is case study a qualitative research

• Privacy Policy

Buy Me a Coffee

Home » Case Study – Methods, Examples and Guide

Case Study – Methods, Examples and Guide

Table of Contents

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

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

Types of Case Study

Types and Methods of Case Study are as follows:

Single-Case Study

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

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

Multiple-Case Study

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

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

Exploratory Case Study

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

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

Descriptive Case Study

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

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

Instrumental Case Study

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

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

Case Study Data Collection Methods

Here are some common data collection methods for case studies:

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

Observations

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

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

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

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

How to conduct Case Study Research

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

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

Examples of Case Study

Here are some examples of case study research:

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

Application of Case Study

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

Business and Management

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

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

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

Social Sciences

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

Law and Ethics

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

Purpose of Case Study

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

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

Case studies can also serve other purposes, including:

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

Advantages of Case Study Research

There are several advantages of case study research, including:

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

Limitations of Case Study Research

There are several limitations of case study research, including:

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

About the author

Muhammad Hassan

Researcher, Academic Writer, Web developer

You may also like

Questionnaire – Definition, Types, and Examples

Observational Research – Methods and Guide

Quantitative Research – Methods, Types and...

Qualitative Research Methods

Explanatory Research – Types, Methods, Guide

Survey Research – Types, Methods, Examples

Have a language expert improve your writing

Run a free plagiarism check in 10 minutes, automatically generate references for free.

• Knowledge Base
• Methodology
• Case Study | Definition, Examples & Methods

Case Study | Definition, Examples & Methods

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

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

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

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 analyse the case.

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.

Prevent plagiarism, run a free check.

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

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

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

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

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

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 .

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

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

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

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

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

Cite this Scribbr article

If you want to cite this source, you can copy and paste the citation or click the ‘Cite this Scribbr article’ button to automatically add the citation to our free Reference Generator.

McCombes, S. (2023, January 30). Case Study | Definition, Examples & Methods. Scribbr. Retrieved 2 April 2024, from https://www.scribbr.co.uk/research-methods/case-studies/

Is this article helpful?

Shona McCombes

Other students also liked, correlational research | guide, design & examples, a quick guide to experimental design | 5 steps & examples, descriptive research design | definition, methods & examples.

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

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

Research question

• Conceptual framework
• Conceptual vs. theoretical framework

Data collection

• Qualitative research methods
• Focus groups
• Observational research

What is a case study?

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

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

Case studies

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

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

Definition of a case study

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

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

Characteristics of case studies

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

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

The role of case studies in research

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

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

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

What is the purpose of a case study?

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

Why use case studies in qualitative research?

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

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

The explanatory, exploratory, and descriptive roles of case studies

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

The impact of case studies on knowledge development

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

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

Types of case studies

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

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

Exploratory case studies

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

Descriptive case studies

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

Explanatory case studies

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

Intrinsic, instrumental, and collective case studies

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

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

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

Critical information systems research

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

Health research

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

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

Asthma research studies

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

Other fields

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

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

Whatever field you're in, ATLAS.ti puts your data to work for you

Download a free trial of ATLAS.ti to turn your data into insights.

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

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

Propositions

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

Units of analysis

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

Argumentation

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

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

Ready to jumpstart your research with ATLAS.ti?

Conceptualize your research project with our intuitive data analysis interface. Download a free trial today.

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

Defining the research question

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

Selecting and defining the case

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

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

Developing a detailed case study protocol

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

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

Collecting data

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

Analyzing and interpreting data

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

Writing the case study report

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

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

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

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

Observations

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

Documents and artifacts

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

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

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

Ensuring the quality of data collection

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

Data analysis

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

Organizing the data

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

Categorizing and coding the data

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

Identifying patterns and themes

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

Interpreting the data

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

Verification of the data

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

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

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

Benefits include the following:

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

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

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

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

Ready to analyze your data with ATLAS.ti?

See how our intuitive software can draw key insights from your data with a free trial today.

• Search Menu

A newer edition of this book is available.

• < Previous chapter
• Next chapter >

22 Case Study Research: In-Depth Understanding in Context

Helen Simons, School of Education, University of Southampton

• Published: 01 July 2014
• Cite Icon Cite
• Permissions Icon Permissions

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

Introduction

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

The Beginnings

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

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

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

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

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

Concepts and Purposes of Case Study

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

Everyday Usage: Stories We Tell

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

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

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

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

Professions Individual Cases

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

Case Studies in Teaching

Exemplars of practice.

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

Case scenarios

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

Country Case Studies

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

Case Study as History

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

Case Study Research

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

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

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

Not Defined by Method or Perspective

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

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

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

Qualitative Case Study Research

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

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

Characteristic Features and Advantages

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

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

Possible Disadvantages

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

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

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

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

Types of Case Study

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

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

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

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

Interlude: Social and Ethical Practice of Evaluation

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

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

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

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

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

documenting how different people interpret and value the program;

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

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

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

disseminating to audiences within and beyond the case.

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

Designing Case Study Research

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

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

Conceptualize the Topic

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

What Constitutes the Case

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

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

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

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

Unit of analysis

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

Framing Questions and Issues

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

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

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

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

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

Methodology and Methods

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

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

Primary Qualitative Data Gathering Methods

Interviewing.

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

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

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

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

Observations

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

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

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

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

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

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

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

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

Document analysis

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

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

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

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

Creative artistic approaches

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

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

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

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

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

Getting It All Together

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

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

Analyzing and Interpreting Data

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

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

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

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

Reporting Case Study Research

Narrative structure and story.

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

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

Matching forms of reporting to audience

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

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

Styles of Reporting

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

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

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

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

Generalization in Case Study Research

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

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

Generalizing from the Single Case

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

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

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

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

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

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

Particularization

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

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

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

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

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

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

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

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

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

Conclusion and Future Directions

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

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

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

Warrant for More Creative Methods in Case Study Research

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

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

Representing Findings to Engage Audiences in Learning

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

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

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

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

Learning from a Study of the Singular

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

Acknowledgments

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

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

Adams, T. ( 2012 ) ‘ Olympics 2012: Team GB falters but London shines bright on opening day ’, Observer, 29.07.12.

Google Scholar

Google Preview

Bassey, M. ( 1999 ). Case study research in educational settings . Buckingham: Open University Press.

Bellah, R. N. , Madsen, R. , Sullivan, W. M. , Swidler, A. , & Tipton, S. M. ( 1985 ). Habits of the heart . London: Harper and Row.

Blake, W. (1798– 1809 ). Annotations to Sir Joshua Reynolds’s Discourses , pp. xvii–xcviii (c. 1798–1809) repr. In Complete Writings , ed.   Geoffrey Keynes   (1957). ‘Discourse II,’ annotations to Sir Joshua Reynolds, Discourses (c. 1808) .

Butler-Kisber, L. ( 2010 ). Qualitative inquiry: Thematic, narrative and arts-informed perspectives . London: Sage.

Cancienne, M. B. , & Snowber, C. N. ( 2003 ). Writing rhythm: Movement as method.   Qualitative Inquiry , 9 (2), 237–253.

Caulley, D. N. ( 2008 ). Making qualitative research reports less boring: The techniques of writing creative nonfiction.   Qualitative Inquiry , 14 (3) pp. 424–449.

Chadderton, C. , & Torrance, H. ( 2011 ). Case study. In B. Somekh & C. Lewin (Eds.), Theory and methods in social research . (2nd ed. pp 53–60). London and Thousand Oaks, CA: Sage.

Clandinin, D. J. & Connelly, F. M. ( 2000 ) Narrative inquiry: Experience and story in qualitative research. Ist edn. SanFrancisco: Jossey Bass Publishers.

Collier, J., Jr. ( 1967 ). Visual anthropology: Photography as a research method . New York: Holt, Reinhart, & Winston.

Denzin, N. K. & Lincoln, Y. S. (Eds.) ( 1994 ) Handbook of Qualitative Research , London and Thousand Oaks, CA:Sage

Donmoyer, R. ( 1990 ). Generalization and the single case study. In E. W. Eisner & A. Peshkin (Eds.), Qualitative inquiry in education (pp. 175–200). New York: Teachers College Press.

Donmoyer, R. ( 2008 ). Generalizability. In L. M. Givens (Ed.), The Sage encyclopedia of qualitative inquiry (vol. 2, pp. 371–372). Thousand Oaks, CA: Sage.

Duke, S. (2007). A narrative case study evaluation of the role of the Nurse Consultant in palliative care. PhD thesis, University of Southampton, England.

Elliott, J. (2008). Dance mirrors: Embodying, actualizing and operationalizing a dance experience in a healthcare context. PhD thesis, University of Ulster, Belfast.

Frank. A. ( 1997 ). Enacting illness stories: When, what, why. In H. L. Nelson (Ed.), Stories and their limits (pp. 31–49). London: Routledge.

Flyvberg, B. ( 2006 ). Five misunderstandings about case-study research.   Qualitative Inquiry , 12 (2), 219–245.

Gomm, R. , Hammersley, M. , & Foster, P. (Eds.). ( 2004 ). Case study method: Key issues, key texts . [First published in 2000]. London and Thousand Oaks, CA: Sage.

Greene, J. C. ( 2000 ). Understanding social programs through evaluation. In N. K. Denzin and Y. S. Lincoln (Eds.), The handbook of qualitative research (2nd ed., pp. 981–999). Thousand Oaks, CA: Sage.

Greene, J. C. ( 2007 ). Mixing methods in social inquiry . San Francisco: Jossey Bass.

Greenhalgh, T. , & Worrall, J. G. ( 1997 ). From EBM to CSM: The evolution of context-sensitive medicine.   Journal of Evaluation in Clinical Practice , 3 (2), 105–108.

Harrington, W. ( 2003 ). What journalism can offer ethnography.   Qualitative Inquiry . 9 (1), 90–114.

Heron, J. ( 1992 ). Feeling and personhood . Sage: London.

Heron, J. ( 1999 ). The complete facilitator’s handbook . London: Kogan Page.

House, E. R. ( 1980 ). Evaluating with validity . London, Beverly Hills, CA: Sage.

House, E. R. ( 1993 ). Professional evaluation: Social impact and political consequences . Newbury Park and London: Sage

Kushner, S. ( 2000 ). Personalizing evaluation . London and Thousand Oaks, CA: Sage.

Liamputtong, P. , & Rumbold, J. (Eds.). ( 2008 ). Knowing differently: Arts-based and collaborative research methods . New York: Nova Science Publishers.

MacDonald, B. ( 1976 ). Evaluation and the control of education. In D. Tawney (Ed.), Curriculum evaluation today: Trends and implications . Schools Council Research Studies (pp. 125– 136). London: Macmillan.

Matarasso, F. ( 2012 ). West Bromwich Operatic Society: fine art of musical theatre . West Bromwich, UK: Multistory.

Merriam, S. B. ( 1988 ). Case study research in education: A qualitative Approach . San Francisco: Jossey Bass.

Mullen, C. A. , & Finley, S. (Eds.). ( 2003 ). Arts-based approaches to qualitative inquiry [Special Issue].   Qualitative Inquiry , 9 (2), 165–329.

Okri, B. ( 1997 ). A way of being free . London: Phoenix.

Parlett, M. , & Hamilton, D. ( 1976 ). Evaluation as illumination: A new approach to the study of innovatory programmes. In G. Glass (Ed.), Evaluation studies review annual, I (pp. 140–157). [First published in 1972 as Occasional Paper 9, Centre for Research in the Educational Sciences, University of Edinburgh.] Beverly Hills: CA: Sage.

Platt, J. ( 2007 ). Case study. In W. Outhwaite & S. P. Turner (Eds.), The Sage handbook of social science methodology (pp. 100–118). London: Sage.

Prosser, J. ( 2000 ). The moral maze of image ethics. In H. Simons & R. Usher (Eds.), Situated ethics in educational research (pp. 116–132). London and New York: Routledge/Falmer.

Ragin, C. C. ( 1992 ). Cases of “What is a case?” In C. C. Ragin & H. S. Becker (Eds.), What is a case?: Exploring the foundations of social inquiry (pp. 1–17). Cambridge: Cambridge University Press.

Reynolds, S. S. (1908). A Poor Man’s House . The Project Guttenberg eBook, July 25, 2008 [eBook#26126]. Accessed February 26, 2013, http.//www.gutenberg.org

Richardson, L. ( 1994 ). Writing as a form of inquiry. In N. K. Denzin & Y. S. Lincoln (Eds.), Handbook of Qualitative Research (pp. 516–529). London: Sage.

Richardson, L. ( 1997 ). Fields of play (Constructing an academic life) . New Brunswick, NJ: Rutgers University Press.

Rugang, L. (2006). Chinese culture in globalisation: A multi-modal case study on visual discourse. PhD thesis, University of Southampton, England.

Seale, C. ( 1999 ). The quality of qualitative research . London and Thousand Oaks, CA: Sage.

Sewell, K. ( 2011 ). Researching sensitive issues: A critical appraisal of “draw and write” as a data collection technique in eliciting children’s perceptions.   International Journal of Research Methods in Education 34(2), pp.175–191.

Shaw, I. , & Gould, N. ( 2001 ). Qualitative research in social work: Context and method . London: Sage.

Silverman, D. ( 2000 ). Doing qualitative research: A practical handbook . London and Thousand Oaks. CA: Sage.

Silverman, D. (Ed.). ( 2004 ). Qualitative research: Theory, methods and practice (2nd ed.). London and Thousand Oaks, CA: Sage.

Simons, H. ( 1971 ). Innovation and the case study of schools.   Cambridge Journal of Education , 3 , 118–123.

Simons, H. (Ed.). ( 1980 ). Towards a science of the singular: Essays about case study in educational research and evaluation . Occasional Papers No. 10. Norwich, UK: Centre for Applied Research, University of East Anglia.

Simons, H. ( 1987 ). Getting to know schools in a democracy: The politics and process of evaluation . Lewes, UK: Falmer Press.

Simons, H. ( 1996 ). The paradox of case study.   Cambridge Journal of Education , 26 (2), 225–240.

Simons, H. ( 2000 ). Damned if you do, damned if you don’t: ethical and political dilemmas in evaluation. In H. Simons & R. Usher (Eds.) Situated ethics in educational research (pp.39– 55) London and New York: Routledge/Falmer.

Simons, H. ( 2002 ). School self-evaluation in a democracy. In D. Nevo (Ed.), School-based evaluation: An international perspective . Advances in Program Evaluation. London: Sage.

Simons, H. ( 2006 ). Ethics and evaluation. In I. F. Shaw , J. C. Greene , & M. M. Mark (Eds.), The international handbook of evaluation (pp. 243–265). London and Thousand Oaks, CA Sage.

Simons, H. ( 2009 ). Case study research in practice . London: Sage.

Simons, H. (2010). Democratic evaluation: Theory and practice. Paper prepared for Virtual Evaluation Conference, University of the Witwatersrand, Johannesburg, South Africa, May, 2010.

Simons, H. , Kushner, S. , Jones, K. , & James, D. ( 2003 ). From evidence-based practice to practice-based evidence: The idea of situated generalization.   Research Papers in Education: Policy and Practice , 18 (4), 347–364.

