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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.

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

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

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

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

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

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

Research bias

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

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Organizing Your Social Sciences Research Assignments

• Annotated Bibliography
• Analyzing a Scholarly Journal Article
• Group Presentations
• Dealing with Nervousness
• Using Visual Aids
• Grading Someone Else's Paper
• Types of Structured Group Activities
• Group Project Survival Skills
• Leading a Class Discussion
• Multiple Book Review Essay
• Reviewing Collected Works
• Writing a Case Analysis Paper
• Writing a Case Study
• About Informed Consent
• Writing Field Notes
• Writing a Policy Memo
• Writing a Reflective Paper
• Writing a Research Proposal
• Generative AI and Writing
• Acknowledgments

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

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

How to Approach Writing a Case Study Research Paper

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

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

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

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

Structure and Writing Style

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

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

I.  Introduction

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

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

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

II.  Literature Review

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

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

III.  Method

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

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

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

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

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

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

IV.  Discussion

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

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

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

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

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

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

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

V.  Conclusion

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

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

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

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

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

Problems to Avoid

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

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

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

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

Writing Tip

At Least Five Misconceptions about Case Study Research

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

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

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

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

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• 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.

Provenance and peer review Commissioned; internally peer reviewed.

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What is a Case Study in Research? Definition, Methods, and Examples

Case study methodology offers researchers an exciting opportunity to explore intricate phenomena within specific contexts using a wide range of data sources and collection methods. It is highly pertinent in health and social sciences, environmental studies, social work, education, and business studies. Its diverse applications, such as advancing theory, program evaluation, and intervention development, make it an invaluable tool for driving meaningful research and fostering positive change.[ 1]  

Table of Contents

What is a Case Study?  

A case study method involves a detailed examination of a single subject, such as an individual, group, organization, event, or community, to explore and understand complex issues in real-life contexts. By focusing on one specific case, researchers can gain a deep understanding of the factors and dynamics at play, understanding their complex relationships, which might be missed in broader, more quantitative studies.  

When to do a Case Study?  

A case study design is useful when you want to explore a phenomenon in-depth and in its natural context. Here are some examples of when to use a case study :[ 2]  

• Exploratory Research: When you want to explore a new topic or phenomenon, a case study can help you understand the subject deeply. For example , a researcher studying a newly discovered plant species might use a case study to document its characteristics and behavior.  
• Descriptive Research: If you want to describe a complex phenomenon or process, a case study can provide a detailed and comprehensive description. For instance, a case study design   could describe the experiences of a group of individuals living with a rare disease.  
• Explanatory Research: When you want to understand why a particular phenomenon occurs, a case study can help you identify causal relationships. A case study design could investigate the reasons behind the success or failure of a particular business strategy.  
• Theory Building: Case studies can also be used to develop or refine theories. By systematically analyzing a series of cases, researchers can identify patterns and relationships that can contribute to developing new theories or refining existing ones.  
• Critical Instance: Sometimes, a single case can be used to study a rare or unusual phenomenon, but it is important for theoretical or practical reasons. For example , the case of Phineas Gage, a man who survived a severe brain injury, has been widely studied to understand the relationship between the brain and behavior.  
• Comparative Analysis: Case studies can also compare different cases or contexts. A case study example involves comparing the implementation of a particular policy in different countries to understand its effectiveness and identifying best practices.  

How to Create a Case Study – Step by Step  

Step 1: select a case  .

Careful case selection ensures relevance, insight, and meaningful contribution to existing knowledge in your field. Here’s how you can choose a case study design :[ 3]  

• Define Your Objectives: Clarify the purpose of your case study and what you hope to achieve. Do you want to provide new insights, challenge existing theories, propose solutions to a problem, or explore new research directions?  
• Consider Unusual or Outlying Cases: Focus on unusual, neglected, or outlying cases that can provide unique insights.  
• Choose a Representative Case: Alternatively, select a common or representative case to exemplify a particular category, experience, or phenomenon.   
• Avoid Bias: Ensure your selection process is unbiased using random or criteria-based selection.  
• Be Clear and Specific: Clearly define the boundaries of your study design , including the scope, timeframe, and key stakeholders.   
• Ethical Considerations: Consider ethical issues, such as confidentiality and informed consent.  

Step 2: Build a Theoretical Framework  

To ensure your case study has a solid academic foundation, it’s important to build a theoretical framework:   

• Conduct a Literature Review: Identify key concepts and theories relevant to your case study .  
• Establish Connections with Theory: Connect your case study with existing theories in the field.  
• Guide Your Analysis and Interpretation: Use your theoretical framework to guide your analysis, ensuring your findings are grounded in established theories and concepts.   

Step 3: Collect Your Data  

To conduct a comprehensive case study , you can use various research methods. These include interviews, observations, primary and secondary sources analysis, surveys, and a mixed methods approach. The aim is to gather rich and diverse data to enable a detailed analysis of your case study .  

Step 4: Describe and Analyze the Case  

How you report your findings will depend on the type of research you’re conducting. Here are two approaches:   

• Structured Approach: Follows a scientific paper format, making it easier for readers to follow your argument.  
• Narrative Approach: A more exploratory style aiming to analyze meanings and implications.  

Regardless of the approach you choose, it’s important to include the following elements in your case study :   

• Contextual Details: Provide background information about the case, including relevant historical, cultural, and social factors that may have influenced the outcome.  
• Literature and Theory: Connect your case study to existing literature and theory in the field. Discuss how your findings contribute to or challenge existing knowledge.  
• Wider Patterns or Debates: Consider how your case study fits into wider patterns or debates within the field. Discuss any implications your findings may have for future research or practice.  

What Are the Benefits of a Case Study   

Case studies offer a range of benefits , making them a powerful tool in research.  

1. In-Depth Analysis  

• Comprehensive Understanding: Case studies allow researchers to thoroughly explore a subject, understanding the complexities and nuances involved.  
• Rich Data: They offer rich qualitative and sometimes quantitative data, capturing the intricacies of real-life contexts.  

2. Contextual Insight  

• Real-World Application: Case studies provide insights into real-world applications, making the findings highly relevant and practical.  
• Context-Specific: They highlight how various factors interact within a specific context, offering a detailed picture of the situation.  

3. Flexibility  

• Methodological Diversity: Case studies can use various data collection methods, including interviews, observations, document analysis, and surveys.  
• Adaptability: Researchers can adapt the case study approach to fit the specific needs and circumstances of the research.  

4. Practical Solutions  

• Actionable Insights: The detailed findings from case studies can inform practical solutions and recommendations for practitioners and policymakers.  
• Problem-Solving: They help understand the root causes of problems and devise effective strategies to address them.  

5. Unique Cases  

• Rare Phenomena: Case studies are particularly valuable for studying rare or unique cases that other research methods may not capture.  
• Detailed Documentation: They document and preserve detailed information about specific instances that might otherwise be overlooked.  

What Are the Limitations of a Case Study   

While case studies offer valuable insights and a detailed understanding of complex issues, they have several limitations .  

1. Limited Generalizability  

• Specific Context: Case studies often focus on a single case or a small number of cases, which may limit the generalization of findings to broader populations or different contexts.  
• Unique Situations: The unique characteristics of the case may not be representative of other situations, reducing the applicability of the results.  

2. Subjectivity  

• Researcher Bias: The researcher’s perspectives and interpretations can influence the analysis and conclusions, potentially introducing bias.  
• Participant Bias: Participants’ responses and behaviors may be influenced by their awareness of being studied, known as the Hawthorne effect.  

3. Time-Consuming  

• Data Collection and Analysis: Gathering detailed, in-depth data requires significant time and effort, making case studies more time-consuming than other research methods.  
• Longitudinal Studies: If the case study observes changes over time, it can become even more prolonged.  

4. Resource Intensive  

• Financial and Human Resources: Conducting comprehensive case studies may require significant financial investment and human resources, including trained researchers and participant access.  
• Access to Data: Accessing relevant and reliable data sources can be challenging, particularly in sensitive or proprietary contexts.  

5. Replication Difficulties  

• Unique Contexts: A case study’s specific and detailed context makes it difficult to replicate the study exactly, limiting the ability to validate findings through repetition.  
• Variability: Differences in contexts, researchers, and methodologies can lead to variations in findings, complicating efforts to achieve consistent results.  

By acknowledging and addressing these limitations , researchers can enhance the rigor and reliability of their case study findings.  

Key Takeaways  

Case studies are valuable in research because they provide an in-depth, contextual analysis of a single subject, event, or organization. They allow researchers to explore complex issues in real-world settings, capturing detailed qualitative and quantitative data. This method is useful for generating insights, developing theories, and offering practical solutions to problems. They are versatile, applicable in diverse fields such as business, education, and health, and can complement other research methods by providing rich, contextual evidence. However, their findings may have limited generalizability due to the focus on a specific case.  

Frequently Asked Questions  

Q: What is a case study in research?  

A case study in research is an impactful tool for gaining a deep understanding of complex issues within their real-life context. It combines various data collection methods and provides rich, detailed insights that can inform theory development and practical applications.  

Q: What are the advantages of using case studies in research?  

Case studies are a powerful research method, offering advantages such as in-depth analysis, contextual insights, flexibility, rich data, and the ability to handle complex issues. They are particularly valuable for exploring new areas, generating hypotheses, and providing detailed, illustrative examples that can inform theory and practice.  

Q: Can case studies be used in quantitative research?  

While case studies are predominantly associated with qualitative research, they can effectively incorporate quantitative methods to provide a more comprehensive analysis. A mixed-methods approach leverages qualitative and quantitative research strengths, offering a powerful tool for exploring complex issues in a real-world context. For example , a new medical treatment case study can incorporate quantitative clinical outcomes (e.g., patient recovery rates and dosage levels) along with qualitative patient interviews.  

Q: What are the key components of a case study?  

