possible with the case study method. Interviews and direct observation are the preferred methods of implementing the case study method because it is cheap and done remotely. The information gathered by researchers can also lead to farming questionnaires that can farm additional data from those being studied. When all of the data resources come together, it is easier to formulate a conclusion that accurately reflects the demographics.

Some people in the case study method may try to manipulate the results for personal reasons, but this advantage makes it possible to identify this information readily. Then researchers can look into the thinking that goes into the dishonest behaviors observed.

List of the Disadvantages of the Case Study Method

1. The case study method offers limited representation. The usefulness of the case study method is limited to a specific group of representatives. Researchers are looking at a specific demographic when using this option. That means it is impossible to create any generalization that applies to the rest of society, an organization, or a larger community with this work. The findings can only apply to other groups caught in similar circumstances with the same experiences.

It is useful to use the case study method when attempting to discover the specific reasons why some people behave in a specific way. If researchers need something more generalized, then a different method must be used.

2. No classification is possible with the case study method. This disadvantage is also due to the sample size in the case study method. No classification is possible because researchers are studying such a small unit, group, or demographic. It can be an inefficient process since the skills of the researcher help to determine the quality of the data being collected to verify the validity of a hypothesis. Some participants may be unwilling to answer or participate, while others might try to guess at the outcome to support it.

Researchers can get trapped in a place where they explore more tangents than the actual hypothesis with this option. Classification can occur within the units being studied, but this data cannot extrapolate to other demographics.

3. The case study method still offers the possibility of errors. Each person has an unconscious bias that influences their behaviors and choices. The case study method can find outliers that oppose a hypothesis fairly easily thanks to its emphasis on finding facts, but it is up to the researchers to determine what information qualifies for this designation. If the results from the case study method are surprising or go against the opinion of participating individuals, then there is still the possibility that the information will not be 100% accurate.

Researchers must have controls in place that dictate how data gathering work occurs. Without this limitation in place, the results of the study cannot be guaranteed because of the presence of bias.

4. It is a subjective method to use for research. Although the purpose of the case study method of research is to gather facts, the foundation of what gets gathered is still based on opinion. It uses the subjective method instead of the objective one when evaluating data, which means there can be another layer of errors in the information to consider.

Imagine that a researcher interprets someone’s response as “angry” when performing direct observation, but the individual was feeling “shame” because of a decision they made. The difference between those two emotions is profound, and it could lead to information disruptions that could be problematic to the eventual work of hypothesis verification.

5. The processes required by the case study method are not useful for everyone. The case study method uses a person’s memories, explanations, and records from photographs and diaries to identify interactions on influences on psychological processes. People are given the chance to describe what happens in the world around them as a way for researchers to gather data. This process can be an advantage in some industries, but it can also be a worthless approach to some groups.

If the social group under study doesn’t have the information, knowledge, or wisdom to provide meaningful data, then the processes are no longer useful. Researchers must weigh the advantages and disadvantages of the case study method before starting their work to determine if the possibility of value exists. If it does not, then a different method may be necessary.

6. It is possible for bias to form in the data. It’s not just an unconscious bias that can form in the data when using the case study method. The narrow study approach can lead to outright discrimination in the data. Researchers can decide to ignore outliers or any other information that doesn’t support their hypothesis when using this method. The subjective nature of this approach makes it difficult to challenge the conclusions that get drawn from this work, and the limited pool of units (people) means that duplication is almost impossible.

That means unethical people can manipulate the results gathered by the case study method to their own advantage without much accountability in the process.

7. This method has no fixed limits to it. This method of research is highly dependent on situational circumstances rather than overarching societal or corporate truths. That means the researcher has no fixed limits of investigation. Even when controls are in place to limit bias or recommend specific activities, the case study method has enough flexibility built into its structures to allow for additional exploration. That means it is possible for this work to continue indefinitely, gathering data that never becomes useful.

Scientists began to track the health of 268 sophomores at Harvard in 1938. The Great Depression was in its final years at that point, so the study hoped to reveal clues that lead to happy and healthy lives. It continues still today, now incorporating the children of the original participants, providing over 80 years of information to sort through for conclusions.

8. The case study method is time-consuming and expensive. The case study method can be affordable in some situations, but the lack of fixed limits and the ability to pursue tangents can make it a costly process in most situations. It takes time to gather the data in the first place, and then researchers must interpret the information received so that they can use it for hypothesis evaluation. There are other methods of data collection that can be less expensive and provide results faster.

That doesn’t mean the case study method is useless. The individualization of results can help the decision-making process advance in a variety of industries successfully. It just takes more time to reach the appropriate conclusion, and that might be a resource that isn’t available.

The advantages and disadvantages of the case study method suggest that the helpfulness of this research option depends on the specific hypothesis under consideration. When researchers have the correct skills and mindset to gather data accurately, then it can lead to supportive data that can verify ideas with tremendous accuracy.

This research method can also be used unethically to produce specific results that can be difficult to challenge.

When bias enters into the structure of the case study method, the processes become inefficient, inaccurate, and harmful to the hypothesis. That’s why great care must be taken when designing a study with this approach. It might be a labor-intensive way to develop conclusions, but the outcomes are often worth the investments needed.

  • Open access
  • Published: 14 February 2024

Implementing a tobacco-free workplace program at a substance use treatment center: a case study

  • Anastasia Rogova 1 , 2 ,
  • Isabel Martinez Leal 1 , 2 ,
  • Maggie Britton 1 , 2 ,
  • Tzuan A. Chen 2 ,
  • Lisa M. Lowenstein 1 ,
  • Bryce Kyburz 3 ,
  • Kathleen Casey 3 ,
  • Kim Skeene 3 ,
  • Teresa Williams 3 &
  • Lorraine R. Reitzel 1 , 2  

BMC Health Services Research volume  24 , Article number:  201 ( 2024 ) Cite this article

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Metrics details

People with substance use disorders smoke cigarettes at much higher rates than the general population in the United States and are disproportionately affected by tobacco-related diseases. Many substance use treatment centers do not provide evidence-based tobacco cessation treatment or maintain comprehensive tobacco-free workplace policies. The goal of the current work is to identify barriers and facilitators to a successful and sustainable implementation of a tobacco-free workplace program, which includes a comprehensive tobacco-free policy and evidence-based cessation treatment services, in a substance use treatment center.