Simons, H. , & McCormack, B. ( 2007 ). Integrating arts-based inquiry in evaluation methodology.   Qualitative Inquiry , 13 (2) 292–311.

Simons, H. , & Usher, R. (Eds.). ( 2000 ). Situated ethics in educational research . London and New York: Routledge/Falmer.

Smith, L. M. , & Pohland, P. A. ( 1974 ). Education, technology, and the rural highlands. In R. H. P. Kraft ., L. M. Smith ., P. A. Pohland ., C. J. Brauner , & C. Gjerde (Eds.), Four evaluation examples: Anthropological, economic, narrative and portrayal (pp. 5–54), AERA Monograph Series on Curriculum Evaluation 7. Chicago: Rand McNally.

Sparkes, A. ( 2002 ). Telling tales in sport and physical activity: A qualitative journey . Champaign, IL: Human Kinetics Press.

Sparkes, A. C. , & Douglas, K. ( 2007 ). Making the case for poetic representations: An example in action.   The Sport Psychologist , 21(2) , 170–190.

Spouse, J. ( 2000 ). Talking pictures: Investigating personal knowledge though illuminating artwork.   Nursing Times Research Journal , 5 (4), 253–261.

Stake, R. E. ( 1978 ) The case study method in social inquiry.   Educational Researcher , 7(2), 5–9.

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

Stake, R. E. ( 2010 ). Qualitative research: Studying how things work . New York & London: Guildford Press.

Stenhouse, L. ( 1978 ). Case study and case records: Towards a contemporary history of education.   British Educational Research Journal , 4 (2), 21–39.

Thomas, G. ( 2011 b)). A typology for the case study in social science following a review of definition, discourse and structure.   Qualitative Inquiry , 17 (6) , 511–521.

Thomas, G. ( 2011 a). How to do your case study: A guide for students and researchers . London: Sage.

Walker, R. ( 1993 ). Finding a silent voice for the researcher: Using photographs in evaluation and research. In M. Schratz (Ed.), Qualitative voices in educational research (pp. 72–92). Lewes, UK: Falmer Press.

Wilson, E. G. ( 2008 ). Against happiness . New York: Sarah Crichton Books.

Yin, R. K. ( 2004 ). Case study research: Design and methods . Thousand Oaks, CA and London: Sage.

Zucker, D. M. ( 2001 ). Using case study methodology in nursing research.   Qualitative Report , 6 (2) June.

• About Oxford Academic
• Publish journals with us
• University press partners
• What we publish
• New features  
• Open access
• Institutional account management
• Rights and permissions
• Get help with access
• Accessibility
• Advertising
• Media enquiries
• Oxford University Press
• Oxford Languages
• University of Oxford

Oxford University Press is a department of the University of Oxford. It furthers the University's objective of excellence in research, scholarship, and education by publishing worldwide

• Copyright © 2024 Oxford University Press
• Cookie settings
• Cookie policy
• Privacy policy
• Legal notice

This Feature Is Available To Subscribers Only

Sign In or Create an Account

This PDF is available to Subscribers Only

For full access to this pdf, sign in to an existing account, or purchase an annual subscription.

Have a language expert improve your writing

Run a free plagiarism check in 10 minutes, generate accurate citations for free.

• Knowledge Base

Methodology

• What Is Qualitative Research? | Methods & Examples

What Is Qualitative Research? | Methods & Examples

Published on June 19, 2020 by Pritha Bhandari . Revised on June 22, 2023.

Qualitative research involves collecting and analyzing non-numerical data (e.g., text, video, or audio) to understand concepts, opinions, or experiences. It can be used to gather in-depth insights into a problem or generate new ideas for research.

Qualitative research is the opposite of quantitative research , which involves collecting and analyzing numerical data for statistical analysis.

Qualitative research is commonly used in the humanities and social sciences, in subjects such as anthropology, sociology, education, health sciences, history, etc.

• How does social media shape body image in teenagers?
• How do children and adults interpret healthy eating in the UK?
• What factors influence employee retention in a large organization?
• How is anxiety experienced around the world?
• How can teachers integrate social issues into science curriculums?

Table of contents

Approaches to qualitative research, qualitative research methods, qualitative data analysis, advantages of qualitative research, disadvantages of qualitative research, other interesting articles, frequently asked questions about qualitative research.

Qualitative research is used to understand how people experience the world. While there are many approaches to qualitative research, they tend to be flexible and focus on retaining rich meaning when interpreting data.

Common approaches include grounded theory, ethnography , action research , phenomenological research, and narrative research. They share some similarities, but emphasize different aims and perspectives.

Note that qualitative research is at risk for certain research biases including the Hawthorne effect , observer bias , recall bias , and social desirability bias . While not always totally avoidable, awareness of potential biases as you collect and analyze your data can prevent them from impacting your work too much.

Receive feedback on language, structure, and formatting

Professional editors proofread and edit your paper by focusing on:

• Academic style
• Vague sentences
• Style consistency

See an example

Each of the research approaches involve using one or more data collection methods . These are some of the most common qualitative methods:

• Observations: recording what you have seen, heard, or encountered in detailed field notes.
• Interviews:  personally asking people questions in one-on-one conversations.
• Focus groups: asking questions and generating discussion among a group of people.
• Surveys : distributing questionnaires with open-ended questions.
• Secondary research: collecting existing data in the form of texts, images, audio or video recordings, etc.
• You take field notes with observations and reflect on your own experiences of the company culture.
• You distribute open-ended surveys to employees across all the company’s offices by email to find out if the culture varies across locations.
• You conduct in-depth interviews with employees in your office to learn about their experiences and perspectives in greater detail.

Qualitative researchers often consider themselves “instruments” in research because all observations, interpretations and analyses are filtered through their own personal lens.

For this reason, when writing up your methodology for qualitative research, it’s important to reflect on your approach and to thoroughly explain the choices you made in collecting and analyzing the data.

Qualitative data can take the form of texts, photos, videos and audio. For example, you might be working with interview transcripts, survey responses, fieldnotes, or recordings from natural settings.

Most types of qualitative data analysis share the same five steps:

• Prepare and organize your data. This may mean transcribing interviews or typing up fieldnotes.
• Review and explore your data. Examine the data for patterns or repeated ideas that emerge.
• Develop a data coding system. Based on your initial ideas, establish a set of codes that you can apply to categorize your data.
• Assign codes to the data. For example, in qualitative survey analysis, this may mean going through each participant’s responses and tagging them with codes in a spreadsheet. As you go through your data, you can create new codes to add to your system if necessary.
• Identify recurring themes. Link codes together into cohesive, overarching themes.

There are several specific approaches to analyzing qualitative data. Although these methods share similar processes, they emphasize different concepts.

Qualitative research often tries to preserve the voice and perspective of participants and can be adjusted as new research questions arise. Qualitative research is good for:

• Flexibility

The data collection and analysis process can be adapted as new ideas or patterns emerge. They are not rigidly decided beforehand.

• Natural settings

Data collection occurs in real-world contexts or in naturalistic ways.

• Meaningful insights

Detailed descriptions of people’s experiences, feelings and perceptions can be used in designing, testing or improving systems or products.

• Generation of new ideas

Open-ended responses mean that researchers can uncover novel problems or opportunities that they wouldn’t have thought of otherwise.

Here's why students love Scribbr's proofreading services

Discover proofreading & editing

Researchers must consider practical and theoretical limitations in analyzing and interpreting their data. Qualitative research suffers from:

• Unreliability

The real-world setting often makes qualitative research unreliable because of uncontrolled factors that affect the data.

• Subjectivity

Due to the researcher’s primary role in analyzing and interpreting data, qualitative research cannot be replicated . The researcher decides what is important and what is irrelevant in data analysis, so interpretations of the same data can vary greatly.

• Limited generalizability

Small samples are often used to gather detailed data about specific contexts. Despite rigorous analysis procedures, it is difficult to draw generalizable conclusions because the data may be biased and unrepresentative of the wider population .

• Labor-intensive

Although software can be used to manage and record large amounts of text, data analysis often has to be checked or performed manually.

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.

• Chi square goodness of fit test
• Degrees of freedom
• Null hypothesis
• Discourse analysis
• Control groups
• Mixed methods research
• Non-probability sampling
• Quantitative research
• Inclusion and exclusion criteria

Research bias

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

Quantitative research deals with numbers and statistics, while qualitative research deals with words and meanings.

Quantitative methods allow you to systematically measure variables and test hypotheses . Qualitative methods allow you to explore concepts and experiences in more detail.

There are five common approaches to qualitative research :

• Grounded theory involves collecting data in order to develop new theories.
• Ethnography involves immersing yourself in a group or organization to understand its culture.
• Narrative research involves interpreting stories to understand how people make sense of their experiences and perceptions.
• Phenomenological research involves investigating phenomena through people’s lived experiences.
• Action research links theory and practice in several cycles to drive innovative changes.

Data collection is the systematic process by which observations or measurements are gathered in research. It is used in many different contexts by academics, governments, businesses, and other organizations.

There are various approaches to qualitative data analysis , but they all share five steps in common:

• Prepare and organize your data.
• Review and explore your data.
• Develop a data coding system.
• Assign codes to the data.
• Identify recurring themes.

The specifics of each step depend on the focus of the analysis. Some common approaches include textual analysis , thematic analysis , and discourse analysis .

Cite this Scribbr article

If you want to cite this source, you can copy and paste the citation or click the “Cite this Scribbr article” button to automatically add the citation to our free Citation Generator.

Bhandari, P. (2023, June 22). What Is Qualitative Research? | Methods & Examples. Scribbr. Retrieved April 5, 2024, from https://www.scribbr.com/methodology/qualitative-research/

Is this article helpful?

Pritha Bhandari

Other students also liked, qualitative vs. quantitative research | differences, examples & methods, how to do thematic analysis | step-by-step guide & examples, unlimited academic ai-proofreading.

✔ Document error-free in 5minutes ✔ Unlimited document corrections ✔ Specialized in correcting academic texts

Qualitative study design: Case Studies

• Qualitative study design
• Phenomenology
• Grounded theory
• Ethnography
• Narrative inquiry
• Action research

Case Studies

• Field research
• Focus groups
• Observation
• Surveys & questionnaires
• Study Designs Home

In depth description of the experience of a single person, a family, a group, a community or an organisation.

An example of a qualitative case study is a life history which is the story of one specific person.  A case study may be done to highlight a specific issue by telling a story of one person or one group. 

• Oral recording

Ability to explore and describe, in depth, an issue or event. 

Develop an understanding of health, illness and health care in context. 

Single case can be used to develop or disprove a theory. 

Can be used as a model or prototype .  

Limitations

Labour intensive and generates large diverse data sets which can be hard to manage. 

Case studies are seen by many as a weak methodology because they only look at one person or one specific group and aren’t as broad in their participant selection as other methodologies. 

Example questions

This methodology can be used to ask questions about a specific drug or treatment and its effects on an individual.

• Does thalidomide cause birth defects?
• Does exposure to a pesticide lead to cancer?

Example studies

• Choi, T. S. T., Walker, K. Z., & Palermo, C. (2018). Diabetes management in a foreign land: A case study on Chinese Australians. Health & Social Care in the Community, 26(2), e225-e232. 
• Reade, I., Rodgers, W., & Spriggs, K. (2008). New Ideas for High Performance Coaches: A Case Study of Knowledge Transfer in Sport Science.  International Journal of Sports Science & Coaching , 3(3), 335-354. 
• Wingrove, K., Barbour, L., & Palermo, C. (2017). Exploring nutrition capacity in Australia's charitable food sector.  Nutrition & Dietetics , 74(5), 495-501. 
• Green, J., & Thorogood, N. (2018). Qualitative methods for health research (4th ed.). London: SAGE. 
• University of Missouri-St. Louis. Qualitative Research Designs. Retrieved from http://www.umsl.edu/~lindquists/qualdsgn.html   
• << Previous: Action research
• Next: Field research >>
• Last Updated: Apr 3, 2024 11:54 AM
• URL: https://deakin.libguides.com/qualitative-study-designs

Research Writing and Analysis

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

Writing a Case Study

What is a case study?

A Case study is: 

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

What are the different types of case studies?

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

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

Who are your case study participants?

What is triangulation ? 

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

How to write a Case Study?

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

Was this resource helpful?

• << Previous: Thematic Data Analysis in Qualitative Design
• Next: Journal Article Reporting Standards (JARS) >>
• Last Updated: Apr 2, 2024 6:35 PM
• URL: https://resources.nu.edu/researchtools

Qualitative Research: Case Studies

• Getting Started
• Focus Groups
• Observation
• Case Studies
• Data Collection
• Cleaning Text
• Analysis Tools
• Institutional Review

Help with case studies

Photo: https://www.professays.com

How To Write a Case Study

How to undertake case study research

From: http://www.emeraldgrouppublishing.com/products/case_studies/index.htm

What is a case study?

• Attempts to shed light on a phenomena by studying a single case example.
• Focuses on an individual person, an event, a group, or an institution.
• Allows for in-depth examination by prolonged engagement or cultural immersion
• Explores processes and outcomes
• Investigates the context and setting of a situation
• Can involve a number of data gathering methods

Duke Resources

• Philanthropy Central from Sanford School of Public Policy Case Study Database Provides real-life case studies of philanthropic initiatives. There are currently more than 600 case studies linked to in the Database.

Suggested Readings

• McNabb, D. (2010).  Case reseach in public management.  NY: M.E.Sharpe.
• Samuels, D. (2013).  Case studies in comparative politics .  NY: Pearson Education.
• Stark, R. (1995). The  art of case study research, Thousand Oaks: Sage.
• Yin, R.K. (2009) Case study research: Design and methods. Los Angeles: Sage.
• << Previous: Observation
• Next: Data Collection >>
• Last Updated: Mar 1, 2024 10:13 AM
• URL: https://guides.library.duke.edu/qualitative-research

Services for...

• Faculty & Instructors
• Graduate Students
• Undergraduate Students
• International Students
• Patrons with Disabilities

• Harmful Language Statement
• Re-use & Attribution / Privacy
• Support the Libraries

An official website of the United States government

The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

• Publications
• Account settings

Preview improvements coming to the PMC website in October 2024. Learn More or Try it out now .

• Advanced Search
• Journal List
• BMC Med Res Methodol

The case study approach

Sarah crowe.

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

Kathrin Cresswell

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

Ann Robertson

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

Anthony Avery

Aziz sheikh.

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.

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 ​ Tables1, 1 , ​ ,2, 2 , ​ ,3 3 and ​ and4) 4 ) and those of others to illustrate our discussion[ 3 - 7 ].

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

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

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

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

What is a case study?

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

Definitions of a case study

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 ​ (Table1), 1 ), we undertook an intrinsic case study to investigate the issue of recruitment of minority ethnic people into the specific context of asthma research studies, but it developed into a instrumental case study through seeking to understand the issue of recruitment of these marginalised populations more generally, generating a number of the findings that are potentially transferable to other disease contexts[ 3 ]. In contrast, the other three examples (see Tables ​ Tables2, 2 , ​ ,3 3 and ​ and4) 4 ) employed collective case study designs to study the introduction of workforce reconfiguration in primary care, the implementation of electronic health records into hospitals, and to understand the ways in which healthcare students learn about patient safety considerations[ 4 - 6 ]. Although our study focusing on the introduction of General Practitioners with Specialist Interests (Table ​ (Table2) 2 ) was explicitly collective in design (four contrasting primary care organisations were studied), is was also instrumental in that this particular professional group was studied as an exemplar of the more general phenomenon of workforce redesign[ 4 ].