A case study typically includes several key components:   

• Introductio n, which provides an overview and sets the context by presenting the problem statement and research objectives;  
• Literature review , which connects the study to existing theories and prior research;  
• Methodology , which details the case study design , data collection methods, and analysis techniques;   
• Findings , which present the data and results, including descriptions, patterns, and themes;   
• Discussion and conclusion , which interpret the findings, discuss their implications, and offer conclusions, practical applications, limitations, and suggestions for future research.  

Together, these components ensure a comprehensive, systematic, and insightful exploration of the case.  

References  

• de Vries, K. (2020). Case study methodology. In  Critical qualitative health research  (pp. 41-52). Routledge.  
• Fidel, R. (1984). The case study method: A case study.  Library and Information Science Research ,  6 (3), 273-288.  
• Thomas, G. (2021). How to do your case study.  How to do your case study , 1-320.  

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Writing a Case Study

What is a case study?

A Case study is: 

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

What are the different types of case studies?

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

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

Who are your case study participants?

What is triangulation ? 

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

How to write a Case Study?

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

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• Published: 27 June 2011

The case study approach

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

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

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

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Introduction

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

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

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

What is a case study?

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

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

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

What are case studies used for?

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

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

How are case studies conducted?

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

Defining the case

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

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

Selecting the case(s)

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

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

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

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

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

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

Collecting the data

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

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

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

Analysing, interpreting and reporting case studies

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

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

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

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

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

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

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

Conclusions

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

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Acknowledgements

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

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

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

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What is a case study and what is it good for.

Published online by Cambridge University Press:  21 June 2004

This paper aims to clarify the meaning, and explain the utility, of the case study method, a method often practiced but little understood. A “case study,” I argue, is best defined as an intensive study of a single unit with an aim to generalize across a larger set of units. Case studies rely on the same sort of covariational evidence utilized in non-case study research. Thus, the case study method is correctly understood as a particular way of defining cases, not a way of analyzing cases or a way of modeling causal relations. I show that this understanding of the subject illuminates some of the persistent ambiguities of case study work, ambiguities that are, to some extent, intrinsic to the enterprise. The travails of the case study within the discipline of political science are also rooted in an insufficient appreciation of the methodological tradeoffs that this method calls forth. This paper presents the familiar contrast between case study and non-case study work as a series of characteristic strengths and weaknesses— affinities —rather than as antagonistic approaches to the empirical world. In the end, the perceived hostility between case study and non-case study research is largely unjustified and, perhaps, deserves to be regarded as a misconception. Indeed, the strongest conclusion to arise from this methodological examination concerns the complementarity of single-unit and cross-unit research designs.

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• Volume 98, Issue 2
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• DOI: https://doi.org/10.1017/S0003055404001182

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AJ SPECIFICATION

Case study: Riverside Primary School by Architype

10 September 2024

The 550-pupil school in Perth is Scotland’s first certified Passivhaus school. Photography by David Barbour  

Riverside Primary School is the first certified Passivhaus school in Scotland. Designed to accommodate over 550 pupils and nursery-age children, the school embraces a modern and supportive pedagogy while providing an internal environment with abundant visual and physical links to the outdoors.  

Attention was given to how the school would sit within its residential setting, considering its connection with the surrounding estate and to encouraging active travel to school. A thoughtful landscape plan allows for pitches and outdoor learning spaces alongside an activity trail and secret garden.  

The layout enhances a unifying central breakout space with direct access to an external play area, and classrooms are orientated to maximise natural daylight. Ground-floor classrooms open directly to the playgrounds to encourage outdoor learning.  

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Passivhaus certification was a key client requirement to guarantee that the building would meet the Scottish Futures Trust Learning Estates Investment Programme energy metric required to release funding. The Architype-led team delivered a design that met the stringent technical performance requirements, estimated to reduce energy costs by approximately 70 per cent.

Sam Boyle, associate, Architype

Project data

Start on site November 2021 Completion July 2023 Gross internal floor area 4,283m 2 Construction cost £16 million Construction cost per m 2 £3,735 Architect Architype Client Perth and Kinross Council Structural engineer Goodson Associates M&E consultant BakerHicks Principal designer Kirk and Marsh CDM coordinator Kirk and Marsh Acoustic consultant Sandy Brown Landscape architect Rankin Fraser Landscape Architects Fire engineer Atelier Ten FF+E consultant Deanestor Passivhaus certifier Warm Main contractor Robertson Construction CAD software used Revit Annual CO 2 emissions 8.5 kgCO 2 /m 2 Predicted design life 60 years Embodied carbon 1,165 kgCO 2 /m 2 (A-C, excluding B6-B8)

Architect’s choices

Troldtekt acoustic ceilings were specified and DYNAMIK perforated acoustic timber wall panels used in the gym hall for their high-performing acoustic properties and natural aesthetic.  

We used Valchromat through-coloured wood-fibre boards as wall protection, coated with clear Osmo oil. Metal Technology triple-glazed windows, doors and curtain walling systems were specified, due to their technical performance and support, which is paramount when striving for stringent airtightness targets.  

Junkers beech flooring was chosen for the gym hall, which is solid wood and can be sanded up to 10 times. Forbo marmoleum flooring was chosen because of its durability and 98 per cent natural raw material make-up. Forbo Chroma carpet tiles were also chosen for durability and contain 61 per cent recycled content by weight.  

Sam Boyle, associate, Architype  

Specification

The internal environments of the previous schools were dark, with poor air quality, and not conducive to learning. For Riverside, the team prioritised a light, fresh environment filled with a calming colour palette and tactile natural materials with low VOC emissions. Natural light penetrates through skylights as well as through internal corridor-to-classroom glazing, allowing direct views and access to the outdoors.  

Non-toxic materials such as linoleum, wood-wool fibre acoustic panels, natural timber finishes, acoustic panels and flooring were chosen for their performance and longevity to create a high-quality, uplifting environment that enhances wellbeing.

As one of the first steel-framed Passivhaus projects in the UK, technical expertise was required to ensure delivery, both in detailing and upskilling the contractor team. A collaborative and no-blame culture was fostered throughout the project by all, which allowed Riverside to be delivered on time and within budget.

Internal environment is an important aspect of Passivhaus, both in its effect on occupant health and operational efficiency. Based on building performance monitoring, the energy demand is reported as 50.12 kWh/m 2 /yr, well below the 67 kWh/m 2 /yr required for an A-rated building for Learning Estate Investment Programme funding. The internal environment is stable and healthy, with CO 2 levels well below required standards, and the average temperature of classrooms is stable despite external fluctuations.  

Selected products

Curtain walling system Metal Technology Metal Tech System 17 Capped Ground floor external envelope metaltechnology.com

External glazed doors Metal Technology Metal Tech 5-20 Hi+ Ground floor external envelope metaltechnology.com

Windows Metal Technology Metal Tech 5-45 Hi+ External envelope metaltechnology.com

Bricks Forterra Belgravia Gault Blend External envelope forterra.co.uk

Standing seam roof Kalzip Standing Seam Roof Teaching block and games hall roof kalzip.com

Flat roof Bauder Bauder Total Roof System Nursery and kitchen roofs bauder.co.uk

External insulation Rainscreen Duoslab Rockwool External envelope rockwool.com

Airtightness membrane Proctor Wraptite External envelope proctorgroup.com

Rooflights Lamilux Glass Skylight FE Passivhaus Standing seam and flat roof lamilux.com

Carpet Forbo Flooring UK Tessera Chroma Nursery and classroom spaces forbo.com

Vinyl Forbo Flooring UK Marmoleum Circulation and wet areas forbo.com

Acoustic ceilings Troldtekt Troldtekt Plus Ceilings and bulkheads generally troldtekt.com

Lay in grid ceilings Ecophon Gedina A Suspended Acoustic Ceiling Ceilings generally ecophon.com

Acoustic wall panels Troldtekt Troldtekt Acoustic First floor circulation troldtekt.com

Perforated ply acoustic panels DYNAMIK Sports Flooring Acoustic (Perforated) Sports Wall Panels Games hall walls dynamiksportsfloors.co.uk

Sprung timber sports floor Junckers Battened SylvaSport Club Beech Games Hall junckers.co.uk

Internal doors and screens Planet Partitions Planet FireEco Throughout radiiplanetgroup.com

Wall protection Invest Wood Valchromat wood fibre panels Throughout investwood.pt

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• Open access
• Published: 07 September 2024

A case study of the informative value of risk of bias and reporting quality assessments for systematic reviews

• Cathalijn H. C. Leenaars   ORCID: orcid.org/0000-0002-8212-7632 1 ,
• Frans R. Stafleu 2 ,
• Christine Häger 1 &
• André Bleich 1  

Systematic Reviews volume  13 , Article number:  230 ( 2024 ) Cite this article

Metrics details

While undisputedly important, and part of any systematic review (SR) by definition, evaluation of the risk of bias within the included studies is one of the most time-consuming parts of performing an SR. In this paper, we describe a case study comprising an extensive analysis of risk of bias (RoB) and reporting quality (RQ) assessment from a previously published review (CRD42021236047). It included both animal and human studies, and the included studies compared baseline diseased subjects with controls, assessed the effects of investigational treatments, or both. We compared RoB and RQ between the different types of included primary studies. We also assessed the “informative value” of each of the separate elements for meta-researchers, based on the notion that variation in reporting may be more interesting for the meta-researcher than consistently high/low or reported/non-reported scores. In general, reporting of experimental details was low. This resulted in frequent unclear risk-of-bias scores. We observed this both for animal and for human studies and both for disease-control comparisons and investigations of experimental treatments. Plots and explorative chi-square tests showed that reporting was slightly better for human studies of investigational treatments than for the other study types. With the evidence reported as is, risk-of-bias assessments for systematic reviews have low informative value other than repeatedly showing that reporting of experimental details needs to improve in all kinds of in vivo research. Particularly for reviews that do not directly inform treatment decisions, it could be efficient to perform a thorough but partial assessment of the quality of the included studies, either of a random subset of the included publications or of a subset of relatively informative elements, comprising, e.g. ethics evaluation, conflicts of interest statements, study limitations, baseline characteristics, and the unit of analysis. This publication suggests several potential procedures.

