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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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Fundamentals of case study research in family medicine and community health

Sergi fàbregues, michael d fetters.

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Correspondence to Dr Sergi Fàbregues, Department of Psychology and Education, Universitat Oberta de Catalunya, Rambla del Poblenou, 156, 08018, Barcelona, Spain; [email protected]

Corresponding author.

Received 2018 Nov 30; Revised 2018 Dec 7; Accepted 2019 Jan 23; Collection date 2019.

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0

The aim of this article is to introduce family medicine researchers to case study research, a rigorous research methodology commonly used in the social and health sciences and only distantly related to clinical case reports. The article begins with an overview of case study in the social and health sciences, including its definition, potential applications, historical background and core features. This is followed by a 10-step description of the process of conducting a case study project illustrated using a case study conducted about a teaching programme executed to teach international family medicine resident learners sensitive examination skills. Steps for conducting a case study include (1) conducting a literature review; (2) formulating the research questions; (3) ensuring that a case study is appropriate; (4) determining the type of case study design; (5) defining boundaries of the case(s) and selecting the case(s); (6) preparing for data collection; (7) collecting and organising the data; (8) analysing the data; (9) writing the case study report; and (10) appraising the quality. Case study research is a highly flexible and powerful research tool available to family medicine researchers for a variety of applications.

Keywords: Case study research, research design, mixed methods, family practice, primary care, general practice

Significance statement

Given their potential for answering ‘how’ and ‘why’ questions about complex issues in their natural setting, case study designs are being increasingly used in the health sciences. Conducting a case study can, however, be a complex task because of the possibility of combining multiple methods and the need to choose between different types of case study designs. In order to introduce family medicine and community health researchers to the fundamentals of case study research, this article reviews its definition, potential applications, historical background and main characteristics. It follows on with a practical, step-by-step description of the case study process that will be useful to researchers interested in implementing this research design in their own practice.

Introduction

This article provides family medicine and community health researchers a concise resource to conduct case study research. The article opens with an overview of case study in the social and health sciences, including its definition, potential applications, historical background and core features. This is followed by a 10-step description of the process of conducting a case study project, as described in the literature. These steps are illustrated using a case study about a teaching programme executed to teach international medical learners sensitive examination skills. The article ends with recommendations of useful articles and textbooks on case study research.

Origins of case study research

Case study is a research design that involves an intensive and holistic examination of a contemporary phenomenon in a real-life setting. 1–3 It uses a variety of methods and multiple data sources to explore, describe or explain a single case bounded in time and place (ie, an event, individual, group, organisation or programme). A distinctive feature of case study is its focus on the particular characteristics of the case being studied and the contextual aspects, relationships and processes influencing it. 4 Here we do not include clinical case reports as these are beyond the scope of this article. While distantly related to clinical case reports commonly used to report unusual clinical case presentations or findings, case study is a research approach that is frequently used in the social sciences and health sciences. In contrast to other research designs, such as surveys or experiments, a key strength of case study is that it allows the researcher to adopt a holistic approach—rather than an isolated approach—to the study of social phenomena. As argued by Yin, 3 case studies are particularly suitable for answering ‘how’ research questions (ie, how a treatment was received) as well as ‘why’ research questions (ie, why the treatment produced the observed outcomes).

Given its potential for understanding complex processes as they occur in their natural setting, case study increasingly is used in a wide range of health-related disciplines and fields, including medicine, 5 nursing, 6 health services research 1 and health communication. 7 With regard to clinical practice and research, a number of authors 1 5 8 have highlighted how insights gained from case study designs can be used to describe patients’ experiences regarding care, explore health professionals’ perceptions regarding a policy change, and understand why medical treatments and complex interventions succeed or fail.

In anthropology and sociology, case study as a research design was introduced as a response to the prevailing view of quantitative research as the primary way of undertaking research. 9 From its beginnings, social scientists saw case study as a method to obtain comprehensive accounts of social phenomena from participants. In addition, it could complement the findings of survey research. Between the 1920s and 1960s, case study became the predominant research approach among the members of the Department of Sociology of the University of Chicago, widely known as ‘The Chicago School’. 10 11 During this period, prominent sociologists, such as Florian Znaniecki, William Thomas, Everett C Hughes and Howard S Becker, undertook a series of innovative case studies (including classical works such as The Polish peasant in Europe and America or Boys in White ), which laid the foundations of case study designs as implemented today.