What are case studies used for?

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

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

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

How are case studies conducted?

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 ​ Table7 7 )[ 1 ]. A theory driven approach to defining the case may help generate knowledge that is potentially transferable to a range of clinical contexts and behaviours; using theory is also likely to result in a more informed appreciation of, for example, how and why interventions have succeeded or failed[ 13 ].

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

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

Selecting the case(s)

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

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 ​ Table3) 3 ) was heavily influenced by NHS Connecting for Health, the government agency that was responsible for overseeing the National Programme for Information Technology (NPfIT)[ 5 ]. This prominent stakeholder had already selected the NHS sites (through a competitive bidding process) to be early adopters of the electronic health record systems and had negotiated contracts that detailed the deployment timelines.

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 ​ (Table2 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 ​ (Table1 1 )[ 3 , 24 ]. Theoretical frameworks may also play an important role in integrating different sources of data and examining emerging themes. For example, we drew on a socio-technical framework to help explain the connections between different elements - technology; people; and the organisational settings within which they worked - in our study of the introduction of electronic health record systems (Table ​ (Table3 3 )[ 5 ]. Our study of patient safety in undergraduate curricula drew on an evaluation-based approach to design and analysis, which emphasised the importance of the academic, organisational and practice contexts through which students learn (Table ​ (Table4 4 )[ 6 ].

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 ​ Table3, 3 , we decided against providing detailed information on the NHS sites and individual participants in order to avoid the risk of inadvertent disclosure of identities[ 5 , 25 ].

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

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

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

Potential pitfalls and mitigating actions when undertaking case study research

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

Conclusions

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.

Competing interests

The authors declare that they have no competing interests.

Authors' contributions

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

Pre-publication history

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

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

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.

• Yin RK. Case study research, design and method. 4. London: Sage Publications Ltd.; 2009. [ Google Scholar ]
• Keen J, Packwood T. Qualitative research; case study evaluation. BMJ. 1995; 311 :444–446. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Sheikh A, Halani L, Bhopal R, Netuveli G, Partridge M, Car J. et al. Facilitating the Recruitment of Minority Ethnic People into Research: Qualitative Case Study of South Asians and Asthma. PLoS Med. 2009; 6 (10):1–11. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Pinnock H, Huby G, Powell A, Kielmann T, Price D, Williams S, The process of planning, development and implementation of a General Practitioner with a Special Interest service in Primary Care Organisations in England and Wales: a comparative prospective case study. Report for the National Co-ordinating Centre for NHS Service Delivery and Organisation R&D (NCCSDO) 2008. http://www.sdo.nihr.ac.uk/files/project/99-final-report.pdf
• Robertson A, Cresswell K, Takian A, Petrakaki D, Crowe S, Cornford T. et al. Prospective evaluation of the implementation and adoption of NHS Connecting for Health's national electronic health record in secondary care in England: interim findings. BMJ. 2010; 41 :c4564. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Pearson P, Steven A, Howe A, Sheikh A, Ashcroft D, Smith P. the Patient Safety Education Study Group. Learning about patient safety: organisational context and culture in the education of healthcare professionals. J Health Serv Res Policy. 2010; 15 :4–10. doi: 10.1258/jhsrp.2009.009052. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• van Harten WH, Casparie TF, Fisscher OA. The evaluation of the introduction of a quality management system: a process-oriented case study in a large rehabilitation hospital. Health Policy. 2002; 60 (1):17–37. doi: 10.1016/S0168-8510(01)00187-7. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Stake RE. The art of case study research. London: Sage Publications Ltd.; 1995. [ Google Scholar ]
• Sheikh A, Smeeth L, Ashcroft R. Randomised controlled trials in primary care: scope and application. Br J Gen Pract. 2002; 52 (482):746–51. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• King G, Keohane R, Verba S. Designing Social Inquiry. Princeton: Princeton University Press; 1996. [ Google Scholar ]
• Doolin B. Information technology as disciplinary technology: being critical in interpretative research on information systems. Journal of Information Technology. 1998; 13 :301–311. doi: 10.1057/jit.1998.8. [ CrossRef ] [ Google Scholar ]
• George AL, Bennett A. Case studies and theory development in the social sciences. Cambridge, MA: MIT Press; 2005. [ Google Scholar ]
• Eccles M. the Improved Clinical Effectiveness through Behavioural Research Group (ICEBeRG) Designing theoretically-informed implementation interventions. Implementation Science. 2006; 1 :1–8. doi: 10.1186/1748-5908-1-1. [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Netuveli G, Hurwitz B, Levy M, Fletcher M, Barnes G, Durham SR, Sheikh A. Ethnic variations in UK asthma frequency, morbidity, and health-service use: a systematic review and meta-analysis. Lancet. 2005; 365 (9456):312–7. [ PubMed ] [ Google Scholar ]
• Sheikh A, Panesar SS, Lasserson T, Netuveli G. Recruitment of ethnic minorities to asthma studies. Thorax. 2004; 59 (7):634. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Hellström I, Nolan M, Lundh U. 'We do things together': A case study of 'couplehood' in dementia. Dementia. 2005; 4 :7–22. doi: 10.1177/1471301205049188. [ CrossRef ] [ Google Scholar ]
• Som CV. Nothing seems to have changed, nothing seems to be changing and perhaps nothing will change in the NHS: doctors' response to clinical governance. International Journal of Public Sector Management. 2005; 18 :463–477. doi: 10.1108/09513550510608903. [ CrossRef ] [ Google Scholar ]
• Lincoln Y, Guba E. Naturalistic inquiry. Newbury Park: Sage Publications; 1985. [ Google Scholar ]
• Barbour RS. Checklists for improving rigour in qualitative research: a case of the tail wagging the dog? BMJ. 2001; 322 :1115–1117. doi: 10.1136/bmj.322.7294.1115. [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Mays N, Pope C. Qualitative research in health care: Assessing quality in qualitative research. BMJ. 2000; 320 :50–52. doi: 10.1136/bmj.320.7226.50. [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Mason J. Qualitative researching. London: Sage; 2002. [ Google Scholar ]
• Brazier A, Cooke K, Moravan V. Using Mixed Methods for Evaluating an Integrative Approach to Cancer Care: A Case Study. Integr Cancer Ther. 2008; 7 :5–17. doi: 10.1177/1534735407313395. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Miles MB, Huberman M. Qualitative data analysis: an expanded sourcebook. 2. CA: Sage Publications Inc.; 1994. [ Google Scholar ]
• Pope C, Ziebland S, Mays N. Analysing qualitative data. Qualitative research in health care. BMJ. 2000; 320 :114–116. doi: 10.1136/bmj.320.7227.114. [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Cresswell KM, Worth A, Sheikh A. Actor-Network Theory and its role in understanding the implementation of information technology developments in healthcare. BMC Med Inform Decis Mak. 2010; 10 (1):67. doi: 10.1186/1472-6947-10-67. [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Malterud K. Qualitative research: standards, challenges, and guidelines. Lancet. 2001; 358 :483–488. doi: 10.1016/S0140-6736(01)05627-6. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Yin R. Case study research: design and methods. 2. Thousand Oaks, CA: Sage Publishing; 1994. [ Google Scholar ]
• Yin R. Enhancing the quality of case studies in health services research. Health Serv Res. 1999; 34 :1209–1224. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Green J, Thorogood N. Qualitative methods for health research. 2. Los Angeles: Sage; 2009. [ Google Scholar ]
• Howcroft D, Trauth E. Handbook of Critical Information Systems Research, Theory and Application. Cheltenham, UK: Northampton, MA, USA: Edward Elgar; 2005. [ Google Scholar ]
• Blakie N. Approaches to Social Enquiry. Cambridge: Polity Press; 1993. [ Google Scholar ]
• Doolin B. Power and resistance in the implementation of a medical management information system. Info Systems J. 2004; 14 :343–362. doi: 10.1111/j.1365-2575.2004.00176.x. [ CrossRef ] [ Google Scholar ]
• Bloomfield BP, Best A. Management consultants: systems development, power and the translation of problems. Sociological Review. 1992; 40 :533–560. [ Google Scholar ]
• Shanks G, Parr A. Proceedings of the European Conference on Information Systems. Naples; 2003. Positivist, single case study research in information systems: A critical analysis. [ Google Scholar ]

• Open access
• Published: 05 April 2024

One Health communication channels: a qualitative case study of swine influenza in Canada in 2020

• José Denis-Robichaud 1 , 6 ,
• Suzanne Hindmarch 2 ,
• Nancy N. Nswal 1 , 5 ,
• Jean Claude Mutabazi 3 ,
• Mireille D’Astous 1 , 5 ,
• Marcellin Gangbè 3 , 6 ,
• Andrea Osborn 4 ,
• Christina Zarowsky 1 , 5 ,
• Erin E. Rees 1 , 3 , 5 , 6 &
• Hélène Carabin 1 , 5 , 6  

BMC Public Health volume  24 , Article number:  964 ( 2024 ) Cite this article

Metrics details

With increased attention to the importance of integrating the One Health approach into zoonotic disease surveillance and response, a greater understanding of the mechanisms to support effective communication and information sharing across animal and human health sectors is needed. The objectives of this qualitative case study were to describe the communication channels used between human and animal health stakeholders and to identify the elements that have enabled the integration of the One Health approach.

We combined documentary research with interviews with fifteen stakeholders to map the communication channels used in human and swine influenza surveillance in Alberta, Canada, as well as in the response to a human case of H1N2v in 2020. A thematic analysis of the interviews was also used to identify the barriers and facilitators to communication among stakeholders from the animal and human health sectors.

When a human case of swine influenza emerged, the response led by the provincial Chief Medical Officer of Health involved players at various levels of government and in the human and animal health sectors. The collaboration of public and animal health laboratories and of the swine sector, in addition to the information available through the surveillance systems in place, was swift and effective. Elements identified as enabling smooth communication between the human and animal health systems included preexisting relationships between the various stakeholders, a relationship of trust between them (e.g., the swine sector and their perception of government structures), the presence of stakeholders acting as permanent liaisons between the ministries of health and agriculture, and stakeholders' understanding of the importance of the One Health approach.

Conclusions

Information flows through formal and informal channels and both structural and relational features that can support rapid and effective communication in infectious disease surveillance and outbreak response.

Peer Review reports

Influenza virus surveillance and response to spillover between species are situations that can benefit from a One Health (OH) approach, as they occur at the intersection of animal, human, and ecosystem health sectors [ 1 ]. An improved understanding of intersectoral communication across OH domains is important because many emerging diseases are of animal origin [ 2 ], and many global forces (increased mobility of people, animals, animal products and goods, climate change, agribusiness expansion, deforestation, etc.) are increasingly altering environments to put animals and humans in close contact, facilitating disease spillover in both directions. Identifying formal and informal structures, processes or practices that support OH communication could improve the integration of the OH approach in different systems.

Human infections with swine influenza virus subtypes have been reported in North America [ 3 , 4 ], and these are reportable under the International Health Regulations (IHR), although data suggest that transmission of influenza from humans to pigs is more frequent [ 5 ]. Here, we report a human case of influenza A H1N2v occurring in Alberta in October 2020. It resulted in rapid collaboration and investigation by human and animal health sectors, but there is limited information about how and why effective communication and coordination occurred between and within these sectors during this event. Bridging this gap requires gathering information from multiple points of view, to which qualitative methods are well suited [ 6 ]. Describing the context and narrative of a specific case study enables identification of patterns that can then be validated in other contexts. Our study objectives were to describe the OH communication channels and flow of information among stakeholders involved in human and swine influenza surveillance and response activities in Alberta (Canada) and to identify elements encouraging and inhibiting OH communication, specifically related to information sharing between livestock Footnote 1 and public health professionals. Our research question was therefore to determine what factors impede or support information sharing between sectors during the occurrence of a human case of zoonotic influenza.

To describe the mechanisms and performance of communication channels, we used interpretive process tracing [ 6 , 7 , 8 ]. We started from the detection of the emergence of a human case of influenza A H1N2v in Alberta in October 2020. We then sought to understand the communication channels related to the surveillance of influenza in pigs and humans generally and how these and other channels operated in this specific case. Our research team included animal and public health researchers and government employees, but none were directly involved in case management or regional surveillance systems related to this event. We relied on the experience and knowledge from our collaborator from the Animal Health Science Directorate of the Canadian Food Inspection Agency (CFIA) to identify some key stakeholders.

Documentary research and interviews with stakeholders influenced each other in an iterative process. The Canadian Animal Health Surveillance System (CAHSS) was a starting point for documentary research, as it already mapped the surveillance system within multiple animal production industries [ 9 ]. Additionally, we used a report created after the 2009 H1N1 pandemic [ 10 ] and a recent study about laboratory and syndromic surveillance in the swine sector [ 11 ] to create a preliminary outline of Canadian influenza communication channels.

We initially identified ten stakeholders occupying strategic positions in the case study communications channels, representing federal and provincial governments, animal and public health, and Canadian swine health surveillance systems. Additional stakeholders were identified through snowballing and findings from concurrent documentary research [ 12 , 13 ]. Interviewees were invited to participate in a one-hour individual semistructured interview to identify and explore structural links and information channels.

We developed semistructured interview questions during the initial phases of the documentary research and created a general interview guide to identify the case study communication channels and the barriers and facilitators for communication between animal and human health stakeholders (Table  1 ). The guide was tested with a team member involved in animal health surveillance who did not participate in developing the questions. The data from this pilot were kept for the analyses. The research team met throughout the project to discuss and assess the guide and minimize biases [ 14 ]. For example, interviewers adapted the guide to make it relevant to each interviewed stakeholder by choosing questions that aligned with their work and position. Some questions were also rephrased or complemented to fill gaps identified during previous interviews. Changes and additions were reviewed by members of the research team, all of whom assessed the questions from their own disciplinary vantage point to ensure these alterations were consistent with the global objectives of the study and did not reflect the implicit assumptions or biases of any one discipline or sector. While the main interviewer was an animal health specialist, she was joined by at least one other member of the team from another discipline during all interviews. Having one interviewer with deep subject matter expertise ensured continuity and rigour across interviews; having a second research team member from a different disciplinary vantage point served as a check to reduce confirmation bias.

Interviews were conducted in English or French between September and December 2021, and (with permission) audio recorded on Zoom (Zoom Video Communications, Inc.) or Teams (Microsoft corp.). Interviews were transcribed and cleaned and then coded and analyzed in NVivo (Luminvero©). To protect anonymity, all interview quotes in this report are presented in English. Participants did not receive compensation. We contacted 23 stakeholders from the human ( n =13) and animal health ( n =10) sectors, of whom eight (human: n = 6, and animal: n = 2) declined or did not reply to our invitations (nonparticipation proportion = 35%). Fifteen participants from the human ( n = 7) and animal ( n = 8) health sectors were interviewed in November and December 2021. Employees of the federal (Public Health Agency of Canada and CFIA) and provincial (Alberta Health Services and Alberta Ministry of Agriculture) governments, stakeholders from the swine health surveillance system and from academia participated in the interviews (Table  2 ).