Peer Review reports

Introduction

Researchers performing systematic reviews (SRs) face bias at two potential levels: first, at the level of the SR methods themselves, and second, at the level of the included primary studies [ 1 ]. To safeguard correct interpretation of the review’s results, transparency is required at both levels. For bias at the level of the SR methods, this is ensured by transparent reporting of the full SR methods, at least to the level of detail as required by the PRISMA statement [ 2 ]. For bias at the level of the included studies, study reporting quality (RQ) and/or risk of bias (RoB) are evaluated at the level of the individual included study. Specific tools are available to evaluate RoB in different study types [ 3 ]. Also, for reporting of primary studies, multiple guidelines and checklists are available to prevent missing important experimental details and more become available for different types of studies over time [ 4 , 5 ]. Journal endorsement of these types of guidelines has been shown to improve study reporting quality [ 6 ].

While undisputedly important, evaluation of the RoB and/or RQ of the included studies is one of the most time-consuming parts of an SR. Experienced reviewers need 10 min to an hour to complete an individual RoB assessment [ 7 ], and every included study needs to be evaluated by two reviewers. Besides spending substantial amounts of time on RoB or RQ assessments, reviewers tend to become frustrated because of the scores frequently being unclear or not reported (personal experience from the authors, colleagues and students). While automation of RoB seems to be possible without loss of accuracy [ 8 , 9 ], so far, this automation has not had significant impact on the speed; in a noninferiority randomised controlled trial of the effect of automation on person-time spent on RoB assessment, the confidence interval for the time saved ranged from − 5.20 to + 2.41 min [ 8 ].

In any scientific endeavour, there is a balance between reliability and speed; to guarantee reliability of a study, time investments are necessary. RoB or RQ assessment is generally considered to be an essential part of the systematic review process to warrant correct interpretation of the findings, but with so many studies scoring “unclear” or “not reported”, we wondered if all this time spent on RoB assessments is resulting in increased reliability of reviews.

Overall unclear risk of bias in the included primary studies is a conclusion of multiple reviews, and these assessments are useful in pinpointing problems in reporting, thereby potentially improving the quality of future publications of primary studies. However, the direct goal of most SRs is to answer a specific review question, and in that respect, unclear RoB/not reported RQ scores contribute little to the validity of the review’s results. If all included studies score “unclear” or “high” RoB on at least one of the analysed elements, the overall effect should be interpreted as inconclusive.

While it is challenging to properly evaluate the added validity value of a methodological step, we had data available allowing for an explorative case study to assess the informative value of various RoB and RQ elements in different types of studies. We previously performed an SR of the nasal potential difference (nPD) for cystic fibrosis (CF) in animals and humans, aiming to quantify the predictive value of animal models for people with CF [ 10 , 11 ]. That review comprised between-subject comparisons of both baseline versus disease-control and treatment versus treatment control. For that review, we performed full RoB and RQ analyses. This resulted in data allowing for comparisons of RoB and RQ between animal and human studies, but also between baseline and treatment studies, which are both presented in this manuscript. RoB evaluations were based on the Cochrane collaboration’s tool [ 12 ] for human studies and SYRCLE’s tool [ 13 ] for animal studies. RQ was tested based on the ARRIVE guidelines [ 14 ] for animal studies and the 2010 CONSORT guidelines [ 15 ] for human studies. Brief descriptions of these tools are provided in Table  1 .

All these tools are focussed on interventional studies. Lacking more specific tools for baseline disease-control comparisons, we applied them as far as relevant for the baseline comparisons. We performed additional analyses on our RQ and RoB assessments to assess the amount of distinctive information gained from them.

The analyses described in this manuscript are based on a case study SR of the nPD related to cystic fibrosis (CF). That review was preregistered on PROSPERO (CRD42021236047) on 5 March 2021 [ 16 ]. Part of the results were published previously [ 10 ]. The main review questions are answered in a manuscript that has more recently been published [ 11 ]. Both publications show a simple RoB plot corresponding to the publication-specific results.

For the ease of the reader, we provide a brief summary of the overall review methods. The full methods have been described in our posted protocol [ 16 ] and the earlier publications [ 10 , 11 ]. Comprehensive searches were performed in PubMed and Embase, unrestricted for publication date or language, on 23 March 2021. Title-abstract screening and full-text screening were performed by two independent reviewers blinded to the other’s decision (FS and CL) using Rayyan [ 17 ]. We included animal and/or human studies describing nPD in CF patients and/or CF animal models. We restricted to between-subject comparisons, either CF versus healthy controls or experimental CF treatments versus CF controls. Reference lists of relevant reviews and included studies were screened (single level) for snowballing. Discrepancies were all resolved by discussions between the reviewers.

Data were extracted by two independent reviewers per reference in several distinct phases. Relevant to this manuscript, FS and CL extracted RoB and RQ data in Covidence [ 18 ], in two separate projects using the same list of 48 questions for studies assessing treatment effects and studies assessing CF-control differences. The k  = 11 studies that were included in both parts of the overarching SR were included twice in the current data set, as RoB was separately scored for each comparison. Discrepancies were all resolved by discussions between the reviewers. In violation of the protocol, no third reviewer was involved.

RoB and SQ data extraction followed our review protocol, which states the following: “For human studies, risk of bias will be assessed with the Cochrane Collaboration’s tool for assessing risk of bias. For animal studies, risk of bias will be assessed with SYRCLE’s RoB tool. Besides, we will check compliance with the ARRIVE and CONSORT guidelines for reporting quality”. The four tools contain overlapping questions. To prevent unnecessary repetition of our own work, we created a single list of 48 items, which were ordered by topic for ease of extraction. For RoB, this list contains the same elements as the original tools, with the same response options (high/unclear/low RoB). For RQ, we created checklists with all elements as listed in the original tools, with the response options reported yes/no. For (RQ and RoB) elements specific to some of the included studies, the response option “irrelevant” was added. We combined these lists, only changing the order and merging duplicate elements. We do not intend this list to replace the individual tools; it was created for this specific study only.

In our list, each question was preceded by a short code indicating the tool it was derived from (A for ARRIVE, C for CONSORT, and S for SYRCLE’s) to aid later analyses. When setting up, we started with the animal-specific tools, with which the authors are more familiar. After preparing data extraction for those, we observed that all elements from the Cochrane tool had already been addressed. Therefore, this list was not explicit in our extractions. The extraction form always allowed free text to support the response. Our extraction list is provided with our supplementary data.

For RoB, the tools provide relatively clear suggestions for which level to score and when, with signalling questions and examples [ 12 , 13 ]. However, this still leaves some room for interpretation, and while the signalling questions are very educative, there are situations where the response would in our opinion not correspond to the actual bias. The RQ tools have been developed as guidelines on what to report when writing a manuscript, and not as a tool to assess RQ [ 14 , 15 ]. This means we had to operationalise upfront which level we would find sufficient to score “reported”. Our operationalisations and corrections of the tools are detailed in Table  2 .

Data were exported from Covidence into Microsoft’s Excel, where the two projects were merged and spelling and capitalisation were harmonised. Subsequent analyses were performed in R [ 21 ] version 4.3.1 (“Beagle Scouts”) via RStudio [ 22 ], using the following packages: readxl [ 23 ], dplyr [ 24 ], tidyr [ 25 ], ggplot2 [ 26 ], and crosstable [ 27 ].

Separate analyses were performed for RQ (with two levels per element) and RoB (with three levels per element). For both RoB and RQ, we first counted the numbers of irrelevant scores overall and per item. Next, irrelevant scores were deleted from further analyses. We then ranked the items by percentages for reported/not reported, or for high/unclear/low scores, and reported the top and bottom 3 (RoB) or 5 (RQ) elements.

While 100% reported is most informative to understand what actually happened in the included studies, if all authors continuously report a specific element, scoring of this element for an SR is not the most informative for meta-researchers. If an element is not reported at all, this is bad news for the overall level of confidence in an SR, but evaluating it per included study is also not too efficient except for highlighting problems in reporting, which may help to improve the quality of future (publications of) primary studies. For meta-researchers, elements with variation in reporting may be considered most interesting because these elements highlight differences between the included studies. Subgroup analyses based on specific RQ/RoB scores can help to estimate the effects of specific types of bias on the overall effect size observed in meta-analyses, as has been done for example randomisation and blinding [ 28 ]. However, these types of subgroup analyses are only possible if there is some variation in the reporting. Based on this idea, we defined a “distinctive informative value” (DIV) for RQ elements, based on the optimal variation being 50% reported and either 0% or 100% reporting being minimally informative. Thus, this “DIV” was calculated as follows:

Thus, the DIV could range from 0 (no informative value) to 50 (maximally informative), visualised in Fig.  1 .

Visual explanation of the DIV value

The DIV value was only used for ranking. The results were visualised in a heatmap, in which the intermediate shades correspond to high DIV values.

For RoB, no comparable measure was calculated. With only 10 elements but at 3 distinct levels, we thought a comparable measure would sooner hinder interpretation of informative value than help it. Instead, we show the results in an RoB plot split by population and study design type.

Because we are interested in quantifying the predictive value of animal models for human patients, we commonly perform SRs including both animal and human data (e.g. [ 29 , 30 ]). The dataset described in the current manuscript contained baseline and intervention studies in animals and humans. Because animal studies are often held responsible for the reproducibility crisis, but also to increase the external validity of this work, explorative chi-square tests (the standard statistical test for comparing percentages for binary variables) were performed to compare RQ and RoB between animal and human studies and between studies comparing baselines and treatment effects. They were performed with the base R “chisq.test” function. No power calculations were performed, as these analyses were not planned.

Literature sample

We extracted RoB and RQ data from 164 studies that were described in 151 manuscripts. These manuscripts were published from 1981 through 2020. Overall, 164 studies comprised 78 animal studies and 86 human studies, 130 comparisons of CF versus non-CF control, and 34 studies assessing experimental treatments. These numbers are detailed in a crosstable (Table  3 ).