This study is based on an ethnographic approach and uses a qualitative case study design. Data were collected via interviews with staff ( n  = 6) and clients ( n  = 16) at the substance use treatment center and site visits ( n  = 8). Data were analyzed using thematic analysis guided by the extended Normalization Process Theory designed to inform the implementation of innovations in healthcare practice.

Staff at the substance use treatment center supported the implementation of the program and shared a good understanding of the purpose of the intervention and its potential benefits. However, the study identified significant challenges faced by the center during implementation, including widespread tobacco use among clients, contributing to attitudes among staff that tobacco cessation was a low-priority problem due to a perceived lack of interest in quitting and inability to quit among their clients. We identified several factors that contributed to changing this attitude, including provision of tobacco training to staff, active leadership support, low number of staff members who smoked, and access to material resources, including nicotine replacement products. The implementation and active enforcement of a comprehensive tobacco-free workplace program contributed to a gradual change in attitudes and improved the provision of evidence-based tobacco cessation care at the substance use treatment center.

Conclusions

Substance use treatment centers can integrate tobacco cessation practices in their daily operations, despite multiple challenges they face due to the complex behavioral health and socioeconomic needs of their clients. With proper support, substance use treatment centers can provide much needed tobacco cessation care to their clients who are disproportionately affected by tobacco-related health conditions and systemic health inequities.

Peer Review reports

According to data from the Centers for Disease Control and Prevention, 12.5% of the US adults aged ≥ 18 years reported current use of cigarettes in 2020 [ 1 ]. While this figure represents a substantial decrease from over 40% of the adult population smoking in the 1960s, tobacco use is still the leading preventable cause of death in the US [ 2 ] with annual deaths directly attributable to tobacco use estimated to be at least 480,000 [ 3 ]. However, these devastating effects of tobacco use do not equally impact all population groups. The proportion of people who use tobacco products is dramatically elevated among the often intersecting groups of people experiencing socioeconomic disadvantage, who are medically underserved, and/or people living with comorbid mental health and non-nicotine substance use disorders [ 4 ]. These health disparity populations have disproportionately high smoking rates; for example, over 65% of adults with substance use disorders (and up to 90% according to some sources) are active smokers [ 5 , 6 , 7 ]. As a result, adults with substance use disorders are disproportionately affected by tobacco-related disease compared to the general population [ 7 , 8 ].

There is an overwhelming body of evidence that adults with substance use disorders are interested in and capable of quitting with appropriate support [ 9 , 10 ]. Current clinical guidelines recommend that all clients be provided with evidence-based cessation care, which includes behavioral interventions such as tobacco use assessment, brief cessation advice, individual or group counseling, and pharmacotherapy such as nicotine replacement therapy or non-nicotine medication (bupropion and varenicline) [ 11 , 12 ]. Moreover, the adoption of system-level policies, including comprehensive tobacco-free workplace policies, which prohibit the use of any form of tobacco inside buildings and on the grounds of behavioral health treatment centers, are also shown to be effective in improving quit rates [ 13 ]. Despite their proven effectiveness, however, evidence-based practices and policies remain underutilized, and tobacco use treatment is given a low priority in substance use treatment centers. For example, according to a 2016 nationwide study, only 64.0% of substance use treatment centers reported screening clients for tobacco use, 47.4% offered tobacco cessation counseling, 26.2% offered nicotine replacement therapy, and 34.5% had tobacco-free policies [ 4 ]. Furthermore, although not reported, it is possible that some proportion of these centers had tobacco-free workplace policies that may have been non-comprehensive in product coverage (e.g., not extending to e-cigarettes/vaping) or workplace area coverage (e.g., allowing smoking areas), which are known to be less effective than their comprehensive policy counterparts [ 14 , 15 , 16 ]. Consequently, there is a missed opportunity for substance use treatment centers to comply with clinical care guidelines [ 11 , 12 ] and to intervene to reduce tobacco use and related health disparities among their clients.

There are several previously identified barriers to providing tobacco cessation treatment at substance use treatment centers, including limited training, limited resources, time restraints, and cultural norms [ 9 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 ]. Additionally, available treatment opportunities that take little time or training, such as referral to a state tobacco cessation quitline, are often unknown by staff at substance use treatment centers [ 23 ]. Our use of “staff” here refers to both clinical employees, those providing direct services to clients, and nonclinical employees. Moreover, despite evidence to the contrary, staff may believe that treating tobacco use and substance use disorders simultaneously will jeopardize substance use treatment and recovery [ 25 ]. Together, these barriers and others may contribute to the known translational lag whereby any type of evidence-based practice takes a long time (e.g., up to 17 years) to be implemented into practice to reach the intended population and ensure the improvement of clients’ health [ 26 , 27 ]. While this translational lag is detrimental for all clients and communities, the negative consequences of these delays are even worse for populations who experience health disparities, such as individuals living with substance use disorders.