Through an interpretive process tracing approach, we explored how actors described their practices, how they perceived their actions, and how information flows [ 8 , 15 ]. We used interview transcripts combined with documentary research to create a map of the communication channels among stakeholders involved in human and swine influenza surveillance in Alberta and in the specific H1N2v zoonotic human influenza case. We then synthesized this information graphically using an online collaborative platform (Miro; RealtimeBoard, Inc.). We identified two distinct categories of communication channels: formal and informal. Formal channels were those that entailed an institutionalized, official structure, often including established written protocols, guidance documents, or terms of reference specifying how actors holding specific positions of authority were to communicate with each other. Informal channels were ad hoc, created by the involved stakeholders to suit a particular situation, and were often dependent on personal relationships between individuals, rather than institutionalized relationships between offices or job functions. We used an iterative thematic analysis [ 16 , 17 ] to identify barriers and facilitators to information sharing in this case. Themes and subthemes summarizing participants’ perspectives were discussed among members of our research team, and representative quotes were selected. We used this information about facilitators and barriers to identify elements that, more broadly, may support or impede information sharing between animal health and human health stakeholders.

While our study focused on a human case of swine influenza, it quickly became clear that the surveillance systems in place prior to the event were important. Surveillance systems have multiple goals. For influenza in Canada, surveillance aims to detect and monitor the viruses, and to inform vaccines and policies [ 18 , 19 ].

Routine communication structures

We describe below the usual communication channels in the swine sector, the human health sector, and across these two sectors.

Routine communication channels for the surveillance of influenza virus infection in the swine sector in Alberta

Figure  1 B shows communication channels as they flow (from left to right) in Alberta. Influenza virus in pigs is provincially notifiable Footnote 2 in Alberta, British Columbia and Saskatchewan, but it is not federally notifiable. At the regional level, the Canada West Swine Health Intelligence Network (CWSHIN) combines and analyzes the data from British Columbia, Alberta, Saskatchewan, and Manitoba. It includes clinical impression surveys from swine veterinarians, laboratory diagnostic data from provincial and university laboratories (presence of pathogens, or serological or anatomical indicators), and condemnation rates from federally inspected slaughterhouses [ 11 ]. Once analyzed, the information is shared quarterly with veterinarians (reports, as private communications) and producers (reports, as public communications) and, when requested to address animal, human, or ecosystem concerns, with provincial governments (Fig.  1 B). While some analyzed data are publicly available via reports for producers, our participants stated that there are no other direct communication channels between the CWSHIN and public health stakeholders. However, the regional surveillance networks (CWSHIN, Ontario Animal Health Network, and Réseau d’alerte et d’information zoosanitaire) are part of the Canadian Swine Health Intelligence Network (CSHIN) and the CAHSS, which include members from the National and Provincial pork councils, veterinary colleges, diagnostic laboratories, provincial governments, CFIA, Agriculture and Agri-Food Canada (AAFC), Public Health Agency of Canada (PHAC), and national and regional veterinary organizations and networks.

Structural communication links identified for human ( A ) and swine ( B ) influenza surveillance in Alberta. Information is usually shared from left to right: from laboratories, through the Provincial Surveillance Initiative system, back to the patients and referring physicians, as well as surveillance groups within the provincial government. Some information (anonymized) also flows to the federal government: from veterinarians, laboratories, and abattoirs to Swine Health Intelligence Networks (e.g., CWSHIN and CSHIN) to governments (provincial and federal). There is also publicly available information shared by the Community for Emerging and Zoonotic Diseases to various stakeholders (from right to left). Dashed lines: samples; Full lines: data; Dotted lines: results/summaries. Blue: field stakeholders; Yellow: laboratories; Purple: intelligence; Red: government. CAHSS Canadian Animal Health Surveillance System; CEZD Community for Emerging and Zoonotic Diseases; CFIA Canadian Food Inspection Agency; CSHIN Canadian Swine Health Intelligence Network; CWSHIN Canada West Swine Health Intelligence Network; GPHIN Global Public Health Intelligence Network; PHAC Public Health Agency of Canada; PSI Provincial Surveillance Initiative

Routine communication channels for the surveillance of influenza virus infection in the human sector in Alberta

In Alberta, laboratory data flow through a single laboratory information system (Provincial Surveillance Initiative; PSI), and information is automatically transmitted to stakeholders (e.g., physicians, patients, and surveillance units within the Ministry of Health; Fig.  1 A) via an online platform. This system allows the linkage of clinical and epidemiological data with laboratory data at the provincial level.

The data about influenza collected by the healthcare system are gathered provincially and then anonymized and shared with FluWatch, a national surveillance program for influenza and influenza-like illnesses (ILI) [ 18 ]. The program monitors, inter alia, health care admission for influenza or ILI, laboratory-confirmed detection, syndromic surveillance, outbreak and severe outcome surveillance, and vaccine coverage; it shares weekly reports online [ 18 ]. At the provincial and federal levels, we were unable to identify other communication channels for providing human influenza surveillance information to animal health stakeholders.

Routine communication channels between the swine and human sectors for the surveillance of influenza in Alberta

Many swine health surveillance stakeholders are members of the Community for Emerging and Zoonotic Diseases (CEZD). This multidisciplinary network of public and animal health experts from government, industry and academia was developed to support early warning, preparedness, and response for animal emerging and zoonotic diseases [ 20 ]. Open source signals are extracted automatically via the Knowledge Integration using Web Based Intelligence (KIWI) [ 21 ] and manually by the CEZD core team (CFIA employees). This team assesses signals daily, with rolling support from volunteer members and from expert partners from federal and provincial governments, academia, and industry when needed. Signals are then shared with the CEZD community, including through immediate notifications of important disease events, group notifications and pings, quarterly sector-specific intelligence reports and weekly intelligence reports.

Although CEZD was growing during the 2020-2021 period [ 22 ], membership is voluntary, as it is the case for CAHSS. Moreover, both networks cover multiple species and diseases, which serves to maximize the reach of the communities but can result in an overwhelming amount of information for members whose main interest is in another sector, such as human or ecosystem health. This large amount of information primarily relevant to other sectors can lead members to leave or not join these two networks.

Communication channels between sectors during a human case of swine influenza in Alberta

In all cases where a new influenza subtype, including an animal influenza subtype, is identified from a human case, this must be reported to the World Health Organization (WHO) under the IHR [ 23 ]. In Canada, PHAC is the body responsible for notifying the WHO of such cases. We examined the IHR-reportable case of a human infected with an animal influenza subtype identified in October 2020 in Alberta. The event we examined happened during an exceptional period for ILI as it was less than a year after the WHO declared the 2019 novel coronavirus disease (COVID-19) a global pandemic. At that time, influenza activity remained below average, most ILI symptoms were due to COVID-19 cases, and most public health and human health resources were dedicated to managing the pandemic [ 24 ].

In the case we investigated, the influenza subtype identified through sequencing performed at a provincial laboratory on October 29, 2020 (Fig.  2 ) in the human case was a variant similar to a swine influenza virus (A H1N2v). Samples from the human case were then sent to a reference laboratory, the National Laboratory of Microbiology (NLM) of PHAC, for confirmation. A provincial laboratory stakeholder also contacted a University Animal Health Laboratory colleague and sent the human sample in parallel for sequencing and confirmation that the variant was a swine virus.

Timeline and communication links during the human influenza A H1N2v case in Alberta. Dashed lines: samples; Full lines: data; Dotted lines: results/summaries Blue: field stakeholders; Yellow: laboratories; Green: intelligence; Red: government, Purple: international.  CEZD Community for Emerging and Zoonotic Diseases; CFIA Canadian Food Inspection Agency; CMOH Chief Medical Officer of Health; CSHIN Canadian Swine Health Intelligence Network; CVO  Chief Veterinary Officer; CWSHIN Canada West Swine Health Intelligence Network; GPHIN Global Public Health Intelligence Network; PHAC Public Health Agency of Canada; PSI Provincial Surveillance Initiative; WHO World Health Organization

Because the human case was IHR reportable and had potential for high visibility, the provincial laboratory immediately contacted the Alberta Chief Medical Officer of Health (CMOH). Provincial and federal government stakeholders (Alberta Health, Alberta Health Services, Alberta Agriculture and Forestry, PHAC, CFIA) were called to an evening meeting to raise awareness and ensure that the situation was managed in a way that satisfied provincial, federal and international obligations. This “H1N2v working group” was put in place quickly, apparently following the initiative of the Alberta CMOH (not confirmed as no interview was conducted with the initiators of this working group).

The information PHAC received through formal communication channels (e.g., from the NLM) took longer compared to the original call by the CMOH and the H1N2v working group. For this study, we did not have access to the guidelines in place for such an event, and it is unclear if the other stakeholders (provincial Ministry of Agriculture and CFIA) were officially needed to be involved.

Because swine influenza is endemic in the porcine population and this case was of importance for human health, the provincial public health stakeholders led the initiative, with the support of other stakeholders. The H1N2v working group met at least twice following the initial meeting. Additionally, follow-up data was gathered at the provincial level via multiple channels (public health, animal health, epidemiological, and laboratory investigations), and findings from the various investigations were shared with PHAC daily for a week and then weekly for two additional weeks. Information sharing between provincial and federal public health entities seemed to follow a formal process, but while we had access to the communication template, none of the interviewed participants had information about the structure supporting this initiative.

In the meantime, regional public health partners (within Alberta Health Services) were mandated to conduct the field investigation for the human case and its contacts with humans and pigs, supported by Alberta Agriculture and Forestry and stakeholders from the swine sector (e.g., Alberta Pork). The investigation’s goal was to clarify whether the infection was contracted from animal-to-person (directly or indirectly) or person-to-person. The public health investigation, the available information about swine influenza in the province (obtained from the CSHIN report), and the farm investigation performed in collaboration with an Animal Health Laboratory all provided supporting data.

The human and animal investigation data were collected by multiple stakeholders. The communication of results followed formal structures through Alberta Health (case, laboratory and epidemiological investigation results) and Alberta Agriculture and Forestry (farm investigation results) and were ultimately shared with PHAC. Interviewees reported that coordination of the two provincial ministries in this case was facilitated by the public health veterinarian, whose position is shared between the two ministries. Interviewees also said that in the investigation’s early stages, the swine sector’s participation in the farm investigation (an informal channel, via Alberta Pork) facilitated communication between the government and the farm involved. This highlights the importance of strong formal and informal government-industry relationships, which ensured that farmers and stakeholders trusted the system enough to support the investigation.

While the investigation was still ongoing and a clearer picture of the case and its transmission was emerging, a decision was made to make the information public. Our interviews did not identify the process leading to this decision, but six days after the initial notification to the government officials, an Alberta CMOH press release was distributed, with information stating there was limited risk for the general population. This now-public information was then identified by at least two Canadian event-based surveillance (EBS) systems that distributed the information to their communities. One of the EBS interviewees mentioned, however, that they received an email from the Alberta Agriculture and Forestry the night before the press release so they could prepare for it and have a notification ready to be shared. This informal communication channel seemed to arise from a preexisting relationship between stakeholders involved.

Encouraging and inhibiting elements involved in OH communication

The communication channels evident in our case study allowed us to identify elements involved in the information flow between animal and human health stakeholders (Table  3 ). Identifying what information needed to be shared between sectors was influenced by actors’ understanding of the evidence needed to trigger decisions and actions. During the surveillance phase, information was available online from the animal health (CWSHIN, CSHIN, CAHSS, CEZD) and human health (FluWatch, Global Public Health Intelligence Network) sectors. However, it was difficult to quantify how much these sources were used by different stakeholders. We identified little other communication between animal and human health stakeholders during this phase. Stakeholders reported having very limited time and resources to consult and use information from other sectors, suggesting a need for policies and structural integration of OH. For example, having a public health veterinarian appointed at both the provincial agriculture and health ministries was mentioned as a key element facilitating communication and coordination (Quote 1).

Quote 1. “When the pandemic started, we had our public health veterinarian position empty. […] That position is essentially fully dedicated to working between the two ministries [Agriculture and Health]. It [the impact of this vacancy] showed itself in terms of just some gaps for them working on things without consulting us, but then [when] that position was filled and the other relationships were in place, everything just went really smoothly. […] it demonstrated the importance of those relationships and… having a good liaison between the two departments.”

During the outbreak, surveillance, laboratory, and industry information on swine influenza was quickly available to human health stakeholders. Animal health stakeholders, however, noted that the communication was, unfortunately and as in many cases, only one way. Barriers to within- and cross-sector communication included complicated or lacking communication channels. In our case study, there was a formal channel between the provincial and federal government due to the IHR requirements, but this is not the case for non-IHR-reportable zoonotic diseases. Moreover, the CMOH’s phone call to other stakeholders to create the H1N2v working group occurred faster than the formal communication channels.

Established professional connections facilitated information flow between stakeholders who understood each other’s needs and interests. While a lack of formal channels was identified as a pitfall due to potentially missed communication opportunities, many participants mentioned that established, informal relationships and networks facilitated information sharing – both the assessment of how much and what type of information to share and with whom it should be shared. Informal and formal communication channels were also affected by privacy and ethical concerns. Raw data, usually confidential, obtained from either the animal or human health sectors cannot easily be shared, adding to the complexity of formal communication channels. Analyzed or summarized data (i.e., information) were easier for both animal and human health sectors to share in reports or online platforms.

Trust, which can be defined as the perceived benevolence, integrity, competence and predictability of the other [ 25 ], was identified as the foundation for good communication among different stakeholders, whether via formal or informal channels. Here, previous interactions between stakeholders likely served as a basis for trusting that the person receiving the information would be kind, competent, honest, and predictable when using it. From the perspective of animal health stakeholders, however, trust was more difficult: the perceived anthropocentric perspective of health initiatives, including OH initiatives [ 26 ], created fear that shared information might not be reciprocated and would have negative repercussions on animals and producers (Quote 2).

Quote 2. “You need to build trust and it takes a long time […] you need to build that trust with individual livestock sectors, that human health is not going to destroy the sector a . The [animal health] sector is generally very cautious because their perspective is very rarely considered […] if you have a human pathogen […] in livestock and it can potentially transfer to people, all the burden is very often on the livestock. […] Human health has a lot of resources and animal health doesn't, but they get all [the burden]. It's a matter of who [has] the cost and who's benefiting.” a While the stakeholder interviewed did not give additional details, they could have been referring to the case of a herd where an emerging influenza virus (H1N1v) was identified, which resulted in depopulation of the herd [ 4 ]. This was a severe consequence for the farmer, while the source of the virus was determined to be an infected human. They could also have been referring to the possibility of zoonotic events decreasing the marketability of meat because of public perception or export restrictions. This was unfortunately not discussed further in the interview

Interviewees suggested that information sharing requires two main steps: (1) identifying what information must be shared and (2) sharing that information with another sector (Fig.  3 ). Once stakeholders within a sector had information, the first step was identifying what should and can be shared, with whom, and through what channels. This could be facilitated or impeded by actors’ perceptions of other sectors’ needs, the type of information that is available, and the resources available. For sharing information itself, both the presence and type of communication channels were critical for external information sharing with other sectors – but so were trust and the availability of resources. Preexisting relationships among stakeholders also shaped actors’ understanding of each other’s needs, the presence of informal channels, and trust.