The 48 elements in our template were completed for these 164 studies, which results in 7872 assessed elements. In total, 954 elements (12.1%) were irrelevant for various reasons (mainly for noninterventional studies and for human studies). The 7872 individual scores per study are available from the data file on OSF.

Of the 48 questions in our extraction template, 38 addressed RQ, and 10 addressed RoB.

Overall reporting quality

Of the 6232 elements related to RQ, 611 (9.8%) were deemed irrelevant. Of the remainder, 1493 (26.6% of 5621) were reported. The most reported elements were background of the research question (100% reported), objectives (98.8% reported), interpretation of the results (98.2% reported), generalisability (86.0% reported), and the experimental groups (83.5% reported). The least-reported elements were protocol violations, interim analyses + stopping rules and when the experiments were performed (all 0% reported), where the experiments were performed (0.6% reported), and all assessed outcome measures (1.2% reported).

The elements with most distinctive variation in reporting (highest DIV, refer to the “ Methods ” section for further information) were as follows: ethics evaluation (64.6% reported), conflicts of interest (34.8% reported), study limitations (29.3% reported), baseline characteristics (26.2% reported), and the unit of analysis (26.2% reported). RQ elements with DIV values over 10 are shown in Table  4 .

Overall risk of bias

Of the 1640 elements related to RoB, 343 (20.9%) were deemed irrelevant. Of the remainder, 219 (16.9%) scored high RoB, and 68 (5.2%) scored low RoB. The overall RoB scores were highest for selective outcome reporting (97.6% high), baseline group differences (19.5% high), and other biases (9.8% high); lowest for blinding of participants, caregivers, and investigators (13.4% low); blinding of outcome assessors (11.6% low) and baseline group differences (8.5% low); and most unclear for bias due to animal housing (100% unclear), detection bias due to the order of outcome measurements (99.4% unclear), and selection bias in sequence generation (97.1% unclear). The baseline group differences being both in the highest and the lowest RoB score are explained by the baseline values being reported better than the other measures, resulting in fewer unclear scores.

Variation in reporting is relatively high for most of the elements scoring high or low. Overall distinctive value of the RoB elements is low, with most scores being unclear (or, for selective outcome reporting, most scores being high).

Animal versus human studies

For RQ, the explorative chi-square tests indicated differences in reporting between animal and human studies for baseline values ( Χ 1  = 50.3, p  < 0.001), ethical review ( Χ 1  = 5.1, p  = 0.02), type of study ( Χ 1  = 11.2, p  < 0.001), experimental groups ( Χ 1  = 3.9, p  = 0.050), inclusion criteria ( Χ 1  = 24.6, p  < 0.001), the exact n value per group and in total ( Χ 1  = 26.0, p  < 0.001), (absence of) excluded datapoints ( Χ 1  = 4.5, p  = 0.03), adverse events ( Χ 1  = 5.5, p  = 0.02), and study limitations ( Χ 1  = 8.2, p  = 0.004). These explorative findings are visualised in a heatmap (Fig.  2 ).

Heatmap of reporting by type of study. Refer to Table  3 for absolute numbers of studies per category

For RoB, the explorative chi-square tests indicated differences in risk of bias between animal and human studies for baseline differences between the groups ( Χ 2  = 34.6, p  < 0.001) and incomplete outcome data ( Χ 2  = 7.6, p  = 0.02). These explorative findings are visualised in Fig.  3 .

Risk of bias by type of study. Refer to Table  3 for absolute numbers of studies per category. Note that the data shown in these plots overlap with those in the two preceding publications [ 10 , 11 ]

Studies assessing treatment effects versus studies assessing baseline differences

For RQ, the explorative chi-square tests indicated differences in reporting between comparisons of disease with control versus comparisons of treatment effects for the title listing the type of study ( X 1  = 5.0, p  = 0.03), the full paper explicitly mentioning the type of study ( X 1  = 14.0, p  < 0.001), explicit reporting of the primary outcome ( X 1  = 11.7, p  < 0.001), and reporting of adverse events X 1  = 25.4, p  < 0.001). These explorative findings are visualised in Fig.  2 .

For RoB, the explorative chi-square tests indicated differences in risk of bias between comparisons of disease with control versus comparisons of treatment effects for baseline differences between the groups ( Χ 2  = 11.4, p  = 0.003), blinding of investigators and caretakers ( Χ 2  = 29.1, p  < 0.001), blinding of outcome assessors ( Χ 2  = 6.2, p  = 0.046), and selective outcome reporting ( Χ 2  = 8.9, p  = 0.01). These explorative findings are visualised in Fig.  3 .

Overall, our results suggest lower RoB and higher RQ for human treatment studies compared to the other study types.

This literature study shows that reporting of experimental details is low, frequently resulting in unclear risk-of-bias assessments. We observed this both for animal and for human studies, with two main study designs: disease-control comparisons and, in a smaller sample, investigations of experimental treatments. Overall reporting is slightly better for elements that contribute to the “story” of a publication, such as the background of the research question, interpretation of the results and generalisability, and worst for experimental details that relate to differences between what was planned and what was actually done, such as protocol violations, interim analyses, and assessed outcome measures. The latter also results in overall high RoB scores for selective outcome reporting.

Of note, we scored this more stringently than SYRCLE’s RoB tool [ 13 ] suggests and always scored a high RoB if no protocol was posted, because only comparing the “Methods” and “Results” sections within a publication would, in our opinion, result in an overly optimistic view. Within this sample, only human treatment studies reported posting protocols upfront [ 31 , 32 ]. In contrast to selective outcome reporting, we would have scored selection, performance, and detection bias due to sequence generation more liberally for counterbalanced designs (Table  2 ), because randomisation is not the only appropriate method for preventing these types of bias. Particularly when blinding is not possible, counterbalancing [ 33 , 34 ] and Latin-square like designs [ 35 ] can decrease these biases, while randomisation would risk imbalance between groups due to “randomisation failure” [ 36 , 37 ]. We would have scored high risk of bias for blinding for these types of designs, because of increased sequence predictability. However, in practice, we did not include any studies reporting Latin-square-like or other counterbalancing designs.

One of the “non-story” elements that is reported relatively well, particularly for human treatment studies, is the blinding of participants, investigators, and caretakers. This might relate to scientists being more aware of potential bias of participants; they may consider themselves to be more objective than the general population, while the risk of influencing patients could be considered more relevant.

The main strength of this work is that it is a full formal analysis of RoB and RQ in different study types: animal and human, baseline comparisons, and treatment studies. The main limitation is that it is a single case study from a specific topic: the nPD test in CF. The results shown in this paper are not necessarily valid for other fields, particularly as we hypothesise that differences in scientific practice between medical fields relate to differences in translational success [ 38 ]. Thus, it is worth to investigate field-specific informative values before selecting which elements to score and analyse in detail.

Our comparisons of different study and population types show lower RoB and higher RQ for human treatment studies compared to the other study types for certain elements. Concerning RQ, the effects were most pronounced for the type of experimental design being explicitly mentioned and the reporting of adverse events. Concerning RoB, the effects were most pronounced for baseline differences between the groups, blinding of investigators and caretakers, and selective outcome reporting. Note, however, that the number of included treatment studies is a lot lower than the number of included baseline studies, and that the comparisons were based on only k  = 12 human treatment studies. Refer to Table  3 for absolute numbers of studies per category. Besides, our comparisons may be confounded to some extent by the publication date. The nPD was originally developed for human diagnostics [ 39 , 40 ], and animal studies only started to be reported at a later date [ 41 ]. Also, the use of the nPD as an outcome in (pre)clinical trials of investigational treatments originated at a later date [ 42 , 43 ].

Because we did not collect our data to assess time effects, we did not formally analyse them. However, we had an informal look at the publication dates by RoB score for blinding of the investigators and caretakers, and by RQ score for ethics evaluation (in box plots with dot overlay), showing more reported and fewer unclear scores in the more recent publications (data not shown). While we thus cannot rule out confounding of our results by publication date, the results are suggestive of mildly improved reporting of experimental details over time.

This study is a formal comparison of RoB and RQ scoring for two main study types (baseline comparisons and investigational treatment studies), for both animals and humans. Performing these comparisons within the context of a single SR [ 16 ] resulted in a small, but relatively homogeneous sample of primary studies about the nPD in relation to CF. On conferences and from colleagues in the animal SR field, we heard that reporting would be worse for animal than for human studies. Our comparisons allowed us to show that particularly for baseline comparisons of the nPD in CF versus control, this is not the case.

The analysed tools [ 12 , 13 , 15 ] were developed for experimental interventional studies. While some of the elements are less appropriate for other types of studies, such as animal model comparisons, our results show that many of the elements can be used and could still be useful, particularly if the reporting quality of the included studies would be better.

Implications

To correctly interpret the findings of a meta-analysis, awareness of the RoB in the included studies is more relevant than the RQ on its own. However, it is impossible to evaluate the RoB if the experimental details have not been reported, resulting in many unclear scores. With at least one unclear or high RoB score per included study, the overall conclusions of the review become inconclusive. For SRs of overall treatment effects that are performed to inform evidence-based treatment guidelines, RoB analyses remain crucial, even though the scores will often be unclear. Ideally, especially for SRs that will be used to plan future experiments/develop treatment guidelines, analyses should only include those studies consistently showing low risk of bias (i.e. low risk on all elements). However, in practice, consistently low RoB studies in our included literature samples (> 20 SRs to date) are too scarce for meaningful analyses. For other types of reviews, we think it is time to consider if complete RoB assessment is the most efficient use of limited resources. While these assessments regularly show problems in reporting, which may help to improve the quality of future primary studies, the unclear scores do not contribute much to understanding the effects observed in meta-analyses.