Together, the previously described evidence-based tobacco cessation practices and policies, such as tobacco use assessment, brief cessation advice, individual or group counseling, pharmacotherapy, tobacco-free policies, form the core components of a comprehensive tobacco-free workplace program [ 28 , 29 ]. Academic-community partnerships can assist substance use treatment centers in implementing comprehensive tobacco-free programs and reducing the translational gap that affects health disparities among their clients [ 29 , 30 , 31 , 32 ]. This study describes the implementation of a tobacco-free workplace program at a substance use treatment center in Houston, Texas, which included a comprehensive tobacco-free workplace policy implementation, education and specialized training support, and the provision of resources to support tobacco cessation care. The goal of the study was to identify barriers and facilitators to successful integration of tobacco-free workplace policy and cessation practices into a substance use treatment center. The current study was based on an ethnographic approach and uses a case study design, which is considered an efficient way to present qualitative ethnographic findings [ 33 , 34 ]. Case study design has been found to be particularly useful in implementation research, as it allows for an in-depth analysis of complex interventions in combination with a participatory approach in a real-life context [ 35 , 36 , 37 , 38 ]. Prior research has shown the importance of studying interventions in close connection with the context of dynamic environments that can have an extensive influence on the implementation process [ 37 ]. In the case of complex interventions, such as comprehensive tobacco-free programs, this is particularly relevant, given their dependence on contextual elements for their effectiveness [ 39 ]. Intervention and context cannot be easily separated in this situation, and there is an urgent need to better understand the relationship between these two core elements of implementation to ensure that research evidence can meaningfully impact policy and healthcare organizational culture [ 38 ]. By applying a case study design, this work contributes to the existing research on implementing tobacco-free workplace programs at substance use treatment centers [ 32 ] by providing an in-depth qualitative description of program implementation in the setting of a nonprofit outpatient substance use treatment center serving diverse clients, most of whom belong to socioeconomically disadvantaged and medically underserved groups. Additionally, this study represents both staff, clinical and nonclinical alike, including leadership, and clients’ perspectives on this program, the latter of which were not included in prior work [ 32 ]. The findings presented in this study can be used by other substance use treatment centers that serve similar populations and seek to implement a comprehensive tobacco-free program in the most sustainable way.

Case description

This initiative was undertaken as a part of the Taking Texas Tobacco Free (TTTF) program, which is a multicomponent, evidence-based comprehensive tobacco-free workplace program that was designed to address tobacco dependence within healthcare treatment settings, including substance use treatment settings [ 30 , 32 ]. TTTF includes (1) tobacco-free policy development and implementation and/or refreshment for comprehensiveness or quality assurance; (2) education and specialized training for staff on tobacco use and cessation, screening practices, and treatment provision; and (3) resource provision, including free nicotine replacement therapy, signage, and passive dissemination materials. Throughout the implementation process, TTTF team members, comprising an academic-community collaboration, provide ongoing technical assistance and support (for more information on the TTTF program, see previously published studies [ 28 , 30 , 31 , 32 , 40 , 41 , 42 , 43 , 44 ]).

To ensure the privacy of the research participants, we refer to the field research location as the “Center” herein. The Center is located in a Houston, Texas, zip code that is among the Centers for Medicare and Medicaid Services-designated low-income and health professional shortage areas. It is a small Center that employs 7 staff (including clinical and nonclinical staff) and serves approximately 1,000 unique clients each year. One of these staff members was designated the TTTF program champion to serve as the main point of contact for all aspects of the tobacco-free workplace program implementation process. This staff member was not financially compensated for accepting this role, but they received additional week-long full-time training to become a Tobacco Treatment Specialist. The financial compensation for this role was not a part of the current program, and the expectation was that the Center’s leadership incorporates this role in the regular scope of work for their staff to ensure the sustainability of the program.

The Center serves a diverse group of clients, with 90% of their clients having histories of incarceration or another form of engagement in the criminal justice system, many of whom come from low socioeconomic backgrounds and/or have been diagnosed with comorbid behavioral health (i.e., mental health or substance use disorders) and physical health conditions. The Center estimated that approximately 80% of their clients smoked conventional cigarettes and 30% used other tobacco products, including e-cigarettes (there is an overlap, as some clients might be dual or multiple product users). Most clients participate in the Center’s substance use treatment program for 90 days. The Center introduced a tobacco-free policy in 2000, which prohibited the use of tobacco products of any type both indoors and outdoors; however, they had not provided any tobacco cessation services to their clients beyond the requirement not to use tobacco on their property prior to their enrollment in the TTTF program. The tobacco-free workplace program implementation components and the Center’s timeline are presented in Table  1 .

This project was approved by the Internal Review Board of the University of Houston and the Quality Improvement Assessment Board at the University of Texas MD Anderson Cancer Center. Oral informed consent was received from all participants prior to participation in qualitative study procedures. The aims of the project and interviews were discussed with participants who were given an opportunity to ask any questions about the interview process and the nature of the study. Additionally, all participants gave oral permission to audio-record the interview; they were given the option to remain anonymous and not use their names or other identifying information in any written summary of the collected data. Participants were informed that their participation was voluntary, that they could decline to answer any questions and stop participating in the interview at any time.

Data collection instruments

Data for this qualitative case study were collected via group and individual interviews with staff and clients at the Center, as well as site visits and participant observations. Data include interview transcripts and fieldnotes. We conducted one pre- and one post-implementation focus group with clients ( n  = 16), two pre-implementation semi-structured interviews with staff ( n  = 2), two individual interviews with staff during the implementation process ( n  = 2), and one post-implementation group interview with staff ( n  = 2). Interview guides were used for interviews and focus groups, which lasted 60–90 min (see Additional file 1 : Interview Guides). Pre-implementation interview questions for staff focused on any Center-specific needs for the program rollout, populations they served, their personal experience with tobacco use, their knowledge of and attitudes toward tobacco use and cessation among their clients, and implementation barriers and facilitators they anticipated. Staff post-implementation interview questions addressed experiences with implementing the program, interventions that were successful and less successful, changes in their practices addressing tobacco dependence, and any challenges they experienced. Focus groups with clients addressed their experiences with tobacco use and cessation, their knowledge of the tobacco-free program at the Center, their attitudes toward and interest in this program, and their experiences with and results of receiving any tobacco cessation support at the Center. In addition, we undertook several site visits ( n  = 8), when A.R. (the 1st author) and I.M.L. (the 2nd author), both cultural anthropologists who worked as qualitative research specialists on the project, conducted observations and made fieldnotes using a free-form approach. The site visits (1 to 2 h long) incorporated both direct and indirect observations. The collected observational data were not subjected to standalone analysis but served to inform the interview questions, gain a more nuanced understanding of how the Center was implementing various parts of the program, and provide further details about the study’s context and setting.