Elements linking the steps involved between obtaining information and sharing information to another health sector

* The two sectors examined in the present case study are animal health and human health

This case study highlights the complex communication structures for influenza surveillance and response in both human and animal health sectors and the limited links between these sectors. It illustrates the importance of rapid and open communication channels between these sectors in both surveillance and response contexts. While day-to-day surveillance aims to detect and monitor influenza viruses, the detection of a human case harboring an animal subtype resulted in a specific response, which triggered different channels. While information flows through formal and informal channels, trust is a critical component in all types of communication: between animal and human health actors, between government and livestock sectors, and between international, federal, provincial and territorial, and regional jurisdictional levels. Developing and maintaining relationships among stakeholders requires time and resources but is essential for mutual understanding of information needs and rapid communication.

While previous studies found that communication is a key factor for OH initiatives [ 27 , 28 ], we were able to identify processes that were in place when good communication occurred. These findings offer a new perspective that could be useful to many surveillance and response programs. For example, networks and structures are often described for influenza programs, but the communication channels and information flow are not detailed [ 29 , 30 , 31 ]. This is a gap that would be useful to address, especially as we found that while formal structures are necessary, informal structures allow for quicker and more efficient communication and coordination.

Limitations

While the findings from this study highlight key elements of good One Health communication, the retrospective interpretive process tracing of a case study has certain limitations. First, our study was based on an influenza case, for which there are established surveillance systems and protocols [ 11 , 18 , 23 ]. This likely contributed to the effective response but also influenced our findings. We think this could have hidden or minimized some of the challenges faced by stakeholders regarding OH communication. For example, in the case of a disease that has no formal surveillance system reporting guidelines, challenges might be different. Second, we purposively selected a “success story” to illustrate what happens when OH communication goes well. Due to this retrospective selection of our case study, we suspected that communication and coordination went well prior to starting the project. This could have influenced our findings, and it is possible that we would have had different conclusions if we used a case study for which communication and coordination were suboptimal. To mitigate this, we designed the study with an interpretive approach focusing on the interviewees’ own perspectives, with as little preconceived bias as possible [ 8 ]. Third, the case we chose happened during the COVID-19 pandemic. The high focus on ILI during this period could have strengthened some communication channels. For example, many resources were deployed to manage the pandemic, which may have facilitated communication and integration among sectors. Fourth, this could have also affected the stakeholders who agreed to participate in the interviews, which were conducted at a later stage of the pandemic. Indeed, six human health stakeholders who had key positions in this case declined or did not reply to our invitation, and our findings lack their perspective. It is possible that more communication channels between human and animal health exist, but we were not able to identify them. The barriers and limitations we identified are possibly different for stakeholders in the human health sector; additional research related to the involvement of these actors in OH communication would be beneficial. Fifth, due to the limited resources available for this project, the focus of the case study (swine and public health), and the process we used to identify the stakeholders to interview, we did not identify stakeholders from the environment and wildlife health sector, or from other livestock health sectors (e.g., poultry). This is, in itself, a finding, highlighting the limited communication channels among these stakeholders. It is however unclear if our findings about facilitators and barriers are generalizable to all sectors.

While additional research, including larger comparative studies, is needed, our findings highlight the importance of investing time and resources in supporting relationship building, as well as formal communication mechanisms, among stakeholders in the human, animal, and ecosystem health sectors.

Availability of data and materials

No datasets were generated or analysed during the current study.

While the One Health approach should in principle engage stakeholders from human, environmental, and animal health sectors, the scope of the current study focused on public health and livestock health sectors. Throughout the manuscript, we used public and human health interchangeably, as for animal and livestock health.

Reportable and notifiable diseases must be reported to federal and/or provincial governments. Reportable diseases generally pose significant threats to animal health, public health, or food safety, while notifiable diseases are monitored for trends or changes.

Abbreviations

Agriculture and Agri-Food Canada

Canadian Animal Health Surveillance System

Canadian Food Inspection Agency

Chief Medical Officer of Health

Canadian Swine Health Intelligence Network

Canada West Swine Health Intelligence Network

Community for Emerging and Zoonotic Diseases

Event-based surveillance

International Health Regulations

Influenza-like illnesses

Knowledge Integration using Web Based Intelligence

National Laboratory of Microbiology

Public Health Agency of Canada

Provincial Surveillance Initiative

World Health Organization

One Health High Level Expert Panel. Tripartite and UNEP support OHHLEP’s definition of “One Health”. 2021 [cited 2022 Feb 8]. Available from: https://www.who.int/news/item/01-12-2021-tripartite-and-unep-support-ohhlep-s-definition-of-one-health .

EFSA and ECDC (European Food Safety Authority and European Centre forDisease Prevention and Control), 2019. The European Union One Health 2018 Zoonoses Report. EFSA J. 2019;17(12):5926, 276. https://doi.org/10.2903/j.efsa.2019.5926 .

CDC. Centers for Disease Control and Prevention. 2022. CDC Confirms Another Human Infection with Flu Virus from Pigs. Available from: https://www.cdc.gov/flu/swineflu/spotlights/swineflu-infection.htm .Cited 2022 Sep 30.

Howden KJ, Brockhoff EJ, Caya FD, McLeod LJ, Lavoie M, Ing JD, et al. An investigation into human pandemic influenza virus (H1N1) 2009 on an Alberta swine farm. Can Vet J. 2009;50(11):1153–61.

PubMed   PubMed Central   Google Scholar  

Nelson MI, Vincent AL. Reverse zoonosis of influenza to swine: new perspectives on the human-animal interface. Trends Microbiol. 2015;23(3):142–53.

Article   CAS   PubMed   PubMed Central   Google Scholar  

Tenny S, Brannan JM, Brannan GD. Qualitative Study. St. Peterburg, FL, US: StatPearls Publishing; 2022. Available from: https://www.ncbi.nlm.nih.gov/books/NBK470395/ . Cited 28 Apr 2023.

Creswell JW, Poth CN. Qualitative inquiry and research design: choosing among five approaches. SAGE Publications; 2016. p. 489.

Beach D. Process Tracing Methods in the Social Sciences. Oxford: Oxford Research Encyclopedias; 2022. Politics:21.

CAHSS. Canadian Animal Health Surveillance System. 2020 . Available from: https://cahss.ca/ . Cited 2021 Sep 1.

Wisener L. Interviews d’intervenants clés : Les défis et les possibilités en matière de prévention, de dépistage précoce et d’atténuation des grippes zoonotiques aux points de contact entre humains et porcs au Canada. Centre de collaboration nationale des maladies infectieuses; 2014 [cited 2021 Oct 18]. Available from: https://ccnmi.ca/publications/prevention-de-depistage-precoce-et-dattenuation-des-grippes-zoonotiques-aux-points-de-contact-entre-humains-et-porcs-au-canada/ .

Christensen J, Byra C, Keenliside J, Huang Y, Harding JCS, Duizer G, et al. Development and evaluation of a new method to combine clinical impression survey data with existing laboratory data for veterinary syndromic surveillance with the Canada West Swine Health Intelligence Network (CWSHIN). Prev Vet Med. 2021;194:105444.

Corbin J, Strauss A. Basics of Qualitative Research. 4th ed. Thousand Oaks: SAGE Publications; 2022 [cited 2022 Oct 1]. Available from: https://us.sagepub.com/en-us/nam/basics-of-qualitative-research/book235578 .

Parker C, Scott S, Geddes A. Snowball Sampling. In: Research Design for Qualitative Research [Internet]. London: SAGE Publications Ltd; 2020 [cited 2022 Jan 10]. Available from: https://methods.sagepub.com/foundations/snowball-sampling .

Kohn L, Christiaens W. Les méthodes de recherches qualitatives dans la recherche en soins de santé : apports et croyances. Reflets et perspectives de la vie économique. 2014;LIII(4):67–82.

Article   Google Scholar  

Bennett A, Checkel JT. Process tracing: from metaphor to analytic tool [Internet]. Cambridge, UK: Cambridge University Press; 2015. 342 p. Available from: www.cambridge.org/9781107686373 .

Srivastava P, Hopwood N. A Practical Iterative Framework for Qualitative Data Analysis. Int J Qual Methods. 2009;8(1):76–84.

Nowell LS, Norris JM, White DE, Moules NJ. Thematic Analysis: Striving to Meet the Trustworthiness Criteria. Int J Qualitative Methods. 2017;16(1):1609406917733847.

Public Health Agency of Canada. Overview of influenza monitoring in Canada. 2014 [cited 2021 Nov 24]. Available from: https://www.canada.ca/en/public-health/services/diseases/flu-influenza/influenza-surveillance/about-fluwatch.html .

Detmer S, Gramer M, Goyal S, Torremorell M, Torrison J. Diagnostics and Surveillance for Swine Influenza. Swine Influenza. 2012;370:85–112.

Article   PubMed Central   Google Scholar  

CEZD. Community for Emerging and Zoonotic Diseases. 2021 [cited 2023 May 30]. Available from: https://cezd.ca .

Mukhi SN. KIWI: A technology for public health event monitoring and early warning signal detection. Online J Public Health Inform. 2016;8(3):e208.

Article   PubMed   PubMed Central   Google Scholar  

Community for Emerging and Zoonotic Diseases (CEZD). CEZD Annual Performance Report 2020-2021. 2021 Nov [cited 2023 Aug 1] p. 19. Available from: https://www.cezd.ca/reports/cezd-annual-report-20202021 .

WHO. International Health Regulations (2005) Third Edition. 2016 [cited 2022 Jan 10]. Available from: https://www.who.int/publications-detail-redirect/9789241580496 .

Canada PHA of. FluWatch report: October 25, 2020 to October 31, 2020 (week 44). 2020 [cited 2024 Mar 10]. Available from: https://www.canada.ca/en/public-health/services/publications/diseases-conditions/fluwatch/2020-2021/week-44-october-25-october-31-2020.html .

Fiske ST, Cuddy AJC, Glick P. Universal dimensions of social cognition: warmth and competence. Trends Cogn Sci. 2007;11(2):77–83.

Article   PubMed   Google Scholar  

Wolf M. Is there really such a thing as “one health”? Thinking about a more than human world from the perspective of cultural anthropology. Soc Sci Med. 2015;129:5–11.

Allen HA. Governance and One Health: Exploring the Impact of Federalism and Bureaucracy on Zoonotic Disease Detection and Reporting. Vet Sci. 2015;2(2):69–83.

Hanin MCE, Queenan K, Savic S, Karimuribo E, Rüegg SR, Häsler B. A One Health Evaluation of the Southern African Centre for Infectious Disease Surveillance. Front Vet Sci. 2018;5:33.

Rambo-Martin BL, Keller MW, Wilson MM, Nolting JM, Anderson TK, Vincent AL, et al. Influenza A Virus Field Surveillance at a Swine-Human Interface. mSphere. 2020;5(1):e00822. https://doi.org/10.1128/msphere.00822-19 .

Simon G, Larsen LE, Dürrwald R, Foni E, Harder T, Reeth KV, et al. European Surveillance Network for Influenza in Pigs: Surveillance Programs, Diagnostic Tools and Swine Influenza Virus Subtypes Identified in 14 European Countries from 2010 to 2013. PLoS One. 2014;9(12):e115815.

Stöhr K. The WHO Global Influenza Program and Its Animal Influenza Network. Avian Dis. 2003;47(s3):934–8.

Download references

Acknowledgments

We want to thank the different stakeholders who generously participated to this project.

This project was funded by the Canadian Safety and Security Program from Defence Research and Development Canada, project 'Improving early warning of emerging threats' (CSSP-2020-TI-2469). This work was supported in part by the Canada Research Chair in Epidemiology and One Health (H.C., grant number: CRC 950-231857).

Author information

Authors and affiliations.

Université de Montréal, QC, Montréal, Canada

José Denis-Robichaud, Nancy N. Nswal, Mireille D’Astous, Christina Zarowsky, Erin E. Rees & Hélène Carabin

University of New Brunswick, NB, Fredericton, Canada

Suzanne Hindmarch

Public Health Agency of Canada, QC, Saint-Hyacinthe, Canada

Jean Claude Mutabazi, Marcellin Gangbè & Erin E. Rees

Canadian Food Inspection Agency, BC, Parksville, Canada

Andrea Osborn

Centre de Recherche en Santé Publique, QC, Montréal, Canada

Nancy N. Nswal, Mireille D’Astous, Christina Zarowsky, Erin E. Rees & Hélène Carabin

Groupe de recherche en épidémiologie des zoonoses et santé publique, Saint-Hyacinthe, QC, Canada

José Denis-Robichaud, Marcellin Gangbè, Erin E. Rees & Hélène Carabin

You can also search for this author in PubMed   Google Scholar

Contributions

HC, ER, CZ, and SH formulated overarching research goals, supervised the research activity planning and execution, and acquired funding. They managed and coordinated responsibility for the research activity planning and execution with the support of MG. SH and CZ developed the methodology, and all authors contributed to the qualitative analysis processes. The investigation and the formal analyses were done by JDR, MD, JCM, and NNN. JCM and NNN curated the data and JDR created the Tables and Figures. JDR wrote the initial manuscript, and all co-authors revised it.

Corresponding author

Correspondence to Hélène Carabin .

Ethics declarations

Ethics approval and consent to participate.

Ethics review and approval were obtained from the Université de Montréal (CERSES, protocol code 2021-1152, approved on September 15, 2021) and Public Health Agency of Canada (protocol code REB 2021-047P, approved on February 8, 2022) ethics committees. Written informed consent to participate was obtained from all interviewees.

Consent for publication

Not applicable.

Competing interests

The co-author JDR was hired by the Université de Montréal and the Public Health Agency of Canada as an independent research for part of her work in this project. The other authors declare no conflict of interest.

Additional information

Publisher’s note.

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

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/ . The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/ ) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Cite this article.

Denis-Robichaud, J., Hindmarch, S., Nswal, N.N. et al. One Health communication channels: a qualitative case study of swine influenza in Canada in 2020. BMC Public Health 24 , 964 (2024). https://doi.org/10.1186/s12889-024-18460-7

Download citation

Received : 04 December 2023

Accepted : 27 March 2024

Published : 05 April 2024

DOI : https://doi.org/10.1186/s12889-024-18460-7

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Public health
• Information dissemination
• Agriculture
• Disease outbreak
• Health services
• Veterinarians

BMC Public Health

ISSN: 1471-2458

• Submission enquiries: [email protected]
• General enquiries: [email protected]

Log in using your username and password

• Search More Search for this keyword Advanced search
• Latest content
• For authors
• Browse by collection
• BMJ Journals More You are viewing from: Google Indexer

You are here

• Volume 14, Issue 4
• Collaborative design of a health research training programme for nurses and midwives in Tshwane district, South Africa: a study protocol
• Article Text
• Article info
• Citation Tools
• Rapid Responses
• Article metrics

• http://orcid.org/0000-0002-8761-2055 Rodwell Gundo ,
• Mavis Fhumulani Mulaudzi
• Department of Nursing Science , University of Pretoria , Pretoria , South Africa
• Correspondence to Dr Rodwell Gundo; rodwell.gundo{at}up.ac.za

Introduction Nurses are essential for implementing evidence-based practices to improve patient outcomes. Unfortunately, nurses lack knowledge about research and do not always understand research terminology. This study aims to develop an in-service training programme for health research for nurses and midwives in the Tshwane district of South Africa.