With PubMed already indexing nearly 300,000 mentioning the term “systematic review” in the title, abstract, or keywords, we can assume that many scientists are spending substantial amounts of time and resources on RoB and RQ assessments. Particularly for larger reviews, it could be worthwhile to restrict RoB assessment to either a random subset of the included publications or a subset of relatively informative elements. Even a combination of these two strategies may be sufficiently informative if the results of the review are not directly used to guide treatment decisions. The subset could give a reasonable indication of the overall level of evidence of the SR while saving resources. Different suggested procedures are provided in Table  5 . The authors of this work would probably have changed to such a strategy during their early data extraction phase, if the funder would not have stipulated full RoB assessment in their funding conditions.

We previously created a brief and simple taxonomy of systematised review types [ 44 ], in which we advocate RoB assessments to be a mandatory part of any SR. We would still urge anyone calling their review “systematic” to stick to this definition and perform some kind of RoB and/or RQ assessment, but two independent scientists following a lengthy and complex tool for all included publications, resulting in 74.6% of the assessed elements not being reported, or 77.9% unclear RoB, can, in our opinion, in most cases be considered inefficient and unnecessary.

Our results show that there is plenty of room for improvement in the reporting of experimental details in medical scientific literature, both for animal and for human studies. With the current status of the primary literature as it is, full RoB assessment may not be the most efficient use of limited resources, particularly for SRs that are not directly used as the basis for treatment guidelines or future experiments.

Availability of data and materials

The data described in this study are available from the Open Science Platform ( https://osf.io/fmhcq/ ) in the form of a spreadsheet file. In the data file, the first tab shows the list of questions that were used for data extraction with their respective short codes. The second tab shows the full individual study-level scores, with lines per study and columns per short code.

Abbreviations

• Cystic fibrosis

High risk of bias

Low risk of bias

No, not reported

• Nasal potential difference
• Risk of bias
• Reporting quality

Systematic review

Unclear risk of bias

Yes, reported

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Acknowledgements

The authors kindly acknowledge Dr. Hendrik Nieraad for his help in study classification.

Open Access funding enabled and organized by Projekt DEAL. This research was funded by the BMBF, grant number 01KC1904. During grant review, the BMBF asked for changes in the review design which we incorporated. Publication of the review results was a condition of the call. Otherwise, the BMBF had no role in the collection, analysis and interpretation of data, or in writing the manuscript.

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CL and AB acquired the grant to perform this work and designed the study. CL performed the searches. FS and CL extracted the data. CL performed the analyses. CH performed quality controls for the data and analyses. CL drafted the manuscript. All authors revised the manuscript and approved of the final version.

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Leenaars, C.H.C., Stafleu, F.R., Häger, C. et al. A case study of the informative value of risk of bias and reporting quality assessments for systematic reviews. Syst Rev 13 , 230 (2024). https://doi.org/10.1186/s13643-024-02650-w

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Spatiotemporal landscape pattern changes and their effects on land surface temperature in greenbelt with semi-arid climate: A case study of the Erbil City, Iraq

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• Suzan Ismail 1 &
• Hamid Maliki 1  

Urban expansion of cities has caused changes in land use and land cover (LULC) in addition to transformations in the spatial characteristics of landscape structure. These alterations have generated heat islands and rise of land surface temperature (LST), which consequently have caused a variety of environmental issues and threated the sustainable development of urban areas. Greenbelts are employed as an urban planning containment policy to regulate urban expansion, safeguard natural open spaces, and serve adaptation and mitigation functions. And they are regarded as a powerful measure for enhancing urban environmental sustainability. Despite the fact that, the relation between landscape structure change and variation of LST has been examined thoroughly in many studies, but there is a limitation concerning this relation in semi-arid climate and in greenbelts as well, with the lacking of comprehensive research combing both aspects. Accordingly, this study investigated the spatiotemporal changes of landscape pattern of LULC and their relationship with variation of LST within an inner greenbelt in the semi-arid Erbil City of northern Iraq. The study utilized remote sensing data to retrieve LST, classified LULC, and calculated landscape metrics for analyzing spatial changes during the study period. The results indicated that both composition and configuration of LULC had an impact on the variation of LST in the study area. The Pearson’s correlation showed the significant effect of Vegetation 1 type (VH), cultivated land (CU), and bare soil (BS) on LST, as increase of LST was related to the decrease of VH and the increases of CU and BS, while, neither Vegetation 2 type (VL) nor built-up (BU) had any effects. Additionally, the spatial distribution of LULC also exhibited significant effects on LST, as LST was strongly correlated with landscape indices for VH, CU, and BS. However, for BU, only aggregation index metric affected LST, while none of VL metrics had a relation. The study provides insights for landscape planners and policymakers to not only develop more green spaces in greenbelt but also optimize the spatial landscape patterns to reduce the influence of LST on the urban environment, and further promote sustainable development and enhance well-being in the cities with semi-arid climate.

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Ismail, S., Maliki, H. Spatiotemporal landscape pattern changes and their effects on land surface temperature in greenbelt with semi-arid climate: A case study of the Erbil City, Iraq. J. Arid Land (2024). https://doi.org/10.1007/s40333-024-0027-x

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Lesson Plan: Civil War Journal - Case Study of Ellen and Samuel Woodworth

Introduction to the Journal

Former President of the Michigan Historical Commission Jack Dempsey provided introductory remarks for his talk about a Michigan woman’s Civil War journal and her experience during the war. The Abraham Lincoln Civil War Roundtable of Michigan hosted this program.

Description

This lesson uses the Civil War era writings of soldier Samuel Woodworth and his wife Ellen to explore the conflict from a unique perspective. The lesson, which features former President of the Michigan Historical Commission Jack Dempsey speaking at the Abraham Lincoln Civil War Roundtable of Michigan, opens with two reflective questions that ask students to reflect on what can be learned from primary sources and consider what the roles of women were during the Civil War. Students then view an introductory video clip in which Dempsey provides opening comments about the journal. Next, students view and analyze two video clips that provide background information about Ellen and Samuel Woodworth and the roles of northern women during the Civil War. From there, students learn about Ellen and Samuel Woodworth’s various roles during the Civil War by watching and responding to four video clips. Next, students view and analyze four video clips that detail the various themes that are evident in the Woodworth journal. Students then view and analyze two final video clips in which Dempsey discusses what happened to the Woodworths after the War and why their writings are worthy of contemporary publication. Finally, students respond to a summative writing prompt that asks them to "detail the challenges [Ellen and Samuel Woodworth] faced and their related contributions during this era."

This lesson offers several options for you to use with your students whether you are teaching in class, using a hybrid model, or engaging through distance learning. It can be completed in steps as a class or students can move at their own pace and complete the activities independently.

You can post links to the videos in the lesson along with the related handout and engage in discussion to share responses on a discussion board or learning management system.

You can also save and share the following Google resource for students to use with this lesson.

Handout: Graphic Organizer (Google Doc).

In Google, choose "File" then "Make a Copy" to get your own copy. You can make any needed adjustments in the instructions such as which activities students need to complete, when it is due, etc. and then make it available to them via Google.

Pose the following brainstorming questions to your students, directing them to record their responses in their graphic organizer, share with a partner, and then with the class if they choose.

• What can we learn from the private letters of those from the past?
• Describe the roles of women during the Civil War.

INTRODUCTION

Play the following introductory video clip of former President of the Michigan Historical Commission Jack Dempsey providing introductory remarks for his talk about a Michigan woman’s Civil War journal and her experience during the war. Direct your students to answer the related question on their graphic organizer and share their findings with a partner, small group, or the class when finished.

Clip #1: Introduction to the Journal (3:14).

• Based on the clip, where is Ellen Woodworth’s journal currently located?
• Is the document shown in the clip actually “a diary or a journal?” Explain.
• How can we be sure that the document is “authentic?”
• What is “interesting” about the letters?
• Who is the “hero” of the story? Why?

Direct your students to their graphic organizers to view and define the vocabulary terms that will appear in the lesson in the chart in their graphic organizer handout. The vocabulary words are also listed to the right on this webpage.

We recommend having your students complete the activity in a jigsaw format to save time. Or, depending on time and resources, you may consider having your students engage in a Frayer's Model activity , where each student is responsible for completing one or two items. Students can then post their models around the room for reference throughout the lesson.

Note: this is not an all-encompassing list of terms included in each video. We recommend you preview the video clips to determine any necessary additions/subtractions to this list for your specific students .

Direct students to the Background section of their graphic organizers. Instruct your students to view the following two video clips that provide background information about Ellen and Samuel Woodworth and the roles of northern women during the Civil War. Direct your students to answer the related questions on their graphic organizer and share their findings with a partner, small group, or the class when finished.

Clip #2: Contributions of Northern Women (1:41).

• Based on the clip, what event did President Abraham Lincoln attend in March of 1864?
• Whose “virtues” did President Lincoln extol during the event?
• Summarize the quote from President Lincoln, as shown in the clip.
• What idea is “often overlooked?” Explain.

Clip #3: Ellen Preston and Samuel Woodworth (2:58).

• Summarize the biographical information about the two individuals, as discussed in the clip.
• Is either person “remarkable?” Explain.
• Based on the clip, who have most of the books about women during the Civil War focused on? Why?
• What “major contributions” did northern women make during the War?

Direct students to the War Time section of their graphic organizers. Instruct your students to view the following four video clips that highlight Ellen and Samuel Woodworth’s various roles during the Civil War. Direct your students to answer the related questions on their graphic organizer and share their findings with a partner, small group, or the class when finished.

Clip #4: Recruitment and Enlistment (2:02).

• Based on the clip, why did Samuel Woodworth enlist in the military?
• Summarize Jack Dempsey’s comments about ‘honor.’ What was a “bounty?”
• What was “not typical” about Samuel? Explain.
• According to Dempsey, what role did Samuel have in the military?

Clip #5: To the Deep South (4:40).