Two authors (A.R. and I.M.L.) moderated the focus groups and completed the interviews. Audio-recordings of focus groups and interviews were transcribed verbatim by a professional transcription service and analyzed using thematic analysis to initially inductively code and identify themes within the dataset. Data analysis was conducted iteratively using constant comparison, and themes were drawn directly from the data. The process of constant comparison provided analytic rigor and ensured accurate accounting of all the data, identifying appropriate selection of categories and themes [ 45 ]. At the next stage of the analysis, the concepts of the extended Normalization Process Theory (discussed in detail below) were applied to these themes to more effectively analyze and evaluate the implementation process.

Approach: extended normalization process theory

When exploring the implementation process, the application of a theoretical framework enhances understanding of the process and highlights barriers to and facilitators of the implementation. Implementation scientists have developed several major frameworks and theories to describe and evaluate the implementation process [ 26 , 46 , 47 , 48 , 49 ]. For this analysis, we followed the extended Normalization Process Theory (eNPT) [ 46 , 47 ], which is a sociological theory that informs the implementation of innovations in healthcare practice, focusing on bridging the translational gap between evidence-based practices and their implementation [ 50 ]. This theory approaches the implementation process as a series of interactions between people’s actions (their ‘agency’) and the context within which the intervention is implemented [ 46 , 50 ].

The eNPT identifies and explains key elements that contribute to or impede normalization of complex interventions within a social system, including four core constructs, two of which are focused on context (potential and capacity) and two of which address agency (capability and contribution, see Fig.  1 for details) [ 46 ]. The identification of these major constructs helps researchers guide and understand the implementation process and provide a systematic description [ 46 ]. The eNPT has been effectively utilized at all stages of research projects, both during the planning stages and the post-implementation analysis, as in this case, where this theory helps to frame emergent themes and consider their implications for further research and implementation practice [ 51 ]. The application of the eNPT as a theoretical framework enhances stakeholders’ ability to improve design for more successful implementation in the future and to enhance the application and normalization of interventions within organizations by community adopters and researchers [ 50 ].

figure 1

Concepts and Constructs of the Extended Normalization Process Theory (eNPT, adapted from May 2013 [ 46 ])

The two constructs of the eNPT that characterize the context of implementation are potential and capacity . Participants’ potential is expressed through individual intentions and collective commitment to participate in the intervention [ 52 ]. Capacity, which is another crucial element of context, is defined as the availability of material and cognitive resources, as well as existing social norms and social roles. Attention to these contextual elements ensures a better understanding of the implementation process and its outcomes, as they shape agents’ ability to effectively cooperate with each other to bring about change [ 46 ]. Capability and contribution are two constructs that characterize the agency of the participants involved in the implementation process. Capability refers to how workable the complex intervention is, as well as to the possibility of integrating it in everyday practice. Contribution refers to the actions of the agents who are involved in the implementation process [ 46 ]. This construct focuses on how the agents, including individuals and groups, enact potential and capacity by undertaking actions to make things happen and ensure that new processes and practices become “the way we do things here.” [ 46 ] Each of these constructs is further divided into categories used to understand and evaluate the implementation process (see Table  2 ).

After conducting the initial coding, the emerged themes were systematized and organized in relation to the major concepts and constructs of the eNPT theory. Table  2 shows the identified themes from the case study data and how they are related to the eNPT constructs and dimensions. In the section below, we present our results in relation to these theoretical constructs.

Context: potential

The Center’s CEO initiated the Center’s participation in the tobacco-free workplace program and continuously expressed their personal support and commitment to implement and maintain the program. The Center’s staff were also enthusiastic about the tobacco-free program and expressed commitment to its implementation. Most participants welcomed this forthcoming change and expansion of tobacco cessation services and agreed that it was necessary and beneficial for the Center’s working environment and for their clients’ needs and well-being. This collective commitment was supported and reinforced during the preparation phase of the implementation process, when all staff received training provided by the TTTF program:

I think one of the biggest things in preparation for implementing the program was when we had our staff retreat. Bryce [B.K.] actually flew in, and he participated in the retreat and helped train our staff prior to us actually implementing the program. So, he did a workshop with us, and that gave us an opportunity to ask him questions […] So, everybody was ready. Everybody was pumped and ready because we knew what to do. We knew what the problem was about . (Staff post-implementation interview)

The number of staff who used tobacco products themselves was very low at the Center. The only staff member who said that she smoked cigarettes participated in the program herself and, at the time of the interview, reported a successful quit attempt and being tobacco-free. In the pre- and post-implementation interviews, staff members shared their negative attitudes towards smoking related to health concerns and their readiness to facilitate tobacco cessation efforts at their center:

I grew up as an athlete, and so smoking is something that was not encouraged in my field. I didn’t partake when I was around people that did such as my mom who later on in life actually stopped smoking. (Staff pre-implementation interview)

Context: capacity

One of the major barriers to the implementation of the tobacco-free workplace program at the Center was associated with the widespread practice of tobacco use among the Center’s clients and within their immediate environment. There are two closely interrelated aspects of this problem: clients’ lived experiences with tobacco being an innate part of their everyday life and staff attitudes and expectations of their clients’ interest in and ability to quit tobacco, both of which are discussed below.