Methods and analysis This protocol outlines a codesign study guided by the five stages of design thinking proposed by the Hasso-Plattner Institute of Design at Stanford University. The participants will include nurses and midwives at two hospitals in the Tshwane district, Gauteng Province. The five stages will be implemented in three phases: Phase 1: Stage 1—empathise and Stage 2—define. Exploratory sequential mixed methods including focus group discussions with nurses and midwives (n=40), face-to-face interviews (n=6), and surveys (n=330), will be used in this phase. Phase 2: Stage 3—ideate and Stage 4—prototype. A team of research experts (n=5), nurses and midwives (n=20) will develop the training programme based on the identified learning needs. Phase 3: Stage 5—test. The programme will be delivered to clinical nurses and midwives (n=41). The training programme will be evaluated through pretraining and post-training surveys and face-to-face interviews (n=4) following training. SPSS V.29 will be used for quantitative analysis, and content analysis will be used to analyse qualitative data.

Ethics and dissemination The protocol was approved by the Faculty of Health Sciences Research Ethics Committee of the University of Pretoria (reference number 123/2023). The protocol is also registered with the National Health Research Database in South Africa (reference number GP_202305_032). The study findings will be disseminated through conference presentations and publications in peer-reviewed journals.

• Nursing Care
• Patient-Centered Care
• Patient Satisfaction

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/ .

https://doi.org/10.1136/bmjopen-2023-076959

Statistics from Altmetric.com

Request permissions.

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.

STRENGTHS AND LIMITATIONS OF THIS STUDY

This study will be strengthened through the use of quantitative and qualitative methods to understand the research problem.

The inclusion of two hospitals and the participation of different nurses and midwives will ensure the credibility of the findings.

Local research experts, nurses and midwives will collaborate to develop a training programme appropriate to the context of the setting.

The findings will be limited to two hospitals; therefore, the findings may not be generalisable to other hospitals.

Introduction

Evidence-based practice (EBP) has gained prominence in health services internationally over the past three decades. 1 EBP integrates individual clinical expertise with clinical evidence generated from systematic research. 2 EBP aims to deliver appropriate, efficient patient care. 3 Consequently, generating evidence that informs care delivery has become increasingly important for improving patient-centred care, patient safety, patient outcomes and the healthcare system. 1 3 In healthcare, nurses are well positioned to implement EBP because they constitute the largest proportion of the health workforce. 1 4 Nurses thus have to be proactive in acquiring, synthesising and using research knowledge and the best evidence to inform their practice and decision-making. 3 4

Recognising the need for EBP, many nursing organisations worldwide have developed best practice guidelines for patient-care decision-making. 4 In South Africa, the roadmap for strengthening nursing and midwifery acknowledges that nurses are vital for providing safe and effective patient care. Strategically, investing in nurse-led research will help develop nurse-led models of care. 5 Similarly, the South African Nursing Council expects nurses to actively participate in research activities, including academic writing, reading and reviewing, as part of continuing professional development. 6 Training nurses and midwives can enhance their research capacity and enable them to use available resources for research, ultimately leading to changes in EBP in clinical settings.

Nurses need to gain research knowledge and become comfortable with research terminology. 7 8 Although undergraduate nursing training includes a research component, this training does not always translate into a strong understanding of research. 7 As such, there needs to be more nurse-led patient-centred research. A recent review of nursing research from 2000 to 2019 showed that most nursing research is conducted by nurses working at higher education institutions. Research output and collaboration are also disproportionately more prominent in high-income countries across North America, Europe, and Oceania than in low-income and middle-income countries. 9 The other challenges that affect health research include limited time, lack of research facilities, research culture, mentors, access to mentors, and workforce capacity. 10

Little is known about the research literacy of nurses and midwives and research training programmes for practicing nurses and midwives in South Africa. Therefore, we developed a protocol to develop a research training programme for nurses and midwives in the Tshwane district of South Africa. This protocol is guided by the following research questions: (a) what are the levels of nurses’ and midwives’ knowledge, attitudes and involvement in research?; (b) what are the learning needs of nurses and midwives regarding research design and implementation?; (c) what content should be included in a research training programme for nurses and midwives?; (d) how does the developed training programme impact nurses’ knowledge about research?

Theoretical framework

The principles of constructivism learning theory will guide this study. This theory is rooted in the work of Piaget and Vygotsky. 11 This paradigm explains how people might acquire and retain knowledge. 12 Through the lens of constructivism learning theory, adult educators acknowledge learners’ previous experiences, appreciate multiple perspectives and embed learning in social contexts. The instructor is a mentor who helps learners understand new information. Constructivism learning theory has three dimensions, namely, individual constructivism, social constructivism and contextualism. In individual constructivism, learners are self-directed and construct knowledge via personal experience. Social constructivism assumes that learning is socially mediated, and that knowledge is constructed through social interaction. In contextualism, learning should be tied to real-life contexts. 13 Some benefits of constructivism theory are that learners enjoy learning because they are actively engaged and have ownership over what they learn. 12 The theory was considered appropriate because the study will be conducted at two research-intensive hospitals. Therefore, nurses and midwives are familiar with the research process.

Methods and analysis

Research design.

We will use a codesign approach guided by the stages of design thinking proposed by the Hasso-Plattner Institute of Design at Stanford University. 14 15 The design originated from participatory research and involves active engagement of the participants to identify needs and collaboratively propose solutions. 14 16 The approach is considered appropriate because it ensures meaningful involvement of end-users, thereby creating meaningful benefits. 17 A codesign approach ensures fewer challenges when implementing the initiative because stakeholders are fully engaged throughout the process. 14 Underpinned by the African philosophy of Ubuntu, the process will promote the culture of working together and collective solidarity. 18

The study will be guided by the five stages of design thinking: empathise, define, ideate, prototype and test. Empathise aims to understand the deeper issues, needs and challenges needed to solve the problem. Define involves data analysis and prioritising the needs of the end users of the training programme. Ideate includes brainstorming for innovative solutions to address the identified needs. In the prototype stage, the idea or innovation is shown to the end users and other stakeholders. Finally, testing involves checking what works in a real-world setting. 14 15

Study setting

The study will be conducted at two public hospitals in the Tshwane district of Gauteng Province in South Africa. The province has the highest population density, the most hospitals and the greatest number of nurses and midwives. 19 According to a 2016 community survey, Gauteng has a population of 13.4 million people. 20 Tshwane is one of the five districts in the province and the third most populous district, accounting for 24% of the population in the province. 21 There are three district hospitals, namely, Tshwane, Pretoria West, Jubilee and ODI; one regional hospital, Mamelodi; and three tertiary hospitals, namely, Steve Biko Academic Hospital, Dr George Mukhari Hospital and Khalafong Hospital. The two hospitals were selected due to their proximity to the University of Pretoria. One of the hospitals is a tertiary hospital with 800 beds. The second hospital is a 240-bed district hospital linked to the University of Pretoria’s Faculty of Health Sciences. 22

Target population

The population will comprise nurses and midwives working at the two hospitals. In South Africa, there are six categories of nurses and midwives based on qualifications as follows: registered auxiliary nurse (higher certificate), registered general nurse (diploma in nursing), registered midwife (advanced diploma), registered professional nurse and midwife (bachelor’s degree), nurse specialist or midwife specialist (postgraduate diploma), advanced specialist nurse (master’s degree) and those with doctorate degrees. 5 Nurses working at academic hospitals are expected to engage in research activities, including academic writing, reading and reviewing, as part of continuing professional development. 6 A preliminary audit revealed 1900 nurses and midwives working at the two hospitals.

Inclusion and exclusion criteria

Participation will be limited to registered auxiliary nurses, registered general nurses, registered midwives, registered professional nurses and midwives older than 18 years, those registered with the South African Nursing Council, and those with more than 3 months of experience. All people older than 18 years are mandated to give legal consent in South Africa. Nurses with less than 3 months of experience or undergoing orientation will be excluded from the study.

As illustrated in table 1 , the study will be implemented in three phases and five stages to address the four objectives. Stage 1 is currently underway. The collection of the qualitative data started in December 2023 at one of the two hospitals. This will proceed at the second hospital until April 2024. The whole study is expected to be completed by September 2024.

• View inline

Illustration of the research process guided by the stages of design thinking

In this phase, we aim to understand the nurses’ and midwives’ perceived knowledge, attitudes and involvement in research and their learning needs. We will base our investigation on empathising and defining. An exploratory sequential mixed methods design will be used. This design begins with collecting and analysing qualitative data. The qualitative findings are used to develop quantitative measures or instruments to test the identified variables. 23 In this study, the qualitative findings will be used to revise a questionnaire for the subsequent quantitative strand.

Strand 1—qualitative study

Qualitative methods are appropriate for investigating the who, what and where of events or experiences of informants of a poorly understood phenomenon. 24 25

Sample size and sampling

Forty-six participants (n=46) will be selected from nurses and midwives working at the two hospitals. The sample size was pragmatically determined according to the mode of data collection and the volume of data to be collected. However, the final sample size will be determined by data saturation.

We will purposively sample nurses and midwives from the following cadres: registered auxiliary nurses, registered general nurses, registered midwives, and registered professional nurses and midwives. As presented in table 2 , two focus group discussions (FGDs) will be held at each hospital and will involve 10 participants each. Due to power differences that can cause a halo effect among the participants, 26 one FGD will include senior professional nurses and midwives. In contrast, the other FDG will include junior nurses and midwives with either diplomas or certificates. For the individual interviews, three participants (one registered auxiliary nurse, one registered general nurse with a diploma and one professional nurse (with either a bachelor’s or postgraduate qualification)) will be invited to participate. The participants will be expected to share their knowledge of the competencies needed for conducting health research.

Sampling plan for the qualitative strand

Data collection

The study information will be communicated through nursing and midwifery managers. Participation will be voluntary. Nurses and midwives willing to participate will be invited for either FGDs or individual interviews. The participants will be given the details of the study and a consent form. The interviews will be conducted in English in hospitals in private settings at times and places that are most convenient for participants. The participants will be requested to use pseudonyms during interviews. A semistructured interview guide will be used for the interviews (refer to online supplemental file 1 ). The interviews will be audiotaped and later transcribed verbatim in English.

Supplemental material

Data analysis.

The data will be analysed manually using conventional content analysis as described by Hsieh and Shannon. 27 The steps of the analysis will be as follows: (a) repeatedly reading the data to achieve immersion and a sense of the whole; (b) deriving and labelling codes by highlighting the words that capture critical thoughts and concepts; (c) sorting the related codes into categories; (d) organising numerous subcategories into fewer categories; (e) defining each category; and (f) identifying the relationship of the categories in terms of their concurrence, antecedents or consequences. To ensure the reliability of the qualitative coding, tHead2he two researchers will code the first transcript independently. The online Coding Analysis Toolkits 28 will be used to calculate intercoder reliability. The two researchers will discuss differences and agree on the coding before proceeding to the next transcript.

Methodological rigour

Trustworthiness will be achieved through credibility, transferability, dependability and confirmability. 24 29 Credibility will be achieved through spatial and personal triangulation. Spatial triangulation refers to collecting data on the same phenomenon from multiple sites, while personal triangulation refers to collecting data from different types and levels of people. 29 This study will collect data from different cadres of nurses and midwives at two hospitals. Transferability will be enhanced by providing sufficient study details. Dependability and confirmability will be achieved by establishing an audit trail describing the procedures and processes. Additionally, reflexivity will be used to ensure the transparency and quality of the study. 29 30 Reflexivity is where researchers critique, appraise and evaluate the influence of subjectivity and context on the research process. 30 In some branches of qualitative inquiries, researchers use reflexive bracketing to prevent subjective influences. However, Olmos-Vega et al 30 observed that this approach is no longer favoured in modern qualitative research because setting aside certain aspects of subjectivity is problematic. In this study, reflexivity will be ensured by keeping memos and field notes to document interpersonal dynamics and critical decisions made throughout the study.

Strand 2—quantitative study

A cross-sectional survey will be used to assess nurses’ and midwives’ perceived knowledge, attitudes and involvement in research.

The sample size was calculated using Yamane’s formula 31 as follows: n=N/(1+N(e2), where n is the sample, N is the population size, and e is the level of precision. Assuming a 95% CI and the estimated proportion of an attribute p=0.5, the calculated sample size for a population N=1900 with ±5% precision is 330. In this study, a convenience sampling technique will be used to select participants.

The researchers will brief nurse managers about the study. Furthermore, posters inviting nurses and midwives to participate in the study will be placed in each department. The poster will include details of the study and relevant contact details. The nurses and midwives willing to participate will be given an information sheet, consent form and questionnaire. They will be requested to leave the completed questionnaire in a designated box in the unit manager’s office.

Data collection instrument

The data will be collected using the Edmonton Research Orientation Survey (EROS). The EROS was developed in Canada and is a valid and reliable self-reported instrument for measuring perceived knowledge, attitudes and involvement in research. The tool has four subscales with 43 items. The four subscales are the value of research, value of innovation, research involvement and research utilisation (EBP). Valuing research is a positive attitude towards research; the value of innovation refers to being on the leading edge or keeping up to date with information; research involvement relates to active participation in research; and research utilisation (EBP) pertains to whether respondents use research to guide their day-to-day practice. Additionally, there is a category for the barriers and support for research. 32–34

The EROS items are measured using a 5-point Likert scale ranging from 1—strongly disagree to 5—strongly agree. The maximum score is 215. Higher overall scores indicate a stronger research orientation. The scores will be categorised into high (between 143 and 215 points), medium (73–142 points) or low (0–72 points). 32 33 The tool has been extensively used to assess the research orientation of health professionals, including physiotherapists, 35 midwives, 36 occupational therapists, 33 academics 32 and undergraduate students. 34 Previous studies reported high internal reliability with Cronbach’s alpha coefficients of 0.95 37 and 0.92. 34

Although the tool has been previously used among South African occupational therapists, 33 the copyright author observed that the tool had been developed at a time when there was no access to information via the internet, hence the need to find ways of incorporating such issues. This study will use qualitative findings to identify items not included in the tool but relevant to the South African context.

The quantitative data will be entered into Microsoft Excel and imported to IBM SPSS statistics V.29. Descriptive statistics will be used to summarise demographic characteristics and questionnaire scores. Mean scores and SD will be calculated for individual items, subgroup scores and overall scores. Independent sample t-tests, Mann-Whitney U tests, and multiple regression will be used to compare the scores of different groups of nurses and midwives. The assumptions for each test will be assessed before analysis. The level of significance will be set at 0.05.

During this phase, we will develop the training programme based on the learning needs identified in Phase 1. Research experts (n=5) will participate in a one-design studio workshop to brainstorm the content to be included in the training programme. Although there is limited literature on the definition and characteristics of an expert, Bruce et al 38 defined an expert as a person who is knowledgeable or informed in a particular discipline. Bruce et al 38 further observed that maximum variation or heterogeneity in sampling experts yields rich information. This study will select experts based on the criteria proposed by Davis 39 and Rubio et al . 40 The characteristics include clinical experience in the setting, professional certification in a related area, research experience, work experience, conference presentation and publication in the topic area.