• How did Samuel Woodworth get to the “deep South?” Why?
• Summarize the history and roles of Samuel’s “regiment.”
• What caused “most” of the deaths in Samuel’s regiment, and what percentage of the soldiers never returned home?
• Why was the regiment especially “important” in 1863 and 1864?

Clip #6: Ellen’s Roles (1:22).

• What was Ellen Woodworth doing while her husband was “away at the front?”
• Based on the clip, what did Ellen routinely offer to send her husband?
• Describe Ellen’s “resourcefulness” during the Civil War.

Clip #7: A Cartoon (2:54).

• Before playing the clip, describe what roles you see depicted in the cartoon image.
• According to Jack Dempsey, was Ellen Woodworth a prognosticator? Explain.
• Based on the clip, was Ellen a teacher, a nurse, or a cook?
• What other roles did Ellen “fulfill” during the Civil War?

THEMES AND LESSONS

Direct students to the Themes and Lessons section of their graphic organizers. Instruct your students to view the following four video clips that detail the various themes that are evident in the Woodworth journal. Direct your students to answer the related questions on their graphic organizer and share their findings with a partner, small group, or the class when finished.

Clip #8: The Journal and Slavery (6:25).

• What is “revealed” throughout the journal?
• Based on the clip, why had Samuel and Ellen Woodworth moved to Michigan? Who was already living in the area?
• What did Samuel see “for the first time” when he became a soldier during the Civil War?
• Why did “most” northern soldiers fight during the War?
• According to Jack Dempsey, what might Samuel have agreed with? How do we know?
• Based on the clip, how did his military service change Samuel’s views regarding slavery? Explain.
• Compare Ellen and Samuel’s views about religion, as discussed by Dempsey.
• What was Ellen’s “motivation” for writing letters to her husband, and what insight does the journal offer us today?

Clip #9 Poignant Moments (1:25).

• Summarize Ellen Woodworth’s Christmas 1863 message to her husband, as discussed in the clip.
• What is a “recurring theme” in many of Ellen’s messages?
• How does the third “comment” parallel events in our own lives? Explain.

Clip #10: Dangers and Faith (4:22).

• What “danger” did Samuel Woodworth face as a soldier?
• Based on the clip, what did Samuel see while working on the railroads?
• What did Samuel “incur” during his time in the military?
• Why did Ellen experience “anxiety?” Explain.
• Describe Ellen’s “abiding faith” and summarize its related impact.

Clip #11: Military Record and Hospital (3:54).

• What does Samuel Woodworth’s military record shown in the clip ‘indicate?’
• According to Jack Dempsey, what were the conditions at General Hospital No. 15?
• Based on the clip, who was Dr. Tripler and what did he do?
• Why has Tripler been “denigrated?” Summarize Dempsey’s related comments about Civil War medicine.

After your students finish sharing their findings from the last section, direct them to the Reflection section of their graphic organizers. Instruct your students to view the following final two video clips in which former President of the Michigan Historical Commission Jack Dempsey discusses what happened to the Woodworths after the War and why their writings are worthy of contemporary publication. Direct your students to answer the related questions and share their findings with a partner, small group, or the class when finished.

Clip #12: After the War (1:31).

• Based on the clip, what happened to Samuel and Ellen Woodworth after the Civil War?
• What is the “description” on Ellen’s grave marker? Why is this “inadequate?”
• How were Ellen and Samuel “reunited?”

Clip #13: Worthy of Publication (4:46).

• How is this journal a “new perspective” about the Civil War? Explain.
• Based on the clip, which unique themes are evident in the letters?
• How do the letters showcase both “intensity” and “intimacy?”
• According to Jack Dempsey, what do primary source materials allow us to do?

After your students are finished with the lesson, direct them to complete the final culminating writing prompt and have students share their responses, comparing their perspectives with their classmates' perspectives: Having learned about the Civil War experiences of Ellen and Samuel Woodworth, detail the challenges they faced and their related contributions during this era . Be sure to include evidence from the video clips in the lesson to support your argument .

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• Bell Ringer: Civil War: Women and Nursing in the South
• Bell Ringer: Civil War Medicine and Disabled Veterans
• Bell Ringer: Abraham Lincoln and the Emancipation Proclamation
• Bell Ringer: Civil War Guerilla Warfare and The Lieber Code
• Bell Ringer: Legalized Prostitution During the Civil War
• Lesson Plan: Rural America after the Civil War
• Lesson Plan: Fraternization During the Civil War
• Lesson Plan: Civil War Attacks on Civilians and Private Property
• Lesson Plan: African American Letters to Abraham Lincoln
• Lesson Plan: African American Civil War Era Letters
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• Bushwhacker
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• Emancipation Proclamation (1863)
• Homestead Act Of 1862

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Analysis of Postponement Practice in Cement Supply Chain: A Case Study

This research focuses on assessing implementing postponement in a cement industry especially for OPC (Ordinary Portland Cement) in Indonesia. The company offers three postponement points; Ciawi and Kampung Rambutan, and Jatiwarna. This research has been done with observational method to map customer condition. Moreover, implementing linear programming model is used to gain optimal solution for allocated truck. The results are, highest proportion of OPC customer is in Jakarta, followed Karawang, and Bogor. The result from linear programming model simulation, Ciawi point is assigned to serve Jakarta and Bogor’ customers, Kampung Rambutan point is assigned for Jakarta and Kawarang’ customers, and Jatiwarna point is prepared for Jakarta, Karawang, Bekasi, Lampung, Pekalongan, Tangerang, and Serang’ customers. So, implementing postponement can increase customer satisfaction without adding higher cost such as investment cost. The cement industry encounter effectiveness and responsiveness even tough, some problem shall be taken such as double administration process (manual and computerized).

Agudelo, I. (2009) Supply Chain Management in the Cement Industry. Master of Engineering in Logistics. MIT. Available at: https://dspace.mit.edu/handle/1721.1/51643.

Dubey, R., Singh, T., Tiwari, S. (2012) “Supply Chain Innovation is a Key to Superior Firm Performance an Insight from Indian Cement Manufacturing,” International Journal of Innovation Science, 4 (4), 217–229.

Gaudêncio, F., Freires, M. (2012). “Economies of scale and postponement as critical factors to the effectiveness and efficiency in reverse logistics systems (RLSs),” in Actes des rencontres RIRL 2012 Proceedings Logistique inversée Reverse Logistics. Available at: https://www.academia.edu/3362254/Economies_of_scale_and_postponement_as_critical_factors_to_the_effectiveness_and_efficiency_in_reverse_logistics_systems_RLSs_.

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Hariawan, J. B. (2007) Pengaruh Perbedaan Karakteristik Type Semen Ordinary Portland Cement (OPC) dan Portland Composite Cement (PCC) Terhadap Kuat Tekan Mortar.

Van Hoek, R. I. (2001) “Rediscovery of postponement a literature review and directions for research,” Journal of Operations Management, 19 (2), 161–184. doi: 10.1016/S0272-6963(00)00057-7.

MacCarthy, B., Brabazon, P. G. (2006) “Variety, Postponement and Reconfiguration: Insights from Automotive Order Fulfilment Systems,” IFAC Proceedings Volumes. IFAC, 39(3), pp. 505–510. doi: 10.3182/20060517-3-FR-2903.00264.

Minguella-Canela, J. et al. (2017) “Comparison of production strategies and degree of postponement when incorporating additive manufacturing to product supply chains,” Procedia Manufacturing. Elsevier B.V., 13, pp. 754–761. doi: 10.1016/j.promfg.2017.09.181.

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Qian, J., Lu, J., Yao, S. (2011) “Inventory and package postponement strategy,” Procedia Engineering, 15, pp. 4687–4692. doi: 10.1016/j.proeng.2011.08.877.

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How to choose the best journal for your case report

Richard a. rison.

1 University of Southern California Keck School of Medicine, Los Angeles County Medical Center, 12401 Washington Blvd., Whittier, CA 90602 USA

2 PIH Health Hospital-Whittier Stroke Center, PIH Health Hospital Non-Invasive Vascular Laboratory, 12401 Washington Blvd., Whittier, CA 90602 USA

Jennifer Kelly Shepphird

3 JKS Science & Medical Writing, Los Angeles, CA USA

Michael R. Kidd

4 Faculty of Medicine, Nursing and Health Sciences, Flinders University, GPO Box 2100, Adelaide, SA 5001 Australia

5 Department of Family & Community Medicine, University of Toronto, 500 University Avenue, Toronto, M5G 1V7 Canada

Since the establishment of the Journal of Medical Case Reports in 2006, the number of journals that publish case reports has increased rapidly, and most of these journals are open access. Open access publishing usually requires authors to pay publication fees while offering the articles online, free of charge, and free of most copyright and licensing restrictions. The movement for open access has gained support in the research community, with the publishers BioMed Central and PLOS ONE becoming leaders in scientific publishing in their number of articles and citations. As the number of open access publishers has exploded, so too has the number of publishers that act in bad faith to profit from the open access model. Simple guidelines have been developed and resources are available to help authors choose a suitable journal for publication of their case reports.

Case reports offer unique value to the body of medical knowledge by describing new diseases, disease mechanisms, therapeutic approaches, and adverse or beneficial effects of drugs. The act of recording, discussing with colleagues, and publishing clinical observations as case reports remains essential to the art of medicine and patient care [ 1 ]. These short communications generate or enforce hypotheses that may lead to further evaluation in larger study designs [ 2 ]. In providing detailed descriptions of the symptoms, signs, diagnosis, treatment, and follow-up of an individual patient, case reports reflect clinical experience and support medical progress. By design, the format lacks statistical sampling, placing it at the bottom of the hierarchy of clinical evidence. Case reports do not include controls, have limited sample size (one to a few individuals), and are unblinded, limitations that require a cautious approach to interpretation of findings. General medical journals publish case reports sparingly, often only publishing those that provide new information on adverse events that can be linked to an intervention [ 3 , 4 ]. Journal editors may limit inclusion of case reports because they are cited less often than meta-analyses and randomized controlled trials, which negatively affects a journal’s impact factor.