In the 1970s, case study increasingly was adopted in the USA and UK in applied disciplines and fields, such as education, programme evaluation and public policy research. 12 As a response to the limitations of quasi-experimental designs for undertaking comprehensive programme evaluations, researchers in these disciplines saw in case studies—either alone or in combination with experimental designs—an opportunity to gain additional insights into the outcomes of programme implementation. In the mid-1980s and early 1990s, the case study approach became recognised as having its own ‘logic of design’ (p46). 13 This period coincides with the publication of a considerable number of influential articles 14–16 and textbooks 4 17 18 on case study research.

These publications were instrumental in shaping contemporary case study practice, yet they reflected divergent views about the nature of case study, including how it should be defined, designed and implemented (see Yazan 19 for a comparison of the perspectives of Yin, Merriam and Stake, three leading case study methodologists). What these publications have in common is that case study revolves around four key features.

First, case study examines a specific phenomenon in detail by performing an indepth and intensive analysis of the selected case. The rationale for case study designs, rather than more expansive designs such as surveys, is that the researcher is interested in investigating the particularity of a case, that is, the unique attributes that define an event, individual, group, organisation or programme. 2 Second, case study is conducted in natural settings where people meet, interact and change their perceptions over time. The use of the case study design is a choice in favour of ‘maintaining the naturalness of the research situation and the natural course of events’ (p177). 20

Third, case study assumes that a case under investigation is entangled with the context in which it is embedded. This context entails a number of interconnected processes that cannot be disassociated from the case, but rather are part of the study. The case study researcher is interested in understanding how and why such processes take place and, consequently, uncovering the interactions between a case and its context. Research questions concerning how and why phenomena occur are particularly appropriate in case study research. 3

Fourth, case study encourages the researcher to use a variety of methods and data types in a single study. 20 21 These can be solely qualitative, solely quantitative or a mixture of both. The latter option allows the researcher to gain a more comprehensive understanding of the case and improve the accuracy of the findings. The four above-mentioned key features of case study are shown in table 1 , using the example of a mixed methods case study evaluation. 22

Key features of case study as presented by Shultz et al 22

There are many potential applications for case study research. While often misconstrued as having only an exploratory role, case study research can be used for descriptive and explanatory research (p7–9). 3 Family medicine and community health researchers can use case study research for evaluating a variety of educational programmes, clinical programmes or community programmes.

Case study illustration from family medicine

In the featured study, Japanese family medicine residents received standardised patient instructor-based training in female breast, pelvic, male genital and prostate examinations as part of an international training collaboration to launch a new family medicine residency programme. 22 From family medicine residents, trainers and staff, the authors collected and analysed data from post-training feedback, semistructured interviews and a web-based questionnaire. While the programme was perceived favourably, they noted barriers to reinforcement in their home training programme, and taboos regarding gender-specific healthcare appear as barriers to implementing a similar programme in the home institution.

A step-by-step description of the process of carrying out a case study

As shown in table 2 and illustrated using the article by Shultz et al , 22 case study research generally includes 10 steps. While commonly conducted in this order, the steps do not always occur linearly as data collection and analysis may occur over several iterations or implemented with a slightly different order.

Ten steps for conducting a case study

SPI, standardised patient instructor.

Step 1. Conduct a literature review

During the literature review, researchers systematically search for publications, select those most relevant to the study’s purpose, critically appraise them and summarise the major themes. The literature review helps researchers ascertain what is and is not known about the phenomenon under study, delineate the scope and research questions of the study, and develop an academic or practical justification for the study. 23

Step 2. Formulate the research questions

Research questions critically define in operational terms what will be researched and how. They focus the study and play a key role in guiding design decisions. Key decisions include the case selection and choice of a case study design most suitable for the study. According to Fraenkel et al , 24 the key attributes of good research questions are (1) feasibility, (2) clarity, (3) significance, (4) connection to previous research identified in the literature and (5) compliance with ethical research standards.

Step 3. Ensure that a case study is appropriate

Before commencing the study, researchers should ensure that case study design embodies the most appropriate strategy for answering the study questions. The above-noted four key features—in depth examination of phenomena, naturalness, a focus on context and the use of a combination of methods—should be reflected in the research questions as well as subsequent design decisions.

Step 4. Determine the type of case study design

Researchers need to choose a specific case study design. Sometimes, researchers may define the case first (step 5), for example, in a programme evaluation, and the case may need to be defined before determining the type. Yin’s 3 typology is based on two dimensions, whether the study will examine a single case or multiple cases, and whether the study will focus on a single or multiple units of analysis. Figure 1 illustrates these four types of design using a hypothetical example of a programme evaluation. Table 3 shows an example of each type from the literature.