A design studio workshop is a process in which participants create, and critique proposed interventions. 16 The researcher will share the findings of Phase 1 and explain the workshop’s goal to the participants. Participants will be provided with pens, sticky notes and flip-chart paper. The researcher will facilitate discussion and capture feedback. At the end of the workshop, the researcher will consolidate the ideas, create a more detailed programme design and communicate with the participants.

Next, we will develop a prototype to be discussed in a consultative meeting and validation meeting. An iterative process will be used to validate the developed training programme. The consultative meeting will be held with research experts (n=5). A validation exercise will also be conducted with nurses and midwives (n=20), the programme’s end-users. The nurses and midwives will be identified in consultation with nurse managers at the two hospitals to avoid disruption of services. During the validation exercise, the participants will be grouped into smaller idea groups to review and discuss the developed programme. Each group will be requested to identify a representative to report on behalf of the group. The feedback from the consultative and validation meeting will help to improve the developed programme.

The purpose of this phase is to assess the impact of the developed training programme. The developed training will be delivered to 41 nurses and midwives in the Tshwane district. The sample is based on similar studies that have implemented interventions for health professionals. For example, a study by Gundo et al 41 used G-Power software 42 to calculate the sample size based on a conservative effect size of d=0.5, a power of 80% and an alpha=0.05. The calculated sample size was 34, but 41 participants were invited to participate in training to allow for a dropout rate of at most 20%. The identification and invitation of the participants will be negotiated with nurse managers at the two hospitals to avoid service disruptions. The selection process will ensure the representation of the different cadres of nurses and midwives. We will invite a team of research experts to facilitate the training. The impact of the training will be assessed by comparing pre-survey and post-survey EROS scores, FGDs with participants, and evaluations at the end of the training. A paired-sample t-test will be used to compare the pretest and post-test scores.

This protocol aims to develop a research training programme for nurses and midwives in the Tshwane district of South Africa. Initially, we will investigate the learning needs of nurses and midwives. The learning needs will inform a training programme to improve research capacity. As observed by Hines et al , 7 implementing a training programme will improve nurses’ research knowledge, critical appraisal ability and research efficacy. Building capacity for health research in Africa will enhance the ownership of research activities that target relevant topics.

Furthermore, findings relevant to local populations will be communicated in a culturally acceptable manner. Research recommendations may also resonate better and have a better uptake among African policymakers than research produced by internationally led teams. 43–45 This research training programme could be used in other hospitals with similar contexts and other categories of healthcare professionals. However, this will require a larger, multicentre validation study. Our findings will be limited to the two hospitals; therefore, the findings may not be generalisable to other hospitals.

Ethics and dissemination

The protocol was approved by the Research Ethics Committee, Faculty of Health Sciences at the University of Pretoria (reference number: 123/2023). The protocol is registered with the National Health Research Database in South Africa (reference number GP_202305_032). The two hospitals also provided permission for the study. Permission to use the EROS was obtained from the copyright authors, Dr Kerrie Pain and Dr Paul Hagler.

The participants will receive an information leaflet and be required to provide written informed consent. The researcher will ensure that the participants’ personal information is anonymised. Participants can give the researcher written permission to share their personal information. During the FGDs and individual interviews in Phase 1, the participants will be asked to use pseudonyms of their choice. In Phases 2 and 3, anonymity will not be possible because the meetings will be in person. However, the participants will be requested to maintain confidentiality. The data will be stored in compliance with the research ethics committee’s guidelines. The findings of the study will be disseminated through conference presentations and publications in peer-reviewed journals. The preparation of this manuscript followed the standards for reporting qualitative research 46 and the guidelines for reporting observational studies. 47

Ethics statements

Patient consent for publication.

Not applicable.

Acknowledgments

The manuscript was written during a writing retreat that was funded by the National Research Foundation through the Ubuntu Community Model of Nursing Project at the University of Pretoria in South Africa. We also thank Dr Cheryl Tosh for editing the manuscript.

• Cassidy CE ,
• Sackett DL ,
• Rosenberg WM ,
• Gray JA , et al
• World Health Organization
• Bassendowski S
• Republic of South Africa
• ↵ South African nursing Council . In : Continuing professional development framework for nurses and midwives in South Africa . Pretoria : South African Nursing Council , 2021 .
• Ramsbotham J ,
• Yanbing S ,
• Chao L , et al
• Dempsey O , et al
• Efgivia MG ,
• Adora Rinanda RY , et al
• Baral KP , et al
• Thabrew H ,
• Fleming T ,
• Hetrick S , et al
• Slattery P ,
• Mulaudzi FM ,
• Anokwuru RA ,
• Mogale R , et al
• Coetzee SK ,
• Ellis SM , et al
• Statistics South Africa
• Mutyambizi C ,
• Pavlova M ,
• Hongoro C , et al
• Abdullah F ,
• Basu D , et al
• Shrestha S ,
• Bradshaw C ,
• Atkinson S ,
• Sefcik JS ,
• O.Nyumba T ,
• Derrick CJ , et al
• Hsieh H-F ,
• MacPhail C ,
• Abler L , et al
• Korstjens I ,
• Olmos-Vega FM ,
• Stalmeijer RE ,
• Varpio L , et al
• Sarmah HK ,
• Hazarika BB ,
• Choudhury G
• Fernandez A ,
• Sadownik L ,
• Lisonkova S , et al
• Peachey AA ,
• Janssen J ,
• Mirfin-Veitch B , et al
• Kuliukas L , et al
• Langley GC ,
• Berg-Weger M ,
• Tebb SS , et al
• Chirwa E , et al
• Cunningham JB ,
• McCrum-Gardner E
• Nyirenda T , et al
• Kasprowicz VO ,
• Chopera D ,
• Waddilove KD , et al
• O’Brien BC ,
• Harris IB ,
• Beckman TJ , et al
• von Elm E ,
• Altman DG ,
• Egger M , et al

Contributors RG and MFM conceptualised the study, developed the proposal, drafted and revised 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 and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

Provenance and peer review Not commissioned; externally peer reviewed.

Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

Read the full text or download the PDF:

• Open access
• Published: 03 April 2024

Women’s experiences of attempted suicide in the perinatal period (ASPEN-study) – a qualitative study

• Kaat De Backer   ORCID: orcid.org/0000-0001-5202-2808 1 ,
• Alexandra Pali   ORCID: orcid.org/0009-0009-5817-156X 1 , 2 ,
• Fiona L. Challacombe   ORCID: orcid.org/0000-0002-3316-8155 3 ,
• Rosanna Hildersley   ORCID: orcid.org/0000-0002-1850-6101 3 ,
• Mary Newburn   ORCID: orcid.org/0000-0001-9471-0908 4 ,
• Sergio A. Silverio   ORCID: orcid.org/0000-0001-7177-3471 5 , 6 ,
• Jane Sandall   ORCID: orcid.org/0000-0003-2000-743X 1 ,
• Louise M. Howard   ORCID: orcid.org/0000-0001-9942-744X 3 &
• Abigail Easter   ORCID: orcid.org/0000-0002-4462-6537 1  

BMC Psychiatry volume  24 , Article number:  255 ( 2024 ) Cite this article

122 Accesses

2 Altmetric

Metrics details

Suicide is a leading cause of maternal death during pregnancy and the year after birth (the perinatal period). While maternal suicide is a relatively rare event with a prevalence of 3.84 per 100,000 live births in the UK [ 1 ], the impact of maternal suicide is profound and long-lasting. Many more women will attempt suicide during the perinatal period, with a worldwide estimated prevalence of 680 per 100,000 in pregnancy and 210 per 100,000 in the year after birth [ 2 ]. Qualitative research into perinatal suicide attempts is crucial to understand the experiences, motives and the circumstances surrounding these events, but this has largely been unexplored.

Our study aimed to explore the experiences of women and birthing people who had a perinatal suicide attempt and to understand the context and contributing factors surrounding their perinatal suicide attempt.

Through iterative feedback from a group of women with lived experience of perinatal mental illness and relevant stakeholders, a qualitative study design was developed. We recruited women and birthing people ( N  = 11) in the UK who self-reported as having undertaken a suicide attempt. Interviews were conducted virtually, recorded and transcribed. Using NVivo software, a critical realist approach to Thematic Analysis was followed, and themes were developed.

Three key themes were identified that contributed to the perinatal suicide attempt. The first theme ‘Trauma and Adversities’ captures the traumatic events and life adversities with which participants started their pregnancy journeys. The second theme, ‘Disillusionment with Motherhood’ brings together a range of sub-themes highlighting various challenges related to pregnancy, birth and motherhood resulting in a decline in women’s mental health. The third theme, ‘Entrapment and Despair’, presents a range of factors that leads to a significant deterioration of women’s mental health, marked by feelings of failure, hopelessness and losing control.

Conclusions

Feelings of entrapment and despair in women who are struggling with motherhood, alongside a background of traumatic events and life adversities may indicate warning signs of a perinatal suicide. Meaningful enquiry around these factors could lead to timely detection, thus improving care and potentially prevent future maternal suicides.

Peer Review reports

Pregnancy, childbirth, and the postnatal period are a positive and empowering experience for many women and birthing people Footnote 1 . Yet it is widely accepted that the perinatal period is also a time of significant stress, with one in four women experiencing mental health difficulties during this time [ 3 ]. Evidence on the impact of perinatal mental ill-health on the mother [ 4 ], her children [ 5 ], the wider family [ 6 ] and society [ 7 ] has grown in the last decade and worldwide, maternal suicide has been identified as a global public health issue [ 8 ]. In European countries with enhanced surveillance systems for maternal mortality maternal suicide has been identified as one of the leading causes of maternal death [ 9 ]. In the UK, the Confidential Enquiries into Maternal Deaths (MBRRACE-UK) have repeatedly highlighted similar findings, leading to the development and expansion of specialist perinatal mental health services in the UK [ 10 ]. Despite this, there has been no sign of a reduction in suicide rates [ 11 , 12 , 13 , 14 ]. The UK Government has therefore identified pregnant women and new mothers for the first time as a priority group in the recent Suicide Prevention Strategy [ 15 ].

While maternal suicide is a relatively rare event with a prevalence of 3.84 per 100,000 live births (95% CI 2.55–5.55) in the UK [ 1 ], many more women will attempt suicide during pregnancy and the year after birth. Worldwide, the pooled prevalence of perinatal suicide attempts has been estimated to be 680 per 100,000 (95% CI 0.10–4.69%) during pregnancy and 210 per 100,000 (95% CI 0.01–3.21%) during the first-year postpartum [ 2 ]. As well as distressing in their own right, perinatal suicide attempts are known to increase the risk of future fatal acts [ 16 ]. Antenatal [ 17 ] and postnatal suicide attempts [ 18 ] are also associated with increased maternal and neonatal morbidity, adverse birth outcomes, and further suicide attempts.

It is important to note that terminology in suicide research has been a contentious issue and a wide range of definitions have been used in various contexts. The US National Center for Injury and Control issued guidance on uniform definitions in the context of self-directed violence’ [ 19 ], which has informed our study definition of ‘suicide attempt’: “a non-fatal, self-directed, potentially injurious behaviour with intent to die as a result of the behaviour. A suicide attempt might not result in injury”. This definition contains three components worth highlighting, i.e. (1) suicidal ideation, (2) suicidal intent and (3) suicidal behaviour. ‘Suicidal ideation’, also known as ‘suicidality’ (i.e. thoughts of engaging in suicide-related behaviour) [ 19 ] is a known risk factor for suicide [ 20 ] but does not necessarily lead to suicidal behaviours (e.g., behaviour that is self-directed and deliberately results in injury or the potential for injury to oneself, with implicit or explicit evidence of suicidal intent’) [ 19 ]. ‘Suicide attempt’ must also be distinguished from ‘near-fatal deliberate self-harm’, which was defined by Douglas et al (2004) as ‘an act of self-harm using a method that would usually lead to death, or self-injury to a “vital” body area, or self-poisoning that requires admission to an intensive care unit or is judged to be potentially lethal [ 21 ]’. This definition does not contain an element of ‘suicidal intent’, ie. explicit or implicit evidence that at the time of injury the individual intended to kill self or wished to die, and that the individual understood the probable consequences of his or her actions [ 19 ].

To date, perinatal suicide research has predominately been based on case note reviews [ 1 ], retrospective cohort studies [ 22 ], or qualitative studies focussing on suicidal ideation [ 23 ]. Research into suicide attempts in the perinatal period is therefore acutely needed, to gain a better understanding of the circumstances surrounding maternal suicide, the support available to perinatal women and how future deaths can be avoided. To our knowledge, no studies in the UK have used qualitative methods to explore the experiences of women who undertook a suicide attempt in pregnancy or during the postnatal period, yet survived. A better understanding of these events could help refine support and early interventions for women and birthing people at risk.

Aim of the study

The aim of this study was to explore the experiences of women and birthing people who had undertaken one or more suicide attempts during the perinatal period.

Study design

The ASPEN-study (Attempted Suicide during the PEriNatal period) utilised a qualitative design, using semi-structured interviews, to allow for an in-depth understanding of the contextual factors of perinatal suicide attempts, and to demystify the taboos and misunderstanding that are enshrouding this phenomenon [ 24 ]. Qualitative methods are particularly helpful to study sensitive topics [ 25 ] and can facilitate a deeper understanding of suicide attempts, beyond merely explaining [ 26 ]. We adopted a critical realist ontology, meaning participants’ accounts were seen as ‘truths’, even when their reported recall might have been impacted by serious mental illness and/or distress at the time of events [ 27 ]. We also adopted an objectivist epistemological stance meaning our belief system of how we acquire knowledge is one of reality existing and not being constructed, thus enabling an approach to participants’ narratives with no preconceived notions of how the participants may experience the phenomenon of interest [ 28 ]. Drawing on our epistemological and ontological positions, a critical realist approach to Thematic Analysis was best aligned with our philosophical underpinnings. Critical realist TA is an alternative approach to Thematic Analysis, that differs from codebook TA with its positivistic assumptions [ 29 ], or reflexive TA that is grounded in philosophical constructivism [ 30 , 31 ]. Critical realist TA is an explanatory approach that aims to produce causal knowledge through qualitative research on phenomena in the world around us [ 32 , 33 ]. We wanted to go beyond merely ‘exploring’ the phenomenon of perinatal suicide attempt, but aimed to understand what women had experienced during this time, such as any significant life course events they identified as relevant to their perinatal suicide attempt, the specific circumstances in the lead-up to the suicide attempt, their views of motherhood and how this impacted their mental health and any key elements or milestones that made a substantial difference on their journey to recovery. As such, this approach informed our development and structure of the interview schedule and analysis of the data to ensure that this was captured.