The merits of large randomized studies are well known, but many clinicians recognize the value of case reports as a complement to evidence-based medicine. The case-based nature of clinical practice often is at odds with the population-based nature of research studies, where the findings may have little relevance to an individual patient. Narrow inclusion criteria and the absence of co-morbidities in randomized trials often create a disconnection between typical patient populations and populations represented in research studies [ 3 ]. Case reports provide enough detail on one or a small number of patients for clinicians to relate to their own practice. They are educational and interesting to read. For the challenging and patient-centered task of reporting on individual cases with inherent heterogeneous human variability in clinical research and the goal of applicability to real-life circumstances, the CARE guidelines provide a framework for completeness and transparency in case reports. The guidelines aid in finding the balance between adequate detail and concise writing [ 5 ].

In response to renewed interest and acknowledgment of their value, the number of peer-reviewed journals that publish case reports has increased in recent years to more than 160 [ 6 ]. In the digital era of paperless journals with few space restrictions, the case report has seen a resurgence. The digital format facilitates searches, which is a key factor in their utility [ 7 ]. Most of the case report journals are open access and have high acceptance rates. As the number of new scientific journals increases, so do the number of questionable publishers that mislead researchers regarding fees, peer review, and academic credentials. The process of submitting scientific work for publication now includes the need for thorough vetting of potential publishers.

New case report journals

In line with the growing demand for case report publishing opportunities, the number of new peer-reviewed journals that focus on case reports had increased to more than 160 journals produced by 78 publishers by mid-2015. Figure  1 shows that the number of case report journals increased rapidly beginning in 2007, a timeframe that coincides with the Great Recession of the late 2000s and the concomitant decline in federal and other funding for basic science and other research. Some of the new journals cover general medicine and others cover specific therapeutic areas. Most case report journals (94%) are open access and approximately 40% are indexed in PubMed. Clinical issues covered by case report journals include previously unreported adverse effects of drugs or other treatments, unexpected events that occur in the course of observing or treating a patient, observations on disease pathogenesis, presentations and/or management of new and emerging diseases, new therapeutic approaches, ethical challenges in patient management, and strategies for preventing or overcoming medical errors [ 6 , 8 ].

Number of case report journals by year. The number of journals that publish case reports has increased rapidly since 2007. (Reprinted with permission from Akers [ 6 ])

Open access publishing offers freely available and unrestricted use of research and scholarship, which many researchers see as vital to efficient dissemination of science in the digital world [ 9 ]. The open access model usually requires authors to pay submission and publication fees upon acceptance, typically between US $300 and $1200 [ 6 ]. The move toward making scholarly publications more accessible through open access has continued to gain supporters among the research community. The open access publisher BioMed Central launched in 2000 with 231 articles published that year in 60 journals. In 2015, the numbers increased to more than 30,000 articles in over 290 journals. In 2014, BioMed Central articles were accessed more than 277 million times and had 426,000 citations [ 10 ]. Similarly, the number of publications from the open access publisher PLOS ONE, increased from 138 at its inception in 2006 to 28,107 in 2015 [ 11 ].

Case report journals

Reprinted with permission from Akers [ 6 ]

Controversial journals and publishers

As scientific publishing shifts from a business model of subscription revenue to open access, the number of open access journals has exploded. However, the proliferation of journals that will publish seemingly anything for a fee has caused alarm among many in the global research community. Alongside many respected open access publishers, others have entered the space acting in bad faith. Some see it as the “dark side” of open access, a growing collection of pseudo-academic, prestigiously titled journals, many of which have similar but not quite identical websites and names to those of well-known established journals. Many of the websites look sufficiently impressive that non-experts doing online research have trouble distinguishing credible research from junk. Experienced academics have been misled into submitting manuscripts and even serving on editorial boards for pseudo-academic journals, agreements that often are difficult to undo. Most of these journals do not post their publication fees, and often authors are not informed of fees until after submitting a manuscript. Withdrawal of a manuscript, which is necessary before submitting the same paper to a legitimate journal, may require payment of the high fees first [ 12 ]. For some authors, this means their work may be lost essentially to the disreputable publisher. Many researchers have complained about poorly executed or absent peer review, hidden fees for submission and publication, and unapproved inclusion of researchers’ names on editorial boards.

Jeffrey Beall, a librarian and associate professor at Auraria Library at the University of Colorado, Denver, coined the term “predatory open access publishing” to describe this situation. He is a critic of open access publishing, blaming the system for creating the problem of predatory publishers. His blog Scholarly Open Access, although removed by Beall for unknown reasons in January 2017, closely monitored the increasing number of open access publishers and alerted readers to individuals, publishers, publications, meetings, and scholarly metrics that, in the view of Mr Beall, appeared to exploit the open access model [ 13 ]. He maintained a list of “potential, possible, or probable predatory scholarly open-access publishers” and another list of standalone journals. His criteria for inclusion on the lists were derived from the Code of Conduct for Journal Publishers from the Committee on Publication Ethics (COPE), and Principles of Transparency and Best Practice in Scholarly Publishing from COPE, the Open Access Scholarly Publishers Association (OASPA), and the World Association of Medical Editors [ 14 – 16 ]. Similarly, information in these communications may help authors to discern whether they can trust a particular publisher or journal. The Federal Trade Commission (FTC) in the USA has taken notice of questionable publication practices. In August 2016 it filed a suit against the OMICS Group, a global conglomerate based in India that publishes more than 700 open access journals. The suit claimed that the OMICS Group misled researchers, particularly with regard to their peer-review process (or lack thereof) and high fees that were not readily apparent to authors upon manuscript submission [ 17 ]. The purpose of the lawsuit, according to the FTC, is to better inform authors of publishing fees and to have a more transparent peer-review system [ 18 ]. The case is still to be litigated in federal court in Nevada at the time of writing this article.

The challenge for watchdogs and authors alike is to decide when a publisher is untrustworthy or simply unprofessional. Some publishers may fall under suspicion due to poor copy editing or amateurish website design, but this may not reflect an outright neglect of scholarly standards. It is important not to blacklist startup publishers who lack experience. Another problem with maintaining lists of disreputable publishers is that because copycat journals are often short-lived, the blacklist will continue to grow but individual entries may quickly become obsolete.

Choose the right journal: Think. Check. Submit.

The “Think. Check. Submit.” campaign arose in response to concerns about publishing practices, and the effort is supported by a coalition of scholarly publishing organizations. “Think. Check. Submit.” takes a positive approach to help researchers identify credible journals, providing up-to-date guidance for choosing where to publish [ 18 , 19 ]. To ascertain whether a journal is trusted, authors are advised to follow this checklist:

• Have you read any articles in the journal before?
• Is it easy to discover the latest papers in the journal?
• Is the publisher name clearly displayed on the journal website?
• Can you contact the publisher by telephone, email, and post?
• Does the journal site explain what these fees are for and when they will be charged?
• Have you heard of the editorial board members?
• Do members of the editorial board mention the journal on their own websites?
• Do they belong to the COPE?
• If the journal is open access, is it listed in the Directory of Open Access Journals (DOAJ)?
• If the journal is open access, does the publisher belong to the OASPA?
• Is the publisher a member of another trade association?

In addition to consulting colleagues and academic librarians for journal suggestions, authors have available to them several online resources. BioMed Central previously collaborated with Edanz, a company that assists authors in navigating the publication process, to create the author academy [ 10 ]. The free online guide describes best practices in writing and publishing a manuscript, including sections on choosing a journal, writing the manuscript, and publication ethics, among others. BioMed Central now contracts with Nature Research Editing Services and American Journal Experts, both of which offer similar services [ 20 , 21 ].

Several automated search tools help identify suitable journals as well. Authors insert keywords from their manuscript abstract into a search engine, which then compares the words to many online publications and Edanz Journal Selector covers a broad range of journals. The online tool is free, and Edanz also offers a journal selection service (US $300) in which experts use their publication experience to identify up to four of the best journals for a given paper [ 22 ]. The Journal/Author Name Estimator (Jane) focuses on biomedical science journals by searching the Medline database published by the US National Library of Medicine [ 23 ]. Other online services offered by publishers Springer and Elsevier suggest journals from their own extensive catalogues [ 24 , 25 ].

Impact factor

Journal impact factors, calculated and published by Thomson Reuters, measure the average number of citations per published article for papers published over a 2-year period. Despite the fact that the simple metric can be misleading, the impact factor has become, over time, a marker of journal prestige and desirability. The judgment of a paper’s value is often based more on the journal in which it appears than on its content. Many researchers contend that reliance on impact factors undervalues disciplines or study designs, such as case reports, which have lower citation rates. Overall, the number of citations of an article is commensurate with hierarchies of evidence, with meta-analyses receiving more citations than any other study design. Case reports typically receive few citations, although there are notable exceptions [ 26 ]. The number of citations of an article, however, does not necessarily reflect how widely the article has been read or the dissemination of the findings in mainstream media [ 27 ].

Efforts to embrace a broader view of value in scientific communication, and perhaps diminish the influence of impact factors, have emerged. Journals of the American Society for Microbiology (ASM) no longer advertise impact factors on their websites. Similarly, in recognizing that impact factors are just one of a number of metrics, Nature journals list a suite of citation-based metrics. Only one case report journal, Taylor & Francis’s Neurocase , has received an impact factor (1.124), dating back to 1998.

Medicine/National Institutes of Health Indexed research databases are often curated to ensure the quality of included publications. Clarivate Analytics (formerly Thomson Reuters) offers The Web of Science™, as one such example, and recently introduced the “Emerging Sources Citation Index” to complement their more selective indexes. This collection reflects the growing number of peer-reviewed publications of regional importance and in emerging fields [ 28 ].