Most of the Center’s clients grew up in an environment where smoking had been normalized for years. They shared their experiences of having parents, older siblings, grandparents, neighbors, and friends who had smoked on a regular basis for most of their lives:

Kind of like I think started smoking from– because I would light cigarettes for my daddy or whatever, so he was smoking. (Client focus group, pre-implementation) Me growing up around my grandfather and stuff, he smokes. […] Mine started just with social. Got out of high school, my own place. All my friends, they bring over rum […] and cigarettes and everything. (Client focus group, pre-implementation)

Some of the clients reported a lack of interest in quitting or their perceived inability to quit:

So officially, once I turned 18 or the age to buy a pack of cigarettes, I bought a pack of cigarettes and since then it’s been– I never had the urge to quit, never tried to quit. Just always adapted to it. (Client focus group, pre-implementation) They [clients] point-blank told me that they feel that if they stop smoking, that they’ll latch back onto something else that is not as legal. (Staff post-implementation interview)

However, these experiences do not mean that none of the clients problematized tobacco use practices and were interested in quitting tobacco. Some clients reported varied attitudes toward quitting. For example, one of the clients who participated in a focus group shared her motivation to quit smoking:

I didn’t want him [her son] to - when he’s picking up pieces of paper towel and putting it to his mouth like a cigarette, it bothers me. I don’t want him to […] also, my baby’s father wasn’t a smoker. It’s a shame thing. I was ashamed. (Client focus group, post-implementation)

In the interviews with the Center’s staff members, they generally revealed that tobacco cessation treatment was a low-priority problem, related partly to a perceived lack of interest in quitting among their clients. Staff shared expectations that clients must be proactive in expressing their interest in quitting and seeking support. Staff at the Center repeatedly expressed the idea that if their clients were interested in quitting tobacco use, they had to ask for help to proactively demonstrate that they were interested in and committed to quitting. As the Center’s program champion said during a conversation with one of the researchers:

I see some of the guys who signed up for the program, but they go out and smoke with other guys outside. I walk by, I see him, but I am not going to say anything to him. It must be his decision, he is an adult, and he must take responsibility. I cannot do it for them. (fieldnotes, conversation with program champion, May 2022)

In a similar way, one of the clinicians at the Center shared during the interview:

I guess if they ask me, if they would like the patches, if they want to participate, I guess that’s when I’ll bring it up […] I think it’s ultimately really up to the client if they really want to make that change. That’s what I love. Some of the clients really want to commit strongly about making the change to stop smoking. (Staff post-implementation interview)

Tobacco education trainings were offered to all Center staff at the beginning of implementation, which were designed to mitigate these barriers (e.g., by providing information about how to proactively address tobacco use with clients) and enhance the implementation capacity by ensuring that they had the knowledge and skills required to implement the program. One of the staff evaluated this training as being very important to help them to be able to deliver tobacco cessation services:

Teaching us about pharmacology, motivational interviewing […]. That thing that was really helpful for us to learn and to be able to explain it to the clients if questions were to come up. (Staff post-implementation interview)

The capacity to implement the program also depends on the availability of material resources. One of most important and expensive resources, nicotine replacement therapy products, were provided to the Center free of charge as a part of the active implementation process. The availability of the nicotine replacement products was widely discussed by the Center’s staff and evaluated as one of the central elements of the program implementation at the Center:

We actually not only have “No Smoking” sign posted up, but we’re able to say, “Here, we have products, nicotine replacement products, that we could give you to help you stop smoking.” (Staff post-implementation interview).

Agency: capability

The Center’s capability to implement the program was evaluated by assessing the implementation’s workability and integration with the everyday workflow and preexisting work processes, following the eNPT framework concepts.

The Center already had a standard tobacco-free policy in place prior to the involvement in the project, and while the TTTF presented them with a much more comprehensive program, the initial buy-in was facilitated by the level of familiarity with the intervention by both staff and clients:

We weren’t really implementing anything. It [tobacco-free policy] was there. It was understood, but this gave us a fuller picture of a way to implement, how to introduce it, a guideline to follow . (Staff post-implementation interview)

One element of the program that contributed to the increased workability was the introduction of the program champion role into the program:

I think the best thing is to have a point person. Because we have a point person, that point person stays on top of all the policy procedures, regulation, inventory, whatever we have going on. (Staff pre-implementation interview)

The Center’s CEO and staff also emphasized that the support they received from the TTTF program increased the workability of the intervention. In addition to regular practical and informational support, they were able to contact program staff with any ongoing questions and requests for assistance. They shared that the focus groups that were conducted with clients also contributed to the program implementation success by increasing clients’ interest in the program:

You guys come in here and working with those guys, because you legitimize the process as a third-party source, and the guys come in to see and you do the surveys [focus group] with them. I think that’s very helpful. (Staff post-implementation interview)

New aspects of the program were reported to be well integrated into the everyday workflow, and while their implementation needed certain changes in practices and attitudes among staff and clients, these changes were not particularly disruptive or time consuming, according to staff who participated in post-implementation interviews:

It’s good to have it embedded into the program that you already have, immerse into what you have going and make it a part of the process, not as something separate, but just this is our program. This is included in the program. I think it’s welcomed a little bit more. (Staff post-implementation interview)

Agency: contribution

Most staff members shared a clear understanding of the purpose of the intervention and its potential benefits. They evaluated the program as important, saw the value of this program for their clients, and shared positive experiences of being involved in its implementation:

I love the program because it gives the clients an opportunity to work on solving that problem of addiction in a positive manner. (Staff post-implementation interview) I felt like it was a great idea to come into play here at the facility. (Staff post-implementation interview)

All staff were well aware of the program being implemented and what new practices and routines were introduced at the Center. They reported very little disagreement about a shared understanding of the need to implement this program:

Everybody was clear on what the mission was, how we would present it, and the way it would be implemented . (Staff post-implementation interview)

One example of effective engagement with the program was one of the staff members quitting smoking herself:

When I came in, he was doing a class and I sat in on it and I’m like, “Hey, I want to do this.” […] we talked about it and I signed up to do it. It’s worked very good for me. (Staff post-implementation interview)

In the interviews, staff at the Center discussed how their engagement in the program and enacting it in their everyday practices contributed to their deeper sense of belonging:

I have the feeling like you can’t disrespect the facility [ by smoking ]. This is our facility and we need to respect her. (Staff post-implementation interview)

Staff members shared a commitment to serving their clients and supporting each other, which was further reinforced by their increased capacity to provide tobacco cessation support to their clients:

That sign right there says we are community, and that’s what we promote, that we are a community center, and this community center has many different programs in it that can provide assistance and this is one of the additional programs that we have that can provide assistance. (Staff post-implementation interview)

Various program components were implemented with different degrees of commitment. The tobacco-free policy was the component that staff reported to be implemented most consistently. The tobacco-free policy has been routinely maintained and reinforced by both the Center’s staff and clients themselves:

They are not allowed to smoke within the facility area. So, that’s worked pretty good. (Staff post-implementation interview) We were always like, “You can’t smoke in here. You got to walk outside.” I think that they just pretty much are just like, “Okay, we got to do the right thing.” […] So yes, they respect it, I think . (Staff post-implementation interview)

However, as A.R. and I.M.L. observed when they visited the Center, clients were often smoking outside. While they were not violating the policy as they were technically outside the property and were smoking while on a public road, they remained physically close to the building, and whoever was leaving or entering the property had to go past a group of clients smoking to enter through the only door to the Center. The Center’s leadership has not found a solution to this problem, as they said they did not have control over the territory and could not prohibit tobacco use beyond their property. This location-specific issue led to a situation in which the tobacco-free policy was technically enforced; however, clients were still able to smoke in the vicinity of the Center, visitors were exposed to secondhand smoke, and this practice was not challenged by leadership or staff, either pre-implementation or after.

Tobacco screenings were reported to be implemented on a regular basis, although there were some discrepancies in the participants’ accounts of screening practices and their regularity. All clients were reportedly screened for all forms of tobacco use during intake, but the follow-up screenings of those clients who reported using tobacco were less consistent. There seemed to be a lack of clear understanding and agreement among staff who was responsible for these screenings, which resulted in a lack of consistency and depended on a specific staff member’s practice rather than established and clearly understood guidelines:

Each time we do an intake on a form, there is an assessment that asks the client if they do smoke, and if they do smoke, do they smoke cigarettes, or do they smoke e-cigarettes? We do offer the NRT [nicotine replacement therapy, and if they want to participate, they would need to say yes or no. Let the counsellor know. […] The individual counsellors, after 30 days in their sessions, ask them again. (Staff post-implementation interview)

However, in individual interviews with staff, at least one of them said that they did not conduct any follow-up screenings unless their clients brought this up and asked about the tobacco cessation program themselves.

As one of the central elements of the program implementation, the program champion provided regular information sessions to inform their clients on the Center’s participation in the program and available support and resources for clients who were interested in quitting tobacco. All clients were expected to attend at least one of these sessions, as these presentations were performed during their mandatory group counseling sessions. Clients were made aware of the resources and support available to them at the Center if they decided to make a quit attempt, as well as given a brief educational presentation on the harms of smoking and the benefits of quitting. These presentations were seen as an effective tool to get clients interested in the program, provide them an opportunity to ask for more information, and engage in conversations about quitting:

People have changed their minds, actually. They initially said no, but then once they heard [the program champion] and people talk about it, they come back and say, well, yes, they would like to. There’s been a couple of guys that have done it, that I know personally, that have done that. (Staff post-implementation interview)

The actual engagement of clients and motivating them to make a quit attempt was the most challenging part of the implementation process for the Center. The overall number of participants who made a quit attempt was 17 clients and two staff members by the end of the implementation period. While the reach of the program is larger than immediate client participation in cessation treatment, there were also some clients’ accounts of inconsistency in support they received during their time at the Center regarding their tobacco use:

Nobody has ever asked me anything [about tobacco use], except you. (Client focus group, post-implementation)

While staff supported the implementation of the program from the beginning, there were some concerns about how well this program might be accepted by their clients. In the post-implementation interview, a counselor shared an observation that their clients were more interested in quitting than they anticipated:

I guess I’m just surprised that I feel like I’m getting some yes’s now instead of a whole bunch of no’s. So, I think that’s actually a good thing because I feel like now that the program has been implemented here, that we’re getting quite a few yes’s. So, that’s definitely something to feel good about, that makes me feel good. (Staff post-implementation interview)

While we observed a variation in the degree to which tobacco cessation intervention services were provided in practice, there was a shared understanding that some of the services needed to be improved:

To be honest, it’s a question [tobacco use and interest in quitting] I feel like I need to ask them more. I haven’t been asking them about it, but I feel like I do need to ask them . […]So, that’s something I could work on. (Staff post-implementation interview)

In the quote above, the counsellor acknowledges that they should ask their clients about their smoking habits and interest in quitting more proactively, which is a positive example of reflexive monitoring of their own actions and practices and could ultimately lead to better outcomes of the intervention.

Staff also demonstrated their involvement by critically evaluating the program delivery and expressing suggestions for improvement:

[We say] “We’re going to have smoking cessation group today and this is going to be the only one for the month.” Well, why can’t we bring it up every meeting? Look, we have three meetings a week, let’s bring it up every time. […] I think there should be a smoking class […] for the whole group at least once a month. (Staff post-implementation interview)

Staff reflected on how this program changed their Center, and they reported a positive change, creating an opportunity to provide more meaningful and involved support and services to their clients:

It’s positively changed or impacted our facility because it gives us some legitimacy behind not only just having a no smoking sign just posted like every public place you see, but actually giving some type of support, nicotine replacement therapy. […] (Staff post-implementation interview).