Types of case study designs. 3 21

Examples of published studies using the four types of case study designs suggested by Yin 3

In type 1 holistic single case design , researchers examine a single programme as the sole unit of analysis. In type 2 embedded single case design , the interest is not exclusively in the programme, but also in its different subunits, including sites, staff and participants. These subunits constitute the range of units of analysis. In type 3 holistic multiple case design , researchers conduct a within and cross-case comparison of two or more programmes, each of which constitutes a single unit of analysis. A major strength of multiple case designs is that they enable researchers to develop an in depth description of each case and to identify patterns of variation and similarity between the cases. Multiple case designs are likely to have stronger internal validity and generate more insightful findings than single case designs. They do this by allowing ‘examination of processes and outcomes across many cases, identification of how individual cases might be affected by different environments, and the specific conditions under which a finding may occur’ (p583). 25 In type 4 embedded multiple case design , a variant of the holistic multiple case design, researchers perform a detailed examination of the subunits of each programme, rather than just examining each case as a whole.

Step 5. Define the boundaries of the case(s) and select the case(s)

Miles et al 26 define a case as ‘a phenomenon of some sort occurring in a bounded context’ (p28). What is and is not the case and how the case fits within its broader context should be explicitly defined. As noted in step 4, this step may occur before choice of the case study type, and the process may actually occur in a back-and-forth fashion. A case can entail an individual, a group, an organisation, an institution or a programme. In this step, researchers delineate the spatial and temporal boundaries of the case, that is, ‘when and where it occurred, and when and what was of interest’ (p390). 9 Aside from ensuring the coherence and consistency of the study, bounding the case ensures that the planned research project is feasible in terms of time and resources. Having access to the case and ensuring ethical research practice are two central considerations in case selection. 1

Step 6. Prepare to collect data

Before beginning the data collection, researchers need a study protocol that describes in detail the methods of data collection. The protocol should emphasise the coherence between the data collection methods and the research questions. According to Yin, 3 a case study protocol should include (1) an overview of the case study, (2) data collection procedures, (3) data collection questions and (4) a guide for the case study report. The protocol should be sufficiently flexible to allow researchers to make changes depending on the context and specific circumstances surrounding each data collection method.

Step 7. Collect and organise the data

While case study is often portrayed as a qualitative approach to research (eg, interviews, focus groups or observations), case study designs frequently rely on multiple data sources, including quantitative data (eg, surveys or statistical databases). A growing number of authors highlight the ways in which the use of mixed methods within case study designs might contribute to developing ‘a more complete understanding of the case’ (p902), 21 shedding light on ‘the complexity of a case’ (p118) 27 or increasing ‘the internal validity of a study’ (p6). 1 Guetterman and Fetters 21 explain how a qualitative case study can also be nested within a mixed methods design (ie, be considered the qualitative component of the design). An interesting strategy for organising multiple data sources is suggested by Yin. 3 He recommends using a case study database in which different data sources (eg, audio files, notes, documents or photographs) are stored for later retrieval or inspection. See guidance from Creswell and Hirose 28 for conducting a survey and qualitative data collection in mixed methods and DeJonckheere 29 on semistructured interviewing.

Step 8. Analyse the data

Bernard and Ryan 30 define data analysis as ‘the search for patterns in data and for ideas that help explain why these patterns are there in the first place’ (p109). Depending on the case study design, analysis of the qualitative and quantitative data can be done concurrently or sequentially. For the qualitative data, the first step of the analysis involves segmenting the data into coding units, ascribing codes to data segments and organising the codes in a coding scheme. 31 Depending on the role of theory in the study, an inductive, data-driven approach can be used where meaning is found in the data, or a deductive, concept-driven approach can be adopted where predefined concepts derived from the literature, or previous research, are used to code the data. 32 The second step involves searching for patterns across codes and subsets of respondents, so major themes are identified to describe, explain or predict the phenomenon under study. Babchuk 33 provides a step-by-step guidance for qualitative analysis in this issue. When conducting a single case study, the within-case analysis yields an in depth, thick description of the case. When the study involves multiple cases, the cross-comparison analysis elicits a description of similarities and divergence between cases and may generate explanations and theoretical predictions regarding other cases. 26

For the quantitative part of the case study, data are entered in statistical software packages for conducting descriptive or inferential analysis. Guetterman 34 provides a step-by-step guidance on basic statistics. In case study designs where both data strands are analysed simultaneously, analytical techniques include pattern matching, explanation building, time-series analysis and creating logic models (p142–167). 3

Step 9. Write the case study report

The case study report should have the following three characteristics. First, the description of the case and its context should be sufficiently comprehensive to allow the reader to understand the complexity of the phenomena under study. 35 Second, the data should be presented in a concise and transparent manner to enable the reader to question, or to re-examine, the findings. 36 Third, the report should be adapted to the interests and needs of its primary audience or audiences (eg, academics, practitioners, policy-makers or funders of research). Yin 3 suggests six formats for organising case study reports, namely linear-analytic, comparative, chronological, theory building, suspense and unsequenced structures. To facilitate case transferability and applicability to other similar contexts, the case study report must include a detailed description of the case.