In conclusion, the growth in number of case report journals has provided authors multiple avenues for publication but, at the same time, it has introduced a new level of uncertainty in the journal selection process. Factors to consider when choosing a journal are: the topics the journal covers, the target audience, length restrictions, and the time to publication. Open access publications, such as the Journal of Medical Case Reports from BioMed Central, offer high visibility, relatively rapid publication, and transparent publication policies. The reputation of the journal plays an increasingly important part of the decision, requiring thorough vetting of potential journals.

Acknowledgements

We thank the reviewers for their insightful and helpful comments on our editorial.

Authors’ contributions

All authors read and approved the final manuscript.

Competing interests

RAR is a Deputy Editor and MRK is the Editor-in-Chief of Journal of Medical Case Reports . JKS has nothing to disclose.

Publisher’s Note

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

Contributor Information

Richard A. Rison, Email: ude.csu@nosir .

Jennifer Kelly Shepphird, Email: moc.gnitirwskj@nej .

Michael R. Kidd, Email: [email protected] .

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Circular economy implementation in an organization: a case study of the taiwan sugar corporation.

1. Introduction

2. literature review, 2.1. overview of circular economy principles, 2.2. bs 8001: 2017 principles of the circular economy in organizations, 2.3. implementation of circular economy, 2.4. hypothesis development.

• Economic Aspects (EA)
• Environmental Aspects (ENVA)
• Social Aspects (SA)
• Degree of Concern and Impact
• Relationship between Economic and Environmental Aspects
• Relationship between Environmental and Social Aspects
• Relationship between Economic and Social Aspects

2.5. Research Procedure

3. research background and information, 3.1. tsc’s circular economy concept and planning, 3.2. promote the circular economy process of oyster shells, 3.3. short-, medium-, and long-term goals of the oyster shell circular economy.

• Short-Term Goals (2018–2020)
• Establish an oyster shell processing plant to recycle discarded shells.
• Achieve green building standards, save energy and water, and reduce carbon emissions.
• Collaborate with research institutes for product applications.
• Begin plant operations and obtain production licenses.
• Mid-Term Goals (2021–2023)
• Obtain necessary operational permits and ISO certifications.
• Optimize equipment and processes, and expand product applications to feed, fertilizers, and 3D printing.
• Enhance research and development in collaboration with academic and industrial partners.
• Long-Term Goals (2024–2026)
• Expand production capacity to 50,000 tons per year.
• Source oyster shells from across Taiwan and outlying islands.
• Achieve carbon neutrality certifications and develop new applications for functional materials.

3.4. Complementary Corrective Measures in Response to Risks and Opportunities

3.5. business objectives and business strategies.

• Efficient utilization and processing of oyster shell raw materials.
• Achieving zero pollution, zero waste, and zero accidents through advanced environmental management.
• Expanding the applications of calcium carbonate to various industries.
• Establishing a model for industrial innovation and circular economy practices.

4. Research Methodology

4.1. data collection, 4.1.1. stakeholder survey.

• Biotechnology Division.
• General Management Office.
• Planning Office.
• Oyster Shell Suppliers: Ji Jin Fishery Marketing Cooperative, located in Chiayi County, Taiwan, and Jiesheng Environmental Co., Ltd., based in Tainan, Taiwan.
• Packaging Material Suppliers: Chengxin Industrial Co., Ltd., situated in Taipei, Taiwan, and Zhangming Enterprise Co., Ltd., located in Taichung, Taiwan.
• Third Party Logistics: Youheng Transportation Co., Ltd., which operates out of Kaohsiung, Taiwan
• YingHe Company located in Tainan, Taiwan.
• Internal Customers: Taiwan Sugar Corporation’s Animal Husbandry Division, Recreation Division, and various district offices.
• External Customers: Nong Sheng Enterprise Co., Ltd. is located in Taichung, Taiwan. Fu Shou Industrial Co., Ltd. is based in Taipei, Taiwan. Mao Sheng Agricultural Economics Co., Ltd. operates out of Taipei, Taiwan. Fumao Oils & Fats Co., Ltd. is situated in Tainan, Taiwan. Taiwan Charoen Pokphand Enterprise Co., Ltd. is headquartered in Taipei, Taiwan. Formosa Plastics Corporation is located in Kaohsiung, Taiwan. Nan Pao Resins Chemical Co., Ltd. is based in Tainan, Taiwan. Uni-President Enterprises Corporation operates from Tainan, Taiwan. Great Wall Enterprise Co., Ltd. is situated in Taipei, Taiwan. Finally, Xie Xin Machinery Co., Ltd. is located in Taichung, Taiwan.
• Internal employees of the biotechnology material factory.
• Degree of Concern: measured the stakeholders’ level of concern regarding the economic, environmental, and social aspects of the Taiwan Sugar Company’s circular economy transition. A five-point Likert scale (1 = Not at all concerned to 5 = Extremely concerned) was used for each aspect.
• Degree of Impact: evaluated the stakeholders’ beliefs about the positive and negative impacts of the Taiwan Sugar Company’s circular economy initiatives on the same three aspects (economic, environmental, and social). A similar five-point Likert scale (1 = Very low impact to 5 = Very high impact) was employed.

4.1.2. Internal Company Documents

• Sustainability reports: providing insights into the Taiwan Sugar Company’s existing sustainability practices and circular economy goals.
• Strategic plans: outlining the company’s vision and objectives related to circularity.
• Operational data: on waste generation, resource consumption, and production processes, used to assess the feasibility of implementing specific circular economy strategies.

4.1.3. Stakeholder Communication

5. assessment and result, 5.1. stakeholder investigation and analysis, 5.1.1. structural model assessment.

• H1(a): EA → ENVA: The positive relationship between the Economic Aspects and Environmental Aspects is confirmed, with a Beta coefficient of 0.855 and an R² value of 0.730. This indicates that the Economic Aspects significantly influence the Environmental Aspects.
• H2(a): ENVA → SA: The positive relationship between the Environmental Aspects and Social Aspects is also supported, with a Beta coefficient of 0.839 and an R² value of 0.814. This suggests that the Environmental Aspects have a substantial impact on the Social Aspects.
• H3(a): EA → SA: The positive relationship between the Economic Aspects and Social Aspects is further validated, with a Beta coefficient of 0.902 and an R² value of 0.703. This implies that the Economic Aspects significantly influence the Social Aspects.
• (b) For Degree of Impact
• H1(b): EA → ENVA: The positive relationship between the Economic Aspects and Environmental Aspects is confirmed, with a Beta coefficient of 0.734 and an R² value of 0.538. This indicates that the Economic Aspects significantly influence the Environmental Aspects.
• H2(b): ENVA → SA: The positive relationship between the Environmental Aspects and Social Aspects is also supported, with a Beta coefficient of 0.814 and an R² value of 0.663. This suggests that the Environmental Aspects have a substantial impact on the Social Aspects.
• H3(b): EA → SA: The positive relationship between Economic Aspects and Social Aspects is further validated, with a Beta coefficient of 0.942 and an R² value of 0.971. This implies that the Economic Aspects significantly influence the Social Aspects.

5.1.2. Identify the Degree of Attention and Impact

5.2. feasibility assessment, 5.2.1. swot analysis of tsc biotech material factory, 5.2.2. strategy evaluation and selection, 5.3. tsc circular economy systematic thinking framework output, 5.4. implementation, assessment, and results of tsc’s circular economy transition, 5.4.1. the carbon reduction benefits are as follows.

• TSC’s Oyster Shell Calcium Carbonate: uses natural gas, resulting in a carbon footprint of 0.02255 metric tons of CO₂e per ton.
• Traditional processing: uses heavy oil, resulting in 0.043 metric tons of CO₂e per ton.
• Mining of Ore: results in 0.18 metric tons of CO 2 e per ton.

5.4.2. The Reduction of Oyster Shell Waste Is as Follows

• Total recycled waste: by the end of 2021, TSC recycled and treated 3012 tons of oyster shells.
• Applications: Oyster shells are used for handmade artworks, raw materials for feed and fertilizers, artificial fishing reefs, and replacing traditional cement breakwaters.

5.4.3. The Solar Panel Installation Results Are as Follows

• Current capacity: TSC has installed rooftop solar power equipment in 39 locations with a total capacity of 14.02 MW.
• Past achievements include the following: ○ 2019: 4.56 MW generating 519.07 MWh (24.84% increase). ○ 2020: 12.30 MW generating 1166 MWh (124.63% increase). ○ 2021: 322.79 MW generating 23,153 MWh (1885.67% increase).

5.4.4. Financial Performance

• Revenue growth: TSC’s total revenue increased from NTD 29,913 million in 2020 to NTD 32,461 million in 2022, marking a 6.27% growth in operating income and a 289.33% increase in other income during this period [ 34 ].
• Profit improvement: despite some fluctuations, TSC managed to maintain profitability with net incomes of NTD 4567 million in 2020, NTD 3908 million in 2021, and NTD 2428 million in 2022. The net profit margin, while experiencing a decrease, remained at a respectable 8.42% in 2022 [ 34 ].
• Cost savings: through various circular economy initiatives, including energy efficiency improvements and waste reduction strategies, TSC has effectively managed its operating costs. For instance, the operating costs were NTD 19,825 million in 2020 and increased to NTD 22,855 million in 2022, a controlled growth relative to the revenue increases.

6. Conclusions

Supplementary materials, author contributions, institutional review board statement, informed consent statement, data availability statement, acknowledgments, conflicts of interest.

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Sah, A.K.; Hong, Y.-M. Circular Economy Implementation in an Organization: A Case Study of the Taiwan Sugar Corporation. Sustainability 2024 , 16 , 7865. https://doi.org/10.3390/su16177865

Sah AK, Hong Y-M. Circular Economy Implementation in an Organization: A Case Study of the Taiwan Sugar Corporation. Sustainability . 2024; 16(17):7865. https://doi.org/10.3390/su16177865

Sah, Amit Kumar, and Yao-Ming Hong. 2024. "Circular Economy Implementation in an Organization: A Case Study of the Taiwan Sugar Corporation" Sustainability 16, no. 17: 7865. https://doi.org/10.3390/su16177865

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