This case study discusses the implementation of a tobacco-free workplace program at a substance use treatment center serving a diverse group of clients, including many from low socioeconomic backgrounds. This analysis and consideration of the interplay between context and emergent agency, facilitated by the application of the eNPT framework, contribute to the existing knowledge on implementing similar programs in substance use treatment settings that serve marginalized and medically underserved populations facing socioeconomic and health challenges. The findings from this study offer insights that can guide other substance use treatment centers with similar populations in implementing sustainable tobacco-free programs effectively.

A key barrier associated with the context of the implementation, as defined by the eNPT framework, was the widespread tobacco use among clients and within their immediate environment. Prior research has indicated that individuals with substance use disorders are often interested in quitting smoking [ 16 ], but they tend to have lower success rates [ 53 , 54 ]. These contextual barriers to achieving success in tobacco cessation efforts among this population require an exceptionally high level of commitment from the staff working at substance use treatment centers to provide continuous, robust support to their clients [ 55 , 56 ]. As our findings suggest, it is essential to acknowledge and consider the difficulties faced by these individuals when they are trying to quit smoking. While these challenges should not deter clinicians from motivating their clients to quit smoking, it is crucial that they are prepared to approach the situation with sensitivity and awareness of the contextual factors and lived experiences of the clients, which is also emphasized in the principles of trauma-informed care.

Other contextual categories, defined by the eNPT, which we addressed in our study to evaluate the Center’s potential to implement the program, include individual intentions and collective commitment shared by staff and leadership. Most of the staff expressed a strong commitment to participate in the program and provide cessation services to the clients. However, we also encountered attitudes indicating that staff, including clinicians, were doubtful about their clients’ interest in quitting and ability to do so. Given their expertise and supportive roles as addiction treatment specialists, clinicians’ attitudes can greatly affect those of their clients; moreover, clinicians’ beliefs and attitudes are often cited as one of the major barriers to effectively implementing tobacco-free programs within substance use treatment settings [ 4 , 22 , 25 , 57 ]. Training given as a part of the program implementation provided staff with information on evidence-based tobacco cessation practices and addressed some of these attitudes to better prepare staff to provide cessation care to their clients. Such training programs are particularly important for successful implementation and can be further enhanced by placing a stronger emphasis on motivational interviewing techniques, providing practitioners with a better understanding of the nature of ambivalence toward behavior change and the diverse factors influencing clients’ readiness to quit tobacco use.

The capacity to successfully implement and maintain the tobacco-free workplace program is also dependent on access to material resources and, specifically, nicotine replacement therapy products. While two shipments of nicotine replacement products were provided free of charge by the TTTF program, ensuring a continuous supply of these products is anticipated to be challenging for the Center. While individual clients can access free nicotine replacement products through services such as the Texas Tobacco Quitline [ 58 ], the availability of these products on-site and the ability to distribute them immediately and at no cost has been emphasized by the Center’s staff as a crucial component of the program. To address this challenge, the TTTF staff provided informational resources to the Center’s leadership and program champion, highlighting the support available in the community to secure additional funding for the ongoing purchase of nicotine replacement products. However, it remains uncertain at this stage whether the Center will be able to secure the necessary funding to sustain the provision of free nicotine replacement products to their clients and how the availability of these products will impact the long-term sustainability of the tobacco-free program. This is a limitation of this study, as it was conducted during the active phase of implementation and shortly after its completion, lacking data on the program’s long-term maintenance and outcomes. Therefore, further investigation specifically focusing on the long-term sustainability of tobacco-free programs at substance-use treatment centers would be valuable to address this gap and provide insights into ensuring ongoing access to nicotine replacement therapy products for patients. We suggest, however, that it is important to maintain communication with centers after the program implementation is completed, highlighting specific local funding opportunities, as well as sharing examples of successful programs maintained by other centers as a mechanism to support collaboration and pursue additional resources.

Analysis of the themes reflecting the expressions of agency, another major eNPT concept, showed a gradual positive change in tobacco treatment practices at the Center following the implementation of the program, including the enforcement of policies and staff quitting smoking. However, the findings also show that these changes did not immediately affect the provision of smoking cessation care to clients at the Center. Tobacco cessation treatment remained a problem of a lower priority, even for staff who had negative experiences with smoking associated with health concerns, did not use tobacco themselves and were overall very supportive of the program and excited about helping their clients to quit. Rather, this seemed closely related to a persistent perception that their clients were not genuinely interested in or capable of quitting, which was also revealed in the expectations shared by staff that clients had to be proactive in expressing their interest in quitting and seeking support.

We suggest that the expectation of clients proactively seeking support shared by the Center’s staff is associated, at least partially, with their understanding of the existing standards of client-clinician communication, which emphasizes the importance of “sharing power” equally with clients and involving them in the decision-making process [ 59 ]. The concept of patient-centered care, designed to improve healthcare provision and outcomes, is often regarded as a matter of ethical and moral healthcare practice, and it assumes patients’ involvement in their care [ 60 , 61 ]. It is important to consider, however, that these expectations might not work as planned with vulnerable populations, including clients who experience socioeconomic disadvantage, limited access to healthcare services, lower literacy levels and/or limited English proficiency [ 62 ]. These individuals’ ability to take a proactive stance and advocate for their health and well-being may be further hindered by systemic inequalities and structural racism disproportionately experienced by minoritized and underserved groups, and these factors have to be considered to improve the delivery of patient-centered care to these clients and ensure that the care they receive is tailored to their specific needs. Taking Texas Tobacco Free program has developed multiple training videos on smoking cessation support to special population groups [ 63 ], which can be used to provide continuing education on working with diverse groups to ensure that healthcare professionals are equipped with knowledge and skills needed to provide such care.