Step 10. Appraise quality

Although presented as the final step of the case study process, quality appraisal should be considered throughout the study. Multiple criteria and frameworks for appraising the quality of case study research have been suggested in the literature. Yin 3 suggests the following four criteria: construct validity (ie, the extent to which a study accurately measures the concepts that it claims to investigate), internal validity (ie, the strength of the relationship between variables and findings), external validity (ie, the extent to which the findings can be generalised) and reliability (ie, the extent to which the findings can be replicated by other researchers conducting the same study). Yin 37 also suggests using two separate sets of guidelines for conducting case study research and for appraising the quality of case study proposals. Stake 4 presents a 20-item checklist for critiquing case study reports, and Creswell and Poth 38 and Denscombe 39 outline a number of questions to consider. Since these quality frameworks have evolved from different disciplinary and philosophical backgrounds, the researcher’s approach should be coherent with the epistemology of the study. Figure 2 provides a quality appraisal checklist adapted from Creswell and Poth 38 and Denscombe. 39

Checklist for evaluating the quality of a case study. 38 39

The challenges to conducting case study research include rationalising the literature based on literature review, writing the research questions, determining how to bound the case, and choosing among various case study purposes and designs. Factors held in common with other methods include analysing and presenting the findings, particularly with multiple data sources.

Other resources

Resources with more in depth guidance on case study research include Merriam, 17 Stake 4 and Yin. 3 While each reflects a different perspective on case study research, they all provide useful guidance for designing and conducting case studies. Other resources include Creswell and Poth, 38 Swanborn 2 and Tight. 40 For mixed methods case study designs, Creswell and Plano Clark, 27 Guetterman and Fetters, 21 Luck et al , 6 and Plano Clark et al 41 provide guidance. Byrne and Ragin’s 42 The SAGE Handbook of Case-Based Methods and Mills et al ’s 43 Encyclopedia of case study research provide guidance for experienced case study researchers.

Conclusions

Family medicine and community health researchers engage in a wide variety of clinical, educational, research and administrative programmes. Case study research provides a highly flexible and powerful research tool to evaluate rigorously many of these endeavours and disseminate this information.

Acknowledgments

The authors would like to acknowledge the help of Dick Edelstein and Marie-Hélène Paré in editing the final manuscript.

Correction notice: This article has been corrected. Reference details have been updated.

Contributors: SF and MDF conceived and drafted the manuscript, and approved the final version of the manuscript.

Funding: The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

Competing interests: None declared.

Patient consent for publication: Not required.

Provenance and peer review: Not commissioned; internally peer reviewed.

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Case Report: A Beginner’s Guide with Examples

A case report is a descriptive study that documents an unusual clinical phenomenon in a single patient. It describes in details the patient’s history, signs, symptoms, test results, diagnosis, prognosis and treatment. It also contains a short literature review, discusses the importance of the case and how it improves the existing knowledge on the subject.

A similar design involving a group of patients (with the similar problem) is referred to as case series.

Advantages of case reports

Case reports offer, in general a fast, easy and cheap way to report an unusual observation or a rare event in a clinical setting, as these have very small probability of being detected in an experimental study because of limitations on the number of patients that can be included.

These events deserve to be reported since they might provide insights on some exceptions to general rules and theories in the field.

Case reports are great to get first impressions that can generate new hypotheses (e.g. detecting a potential side effect of a drug) or challenge existing ones (e.g. shedding the light on the possibility of a different biological mechanism of a disease).

In many of these cases, additional investigation is needed such as designing large observational studies or randomized experiments or even going back and mining data from previous research looking for evidence for theses hypotheses.

Limitations of case reports

Observing a relationship between an exposure and a disease in a case report does not mean that it is causal in nature.

This is because of:

• The absence of a control group that provides a benchmark or a point of reference against which we compare our results. A control group is important to eliminate the role of external factors which can interfere with the relationship between exposure and disease
• Unmeasured Confounding caused by variables that influence both the exposure and the disease

A case report can have a powerful emotional effect (see examples of case reports below). This can lead to overrate the importance of the evidence provided by such case. In his book Against Empathy: The Case for Rational Compassion , Paul Bloom explains how a powerful story affects our emotions, can distort our judgement and even lead us to make bad moral choices.

When a case report describes a rare event it is important to remember that what we’re reading about is exceptional and most importantly resist generalizations especially because a case report is, by definition, a study where the sample is only 1 patient.

Selection bias is another issue as the cases in case reports are not chosen at random, therefore some members of the population may have a higher probability of being included in the study than others.

So, results from a case report cannot be representative of the entire population.

Because of these limitations, case reports have the lowest level of evidence compared to other study designs as represented in the evidence pyramid below:

Real-world examples of case reports

Example 1: normal plasma cholesterol in an 88-year-old man who eats 25 eggs a day.

This is the case of an old man with Alzheimer’s disease who has been eating 20-30 eggs every day for almost 15 years. [ Source ]

The man had an LDL-cholesterol level of only 142 mg/dL (3.68 mmol/L) and no significant clinical atherosclerosis (deposition of cholesterol in arterial walls)!

His body adapted by reducing the intestinal absorption of cholesterol, lowering the rate of its synthesis and increasing the rate of its conversion into bile acid.

This is indeed an unusual case of biological adaptation to a major change in dietary intake.

Example 2: Recovery from the passage of an iron bar through the head

This is an interesting case of a construction foreman named Phineas Gage. [ Source ]

In 1848, due to an explosion at work, an iron bar passed through his head destroying a large portion of his brain’s frontal lobe. He survived the event and the injury only affected 1 thing: His personality!

After the accident, Gage became profane, rough and disrespectful to the extent that he was no longer tolerable to people around him. So he lost his job and his family.

His case inspired further research that focused on the relationship between specific parts of the brain and personality.

• Sayre JW, Toklu HZ, Ye F, Mazza J, Yale S.  Case Reports, Case Series – From Clinical Practice to Evidence-Based Medicine in Graduate Medical Education .  Cureus . 2017;9(8):e1546. Published 2017 Aug 7. doi:10.7759/cureus.1546.
• Nissen T, Wynn R.  The clinical case report: a review of its merits and limitations .  BMC Res Notes . 2014;7:264. Published 2014 Apr 23. doi:10.1186/1756-0500-7-264.

Further reading

• Case Report vs Cross-Sectional Study
• Cohort vs Cross-Sectional Study
• How to Identify Different Types of Cohort Studies?
• Matched Pairs Design
• Randomized Block Design

What is a case study?

Affiliations.

• 1 School of Nursing, Laurentian University, Sudbury, Ontario, Canada.
• 2 School of Health and Social Care, London South Bank University, London, UK.
• PMID: 29146764
• DOI: 10.1136/eb-2017-102845

Publication types

• Case-Control Studies*
• Nursing Research / organization & administration*
• Research Design

Fundamentals of case study research in family medicine and community health

Author affiliations

Michael D Fetters 2

The aim of this article is to introduce family medicine researchers to case study research, a rigorous research methodology commonly used in the social and health sciences and only distantly related to clinical case reports. The article begins with an overview of case study in the social and health sciences, including its definition, potential applications, historical background and core features. This is followed by a 10-step description of the process of conducting a case study project illustrated using a case study conducted about a teaching programme executed to teach international family medicine resident learners sensitive examination skills. Steps for conducting a case study include (1) conducting a literature review; (2) formulating the research questions; (3) ensuring that a case study is appropriate; (4) determining the type of case study design; (5) defining boundaries of the case(s) and selecting the case(s); (6) preparing for data collection; (7) collecting and organising the data; (8) analysing the data; (9) writing the case study report; and (10) appraising the quality. Case study research is a highly flexible and powerful research tool available to family medicine researchers for a variety of applications.

• Significance statement

Given their potential for answering ‘how’ and ‘why’ questions about complex issues in their natural setting, case study designs are being increasingly used in the health sciences. Conducting a case study can, however, be a complex task because of the possibility of combining multiple methods and the need to choose between different types of case study designs. In order to introduce family medicine and community health researchers to the fundamentals of case study research, this article reviews its definition, potential applications, historical background and main characteristics. It follows on with a practical, step-by-step description of the case study process that will be useful to researchers interested in implementing this research design in their own practice.

• Introduction

This article provides family medicine and community health researchers a concise resource to conduct case study research. The article opens with an overview of case study in the social and health sciences, including its definition, potential applications, historical background and core features. This is followed by a 10-step description of the process of conducting a case study project, as described in the literature. These steps are illustrated using a case study about a teaching programme executed to teach international medical learners sensitive examination skills. The article ends with recommendations of useful articles and textbooks on case study research.