It is important to acknowledge that concerns about promoting smoking cessation are not entirely unfounded, as clinicians’ advice can have various consequences beyond the client simply following or not following it [ 64 ], and prior research has shown that avoidance of hearing specific recommendations to change behavior, including smoking, is reported as one of the reasons why people avoid seeking medical care [ 65 ]. However, these findings should not discourage health care providers from asking their clients about tobacco use, as this practice is associated with increased quit attempts and is recommended by The US Public Health Service Clinical Practice Guideline [ 66 ]. The potential risk of inadvertently stigmatizing clients who may already feel shame and guilt regarding their tobacco use and inability to quit might be avoided if clinicians use non-stigmatizing approaches identified in prior research [ 67 , 68 , 69 , 70 , 71 ]. It is particularly important to address these concerns in tobacco cessation trainings and educate staff on non-stigmatizing approaches. It is important to incorporate motivational interviewing in these trainings as this approach highlights the importance of displaying unconditional positive regard toward clients, which may increase client resilience in the face of behavioral change advice offered and minimize perceived stigma. It is crucial to find a balance between being sensitive to clients’ choices and priorities and providing the healthcare necessary to alleviate the consequences of systemic health inequities among minoritized and medically underserved groups.

One of the limitation of the study is the limited data on clients’ quit attempts and their outcomes. While the Center attempted to collect these data, they had difficulties following up with their clients after they left the program (most of the clients attended a 90-day program), which created difficulties in evaluating outcomes of those clients who initiated a quit attempt while being treated at the Center. While a more detailed analysis of client outcomes would enhance the evaluation of the intervention, the focus of this study has been on the implementation outcomes, including changes in provider behavior regarding assessing and treating tobacco dependence rather than assessing its direct impact on clients’ tobacco use and cessation [ 72 ]. Future research is needed to delve into evaluating the effects of the intervention on clients’ outcomes, which would provide valuable insights for further refining and optimizing the program.

While the Center’s staff exhibited strong potential and capacity to implement the program, our findings indicate that the actual change in practice has been less successful than anticipated based on the overall support of the program, high potential, and capability. Tobacco cessation treatment had not yet become a routine practice for all staff members by the end of the implementation process. However, despite encountering significant barriers, there is evidence that the program has led to a change in attitudes, including a better understanding of the need and improved ability to provide evidence-based tobacco cessation treatment to their patients. The staff at the Center have started to integrate tobacco treatment into their routine practices, informing clients about the available support, including nicotine replacement therapy products, providing personalized assistance, and assessing patients who may not be ready to quit. Although there are areas for improvement, the program has effectively initiated change in practices, normalizing tobacco cessation treatment and incorporating it as a routine practice at the Center.

The results of this study suggest that substance use treatment centers can maintain tobacco-free workplace policies and integrate evidence-based tobacco cessation practices in their daily operations, but they face extreme challenges due to the complex behavioral health needs and socioeconomic needs of their clients. Understanding the complex interplay between social norms, social roles, and limited resources within such settings is paramount for the success of tobacco cessation efforts. These organizations need extensive support, including a longer implementation period, as well as additional material resources, informational and educational support, and assistance in preparing and maintaining local policies. Regular training of staff, including implementing a train-the-trainer program, would allow to promote and sustain local expertise on evidence-based tobacco cessation interventions for minoritized and medically underserved populations. With proper support, substance use treatment settings have the potential to play a crucial role in addressing tobacco use and provide much needed cessation services to their clients who are disproportionately affected by tobacco-related health conditions and systemic health inequities.

Data availability

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

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Acknowledgements

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This project was supported by funding from the Cancer Prevention & Research Institute of Texas (grant #PP210003 to L.R.R.). A.R.’s time and effort for manuscript drafting was supported in part by MD Anderson’s Tobacco Settlement Funds and by Halliburton Employees Fellowship in Cancer Prevention Fund from The University of Texas MD Anderson Cancer Center. Publication was supported by start-up funds provided by MD Anderson to L.R.R. The funders had no role in the design of the study, the collection, analyses or interpretation of the data, the writing of the manuscript or the decision to publish the results.

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AR, LRR, IML conceptualized the research question and design of the case study; AR and IML completed the collection, analysis, and interpretation of qualitative data; TC completed the analysis of survey data; AR drafted the manuscript text; IML, LRR, MB, LML substantively revised it; MB, BK, KS, KC, TW administered the project and contributed to data collection. All authors reviewed and approved the manuscript.

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This project was approved by the Internal Review Board of the University of Houston (STUDY00002885, initial approval 4/20/2021) and the Quality Improvement Assessment Board at the University of Texas MD Anderson Cancer Center (initial approval 11/21/2022). All parts of the study were performed in accordance with the relevant guidelines and regulations as outlined in the approved research protocol. Oral informed consent was received from all participants prior to participation in qualitative study procedures. The aims of the project and interviews were discussed with participants who were given an opportunity to ask any questions about the interview process and the nature of the study. Additionally, all participants gave oral permission to audio-record the interview. Participants were informed that their participation was voluntary and that they could decline to answer any questions and stop participating in the interview at any time. Clients who participated in the interviews each received a $25.00 Amazon e-gift card as compensation for their time. Staff members did not receive remuneration.

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Rogova, A., Leal, I.M., Britton, M. et al. Implementing a tobacco-free workplace program at a substance use treatment center: a case study. BMC Health Serv Res 24 , 201 (2024). https://doi.org/10.1186/s12913-024-10629-5

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DOI : https://doi.org/10.1186/s12913-024-10629-5

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