• Origins of case study research

Case study is a research design that involves an intensive and holistic examination of a contemporary phenomenon in a real-life setting. 1–3 It uses a variety of methods and multiple data sources to explore, describe or explain a single case bounded in time and place (ie, an event, individual, group, organisation or programme). A distinctive feature of case study is its focus on the particular characteristics of the case being studied and the contextual aspects, relationships and processes influencing it. 4 Here we do not include clinical case reports as these are beyond the scope of this article. While distantly related to clinical case reports commonly used to report unusual clinical case presentations or findings, case study is a research approach that is frequently used in the social sciences and health sciences. In contrast to other research designs, such as surveys or experiments, a key strength of case study is that it allows the researcher to adopt a holistic approach—rather than an isolated approach—to the study of social phenomena. As argued by Yin, 3 case studies are particularly suitable for answering ‘how’ research questions (ie, how a treatment was received) as well as ‘why’ research questions (ie, why the treatment produced the observed outcomes).

Given its potential for understanding complex processes as they occur in their natural setting, case study increasingly is used in a wide range of health-related disciplines and fields, including medicine, 5 nursing, 6 health services research 1 and health communication. 7 With regard to clinical practice and research, a number of authors 1 5 8 have highlighted how insights gained from case study designs can be used to describe patients’ experiences regarding care, explore health professionals’ perceptions regarding a policy change, and understand why medical treatments and complex interventions succeed or fail.

In anthropology and sociology, case study as a research design was introduced as a response to the prevailing view of quantitative research as the primary way of undertaking research. 9 From its beginnings, social scientists saw case study as a method to obtain comprehensive accounts of social phenomena from participants. In addition, it could complement the findings of survey research. Between the 1920s and 1960s, case study became the predominant research approach among the members of the Department of Sociology of the University of Chicago, widely known as ‘The Chicago School’. 10 11 During this period, prominent sociologists, such as Florian Znaniecki, William Thomas, Everett C Hughes and Howard S Becker, undertook a series of innovative case studies (including classical works such as The Polish peasant in Europe and America or Boys in White ), which laid the foundations of case study designs as implemented today.

In the 1970s, case study increasingly was adopted in the USA and UK in applied disciplines and fields, such as education, programme evaluation and public policy research. 12 As a response to the limitations of quasi-experimental designs for undertaking comprehensive programme evaluations, researchers in these disciplines saw in case studies—either alone or in combination with experimental designs—an opportunity to gain additional insights into the outcomes of programme implementation. In the mid-1980s and early 1990s, the case study approach became recognised as having its own ‘logic of design’ (p46). 13 This period coincides with the publication of a considerable number of influential articles 14–16 and textbooks 4 17 18 on case study research.

These publications were instrumental in shaping contemporary case study practice, yet they reflected divergent views about the nature of case study, including how it should be defined, designed and implemented (see Yazan 19 for a comparison of the perspectives of Yin, Merriam and Stake, three leading case study methodologists). What these publications have in common is that case study revolves around four key features.

First, case study examines a specific phenomenon in detail by performing an indepth and intensive analysis of the selected case. The rationale for case study designs, rather than more expansive designs such as surveys, is that the researcher is interested in investigating the particularity of a case, that is, the unique attributes that define an event, individual, group, organisation or programme. 2 Second, case study is conducted in natural settings where people meet, interact and change their perceptions over time. The use of the case study design is a choice in favour of ‘maintaining the naturalness of the research situation and the natural course of events’ (p177). 20

Third, case study assumes that a case under investigation is entangled with the context in which it is embedded. This context entails a number of interconnected processes that cannot be disassociated from the case, but rather are part of the study. The case study researcher is interested in understanding how and why such processes take place and, consequently, uncovering the interactions between a case and its context. Research questions concerning how and why phenomena occur are particularly appropriate in case study research. 3

Fourth, case study encourages the researcher to use a variety of methods and data types in a single study. 20 21 These can be solely qualitative, solely quantitative or a mixture of both. The latter option allows the researcher to gain a more comprehensive understanding of the case and improve the accuracy of the findings. The four above-mentioned key features of case study are shown in table 1 , using the example of a mixed methods case study evaluation. 22

There are many potential applications for case study research. While often misconstrued as having only an exploratory role, case study research can be used for descriptive and explanatory research (p7–9). 3 Family medicine and community health researchers can use case study research for evaluating a variety of educational programmes, clinical programmes or community programmes.

• Case study illustration from family medicine

In the featured study, Japanese family medicine residents received standardised patient instructor-based training in female breast, pelvic, male genital and prostate examinations as part of an international training collaboration to launch a new family medicine residency programme. 22 From family medicine residents, trainers and staff, the authors collected and analysed data from post-training feedback, semistructured interviews and a web-based questionnaire. While the programme was perceived favourably, they noted barriers to reinforcement in their home training programme, and taboos regarding gender-specific healthcare appear as barriers to implementing a similar programme in the home institution.

• A step-by-step description of the process of carrying out a case study

As shown in table 2 and illustrated using the article by Shultz et al , 22 case study research generally includes 10 steps. While commonly conducted in this order, the steps do not always occur linearly as data collection and analysis may occur over several iterations or implemented with a slightly different order.

Step 1. Conduct a literature review

During the literature review, researchers systematically search for publications, select those most relevant to the study’s purpose, critically appraise them and summarise the major themes. The literature review helps researchers ascertain what is and is not known about the phenomenon under study, delineate the scope and research questions of the study, and develop an academic or practical justification for the study. 23

Step 2. Formulate the research questions

Research questions critically define in operational terms what will be researched and how. They focus the study and play a key role in guiding design decisions. Key decisions include the case selection and choice of a case study design most suitable for the study. According to Fraenkel et al , 24 the key attributes of good research questions are (1) feasibility, (2) clarity, (3) significance, (4) connection to previous research identified in the literature and (5) compliance with ethical research standards.

Step 3. Ensure that a case study is appropriate

Before commencing the study, researchers should ensure that case study design embodies the most appropriate strategy for answering the study questions. The above-noted four key features—in depth examination of phenomena, naturalness, a focus on context and the use of a combination of methods—should be reflected in the research questions as well as subsequent design decisions.

Step 4. Determine the type of case study design

Researchers need to choose a specific case study design. Sometimes, researchers may define the case first (step 5), for example, in a programme evaluation, and the case may need to be defined before determining the type. Yin’s 3 typology is based on two dimensions, whether the study will examine a single case or multiple cases, and whether the study will focus on a single or multiple units of analysis. Figure 1 illustrates these four types of design using a hypothetical example of a programme evaluation. Table 3 shows an example of each type from the literature.

Types of case study designs. 3 21

In type 1 holistic single case design , researchers examine a single programme as the sole unit of analysis. In type 2 embedded single case design , the interest is not exclusively in the programme, but also in its different subunits, including sites, staff and participants. These subunits constitute the range of units of analysis. In type 3 holistic multiple case design , researchers conduct a within and cross-case comparison of two or more programmes, each of which constitutes a single unit of analysis. A major strength of multiple case designs is that they enable researchers to develop an in depth description of each case and to identify patterns of variation and similarity between the cases. Multiple case designs are likely to have stronger internal validity and generate more insightful findings than single case designs. They do this by allowing ‘examination of processes and outcomes across many cases, identification of how individual cases might be affected by different environments, and the specific conditions under which a finding may occur’ (p583). 25 In type 4 embedded multiple case design , a variant of the holistic multiple case design, researchers perform a detailed examination of the subunits of each programme, rather than just examining each case as a whole.

Step 5. Define the boundaries of the case(s) and select the case(s)

Miles et al 26 define a case as ‘a phenomenon of some sort occurring in a bounded context’ (p28). What is and is not the case and how the case fits within its broader context should be explicitly defined. As noted in step 4, this step may occur before choice of the case study type, and the process may actually occur in a back-and-forth fashion. A case can entail an individual, a group, an organisation, an institution or a programme. In this step, researchers delineate the spatial and temporal boundaries of the case, that is, ‘when and where it occurred, and when and what was of interest’ (p390). 9 Aside from ensuring the coherence and consistency of the study, bounding the case ensures that the planned research project is feasible in terms of time and resources. Having access to the case and ensuring ethical research practice are two central considerations in case selection. 1

Step 6. Prepare to collect data

Before beginning the data collection, researchers need a study protocol that describes in detail the methods of data collection. The protocol should emphasise the coherence between the data collection methods and the research questions. According to Yin, 3 a case study protocol should include (1) an overview of the case study, (2) data collection procedures, (3) data collection questions and (4) a guide for the case study report. The protocol should be sufficiently flexible to allow researchers to make changes depending on the context and specific circumstances surrounding each data collection method.

Step 7. Collect and organise the data

While case study is often portrayed as a qualitative approach to research (eg, interviews, focus groups or observations), case study designs frequently rely on multiple data sources, including quantitative data (eg, surveys or statistical databases). A growing number of authors highlight the ways in which the use of mixed methods within case study designs might contribute to developing ‘a more complete understanding of the case’ (p902), 21 shedding light on ‘the complexity of a case’ (p118) 27 or increasing ‘the internal validity of a study’ (p6). 1 Guetterman and Fetters 21 explain how a qualitative case study can also be nested within a mixed methods design (ie, be considered the qualitative component of the design). An interesting strategy for organising multiple data sources is suggested by Yin. 3 He recommends using a case study database in which different data sources (eg, audio files, notes, documents or photographs) are stored for later retrieval or inspection. See guidance from Creswell and Hirose 28 for conducting a survey and qualitative data collection in mixed methods and DeJonckheere 29 on semistructured interviewing.

Step 8. Analyse the data

Bernard and Ryan 30 define data analysis as ‘the search for patterns in data and for ideas that help explain why these patterns are there in the first place’ (p109). Depending on the case study design, analysis of the qualitative and quantitative data can be done concurrently or sequentially. For the qualitative data, the first step of the analysis involves segmenting the data into coding units, ascribing codes to data segments and organising the codes in a coding scheme. 31 Depending on the role of theory in the study, an inductive, data-driven approach can be used where meaning is found in the data, or a deductive, concept-driven approach can be adopted where predefined concepts derived from the literature, or previous research, are used to code the data. 32 The second step involves searching for patterns across codes and subsets of respondents, so major themes are identified to describe, explain or predict the phenomenon under study. Babchuk 33 provides a step-by-step guidance for qualitative analysis in this issue. When conducting a single case study, the within-case analysis yields an in depth, thick description of the case. When the study involves multiple cases, the cross-comparison analysis elicits a description of similarities and divergence between cases and may generate explanations and theoretical predictions regarding other cases. 26

For the quantitative part of the case study, data are entered in statistical software packages for conducting descriptive or inferential analysis. Guetterman 34 provides a step-by-step guidance on basic statistics. In case study designs where both data strands are analysed simultaneously, analytical techniques include pattern matching, explanation building, time-series analysis and creating logic models (p142–167). 3

Step 9. Write the case study report

The case study report should have the following three characteristics. First, the description of the case and its context should be sufficiently comprehensive to allow the reader to understand the complexity of the phenomena under study. 35 Second, the data should be presented in a concise and transparent manner to enable the reader to question, or to re-examine, the findings. 36 Third, the report should be adapted to the interests and needs of its primary audience or audiences (eg, academics, practitioners, policy-makers or funders of research). Yin 3 suggests six formats for organising case study reports, namely linear-analytic, comparative, chronological, theory building, suspense and unsequenced structures. To facilitate case transferability and applicability to other similar contexts, the case study report must include a detailed description of the case.

Step 10. Appraise quality

Although presented as the final step of the case study process, quality appraisal should be considered throughout the study. Multiple criteria and frameworks for appraising the quality of case study research have been suggested in the literature. Yin 3 suggests the following four criteria: construct validity (ie, the extent to which a study accurately measures the concepts that it claims to investigate), internal validity (ie, the strength of the relationship between variables and findings), external validity (ie, the extent to which the findings can be generalised) and reliability (ie, the extent to which the findings can be replicated by other researchers conducting the same study). Yin 37 also suggests using two separate sets of guidelines for conducting case study research and for appraising the quality of case study proposals. Stake 4 presents a 20-item checklist for critiquing case study reports, and Creswell and Poth 38 and Denscombe 39 outline a number of questions to consider. Since these quality frameworks have evolved from different disciplinary and philosophical backgrounds, the researcher’s approach should be coherent with the epistemology of the study. Figure 2 provides a quality appraisal checklist adapted from Creswell and Poth 38 and Denscombe. 39

Checklist for evaluating the quality of a case study. 38 39

The challenges to conducting case study research include rationalising the literature based on literature review, writing the research questions, determining how to bound the case, and choosing among various case study purposes and designs. Factors held in common with other methods include analysing and presenting the findings, particularly with multiple data sources.

Other resources

Resources with more in depth guidance on case study research include Merriam, 17 Stake 4 and Yin. 3 While each reflects a different perspective on case study research, they all provide useful guidance for designing and conducting case studies. Other resources include Creswell and Poth, 38 Swanborn 2 and Tight. 40 For mixed methods case study designs, Creswell and Clark, 27 Guetterman and Fetters, 21 Luck et al , 6 and Plano Clark et al 41 provide guidance. Byrne and Ragin’s 42 The SAGE Handbook of Case-Based Methods and Mills et al ’s 43 Encyclopedia of case study research provide guidance for experienced case study researchers.

• Conclusions

Family medicine and community health researchers engage in a wide variety of clinical, educational, research and administrative programmes. Case study research provides a highly flexible and powerful research tool to evaluate rigorously many of these endeavours and disseminate this information.

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