Participants and recruitment

The study was advertised through social media and third sector organisations in the field of perinatal mental health and suicide prevention (see Acknowledgements). Interested participants were included if they: (1) were 18 years of age or older; (2) had one or more suicide attempts during the perinatal period (i.e. from pregnancy up to the first year after giving birth), including when the attempt was prevented by self, a loved one or a member of the public; (3) and this happened less than 10 years ago; (4) were residing in the UK; and (5) were not receiving inpatient psychiatric care or experiencing an acute episode of a psychiatric disorder at the time of recruitment. The latter exclusion criterium was adopted in line with our safety protocol, to prevent delays in recovery by addressing such a difficult event outside a therapeutic environment. We used both convenience sampling and purposive sampling techniques: we interviewed anyone who responded to our recruitment materials, met the inclusion criteria and wanted to participate in the study after reading the participant information sheet (convenience sampling). Simultaneously, we also made concerted efforts through intense collaboration with community leaders and third sector organisations to recruit a diverse sample of women and birthing people from different ethnic, cultural, socio-economic and religious backgrounds (purposive sampling). A total of twelve women and birthing people contacted the research team with an interest in the study. Eligibility for the study was explored in a sensitive way, against the overall inclusion criteria and the three components of the study’s definition of ‘suicide attempt’ (suicidal ideation, intent and behaviour). Where in doubt, eligibility was discussed with the wider supervision team. In total, eleven interviews were conducted. A twelfth interested participant did not attend the (online) interview and did not respond to any follow-up emails. Recruitment was finalised when no new themes were being generated from data analysis of the last two interviews [ 34 ]. Participants received reimbursement of £50 for their time to complete the interview and a short demographic survey.

Data collection and analysis

Semi-structured interviews lasted between 38 and 115 min ( MTime  = 65 min) and were conducted via video-conference software (Microsoft Teams) by one researcher (KDB) between October 2022 and April 2023. Interviews were audio-recorded, transcribed and de-identified by a professional transcription company. Field notes were taken during the interview. Transcriptions were checked for accuracy by two researchers (KDB, AP). The interview schedule, which was co-designed with a panel of women with lived experience of perinatal mental illness, aimed to explore experiences of mental health difficulties prior to and during the perinatal period, the circumstances in the lead-up to the suicide attempt, and those following the suicide attempt. The interview schedule was used flexibly and did not prevent participants from sharing their story in the order they preferred, but instead, was used as an aid to prompt where required. Interview data was so rich that a secondary analysis focusing on social support prior and after women’s suicide attempts was undertaken, to be published separately.

Thematic Analysis (TA) [ 30 , 31 , 33 ] of the interview data was conducted using NVivo software while adopting a critical realist approach to Thematic Analysis [ 30 , 31 , 33 ]. The process of data analysis is rarely a linear event, and guided by Fryer’s previous work on critical realist TA [ 33 ], our approach to data analysis is presented in Fig.  1 and can best be described as follows:

Display of critical realist approach to thematic analysis

Public and patient involvement and engagement (PPIE)

An established advisory panel of women with lived experience of perinatal mental illness was consulted during different phases of the study with additional feedback sought from key stakeholders in the field of perinatal mental illness (see Acknowledgements). The process of PPIE during the study design and data collection phase of this study has been documented elsewhere [ 35 ]. A draft manuscript was shared with research participants to sense-check findings and comment on the manuscript. Participants were also given the opportunity to select a pseudonym of their choice. A total of 8 participants reviewed the draft manuscript and their feedback was incorporated in the final version of this paper.

The study team and reflexivity

The research team are a multidisciplinary team of researchers and clinical academics, with backgrounds in psychology (FLC, AE, RH, SAS, AP), psychiatry (LMH), and midwifery (KDB, JS), and several had clinical experience of supporting women who attempted suicide during the perinatal period (KDB, FLC, LMH). Within the research team, there was a balance between those who were parents and those who did not have children and researchers were at different stages of their life, spanning nearly three generations. The phenomenon of suicidality in the perinatal period was familiar to most of the research team, through extensive clinical experience and/or previous research in the field of perinatal mental health. Our positionality is therefore best described as ‘hybrid’, concordant with our critical realist ontology, as we aimed to align our existing knowledge and understanding (i.e. being embedded in the data) with the uniqueness and unfamiliarity of each individual story that was shared with us as a ‘truth’ (i.e. being an objective onlooker), in order to analyse the data in a coherent and sensitive matter [ 36 ]. Data were collected by one researcher (KDB) who was trained in advanced qualitative research techniques as well as having clinical experience as a perinatal mental health midwife. Analysis was conducted by the same researcher and a MSc Student with a background in clinical psychology (AP). Regular team meetings were held throughout the data collection and analysis phase to discuss and sense-check the developing themes and sub-themes.

Participant safety and researcher wellbeing

The safety and emotional wellbeing of all participants was key throughout the study. Thus, we adopted key elements of trauma-informed care into our study design [ 37 ]. A robust safety protocol, with clear pathways for escalation if required, was developed with the input of the PPIE advisory panel [ 38 ]. The study team undertook bespoke training in trauma-informed interviewing and the interview schedule was developed with this in mind. A safety check prior and after the interview was carried out by the same researcher (KDB), either via email or by phone and all participants were offered a confidential de-brief session with an independent clinical psychologist. The psychological safety of the researchers was also considered [ 25 ] and supported by access to regular reflective supervision sessions provided by a clinical psychologist and regular debrief sessions with supervisors to process any difficult emotions arising from conducting the interviews [ 39 ]. We were acutely aware of the potentially triggering content of the audio files and raised this with the transcription company [ 40 ]. When sending audio recordings for transcription, a summary of triggering content was provided to ensure the transcription would be appropriately allocated.

The majority of our sample ( N  = 11) were White British women ( n  = 10), with one woman from a mixed ethnic background. Participants were predominantly married ( n  = 8) and had higher education qualifications ( n  = 7). All but one participant had received a mental health diagnosis by a doctor or other healthcare professional in the past although the demographic survey did not allow to ascertain when this diagnosis had been given. More than half of the participants in our sample were given multiple diagnoses, indicating a high level of complexity in mental health presentation. In most cases, pregnancies had been planned ( n  = 9). All but two women were multiparous, with half of the sample having two children ( n  = 6), and three participants having three or more children. Two women were first-time mothers at the time of the attempt. Four women undertook their suicide attempt during pregnancy, with a fifth woman being pregnant whilst her older child was still under the age of one. The remaining six women undertook a suicide attempt within the year after giving birth. Four participants had a stay in an inpatient psychiatric Mother and Baby Unit (MBU), and for three of them the admission was preceded by their suicide attempt. For one participant, the admission in the Mother and Baby Unit was subsequently followed by an admission in a general psychiatric hospital, where she undertook the actual suicide attempt. A full table of demographic and clinical information can be found in Table  1 .

Qualitative analysis resulted in the identification of three key themes that played a significant role in the deterioration of women’s mental health during the perinatal period, ultimately culminating into a suicide attempt. Saturation for all themes and sub-themes was achieved after nine interviews when no new themes or subthemes were generated. Data from the remaining two interviews confirmed our analysis and provided additional depth and detail [ 34 ]. The three overarching themes are presented in Fig.  2 : Theme 1 ‘Trauma and Adversities’ , consisting of family history of perinatal mental illness and psycho-social adversities, including grief and trauma; Theme 2 ‘Disillusionment with Motherhood’ , marked by a variety of challenges that arose during pregnancy or the postnatal period; and Theme 3 ‘Entrapment and Despair’ , where multiple stressors piled up with no respite or support available, leading to a severe deterioration of mental ill-health, and ultimately, the suicide attempt.

Display of themes and sub-themes

Qualitative data is presented below, with the most representative quotations in text and an additional table of supplementary of quotations included in Supplementary Material 1 .

Theme 1: trauma and adversities

All respondents in our sample started their pregnancy journeys with a range of vulnerabilities, such as previous mental health difficulties, loss, trauma, or social risk factors including domestic abuse and substance misuse. Nevertheless, participants were not always aware of the profound impact these would have on their mental health later in pregnancy and in the postnatal period. Subthemes contributing to this were:

Psycho-social adversities

Many women had experienced mental health difficulties at some point in their life, and most were fully aware of their potentially devastating impact. Some had experienced poor mental health during adolescence and young adulthood and anticipated mental health problems during the perinatal period.

“I’ve had some terrible things happen in my life about failed marriage and fertility problems. Big, big things that I’ve sort of managed with a strength of mine that I perhaps didn’t have in my late teens or early 20s to overcome. So I guess it was always on my radar knowing the stats around you are more likely to have perinatal mental health problems if you’ve had bouts of depression in the past.” – Rosy .

In contrast, others had dealt with traumatic experiences in their life, but could not see how this would be relevant to their mental health during pregnancy and the postnatal period. They started their pregnancy unaware of any potential risks to their mental health.

“I lost my brother when he was 18. […] And I didn’t get a lot of time off work, I was kind of straight back into work. I’m a [professional role in mental health], so I was working in acute psychiatry. Back to work, dealing with other people’s trauma and I don’t think I really dealt with my own particularly well. And it was kind of I think eight months later I had an episode of depression, just very low mood, apathy, poor motivation, poor concentration, was treated briefly with antidepressants and then just kind of did okay after that. So there had been nothing.” – Simone .

Previous trauma was reported by almost all respondents, whether it being through a bereavement, or traumatic life experiences, such as miscarriage and infertility, domestic abuse, fractured relationships, or suicide of a loved one. Two women reported having experienced domestic abuse. One of them reported the abuse, which she described as a ‘punishment’, only started after informing her partner of the pregnancy.

“It was a punishment actually that I dared to be pregnant even though he knew I wasn’t on any contraception or anything. And it really shocked me because he had never ever been like that before.” – Lauren .

For the other respondent, the domestic abuse had been long-lasting and led her to seek coping strategies to deal with the trauma and pain. Being in an abusive relationship created the worst possible start for pregnancy, with no support available.

“Well, it was my first pregnancy. I was 24 so I still hadn’t grown up properly, and I was in a really bad domestic violence relationship so there was a lot going on around that. I was getting no support [for] my pregnancy. I was also using as well which I regret profoundly, but I was drinking, like I drank occasionally because of my mental health, and my mental health was just all over the place; I was really, really unwell.” – Selina .

For some, their previous mental health difficulties were related to an earlier pregnancy or birth experience:

“I had huge amounts of birth trauma from my first, which I had a debrief for from the hospital, which was incredibly unhelpful. And it ended in emergency caesarean [section], after nine days of labour, and being in hospital, as a very naïve 19-year-old, having her first baby; looking back on it, feeling quite coerced by doctors, but not realising at the time that that’s what was happening. And that has impacted me for the rest of my life.” – Sam .

The severity of previous perinatal mental health problems was varied, with one woman having experienced postpartum psychosis after the birth of her first child. Going into the second pregnancy, the risk of relapse was hanging over her like a dark cloud:

“I remember sort of going to the 12-week scan with [second pregnancy] and getting the picture and thinking like shit, it’s really real now and it could all happen again. So I was really scared about that. Because the reccurrence rates are quite high for psychosis, so it’s quite likely that I was going to become unwell. So I was worried, yes, I was really concerned.” – Marie .

This feeling of worry was also reported by women with mild to moderate mental health difficulties and was compounded by a fear of being dismissed and not being able to access support if they would require it.

“I think there was something about the anxiousness of doing it all again, because I think I had some prenatal depression with my first, that wasn’t picked up, and then postnatal anxiety through the roof, that was also never picked up, and was told that was normal.” – Sam .

Family history of perinatal mental illness

Several respondents had a family history of perinatal mental illness and were vigilant that they might experience something similar. To mitigate this risk, they actively sought perinatal mental health support at the earliest opportunity.

“My mum had severe perinatal mental illness, she was hospitalised after my older brother for a year without him […]. At the time they didn’t really have Mother and Baby Units. Then I came [a few] years later and she was hospitalised again but with me for six months, and she passed away […] So my dad said she was saying the same things as each time she’d been sectioned; she would present with very religious ideation and stuff like this, so it was exactly the same stuff, and she died by suicide. So because of that collective history, when we were trying to get pregnant we thought “We need to let someone know we’re trying to get pregnant,” and so I was referred then to a Perinatal Psychiatrist before we got pregnant” - Sarah .

For others, this family history was not something which was spoken about prior to their own experiences of perinatal mental illness. One respondent mentioned she had never been aware of her mother’s history of postnatal depression until she herself started to experience postnatal depression.

“I didn’t know that my mum had postnatal depression. That’s not anything that she’d shared until… I knew that my brother cried a lot and I think he had a cows’ milk protein intolerance, but I didn’t know that my mum…” – Rosy .

Theme 2: disillusionment with motherhood

While previous mental health challenges or trauma were present in the background, all women were profoundly disillusioned with motherhood which contributed to a deterioration in their mental health. This theme of ‘Disillusionment with Motherhood’ captures three sub-themes that reflect a discrepancy between what women thought or hoped motherhood would be like, and the crushing reality they found themselves in. Together, these sub-themes compounded each other and became a catalyst for worsening mental health. The following sub-themes address the various areas of disillusionment that women in our sample reported: in their bodies, in their identity and in the bond with their baby.

The physical and mental struggle of pregnancy and birth

All participants held hopes and expectations of what their pregnancy, birth or the postnatal period would be like. For some first-time mothers, it soon became clear that the societal rosy-hued image of pregnancy was very far removed from their own experience of pregnancy. As they came to grips with how pregnancy was unfolding, the harsh contrast between expectation and reality was so high that many struggled to adjust to this:

“There’s all this thing about pregnancy you’re supposed to be glowing and it’s all marvellous and you’ve got these wonderful hormones, but I was just beached on the sofa feeling hot and sweaty thinking when is this baby going to come out, when’s it going to come out?” – Simone .

For those who had been pregnant before, the reality of another pregnancy, knowing full well what was in store, started to dawn on them:

“I don’t know, it hit me like a ton of bricks. Like oh shit, I’m doing this again. I’m pregnant again.” – Liv .

In addition to these psychological adjustments to reality, respondents mentioned how the physical toll of pregnancy and childbirth played a significant role in the deterioration of their mental health. This close correlation between physical issues and mental health decline was abundantly clear across the sample.

“I was horribly, horribly sick [hyperemesis]; that got worse each pregnancy. I don’t know if that’s normal; I’d heard it is. But horribly sick, which makes you absolutely miserable anyway.” – Sam . “I just sort of couldn’t wait for it [the pregnancy] to end. Yes, I just wanted to give birth. So when they said that they were going to induce me at 40 weeks I thought thank goodness, because my sickness started again quite late on. Again, I don’t know if it was because of the pre-eclampsia. But yes, I was just very ready, very ready to have little one.” – Hannah .

In the most extreme cases, pregnancy was not viewed as something to be enjoyed, but something that left women feeling repulsive.

“So since the pregnancy, just my life fell apart really, I was unemployed, and I just felt the whole way through not just sick and ill, absolutely physically repulsive, like I just felt like an absolute filthy animal. I can’t describe the disgust I felt for myself and the bigger my bump grew, the more disgusting I felt. And I don’t know, it’s just everything was awful, every day was awful.” – Lauren .

For other women physical injuries as a result of childbirth left them unable to function and to enjoy the things they were looking forward to as a new mother.

“I had some tearing and I’d had an episiotomy and they hadn’t healed, so my episiotomy had opened up and there were lots of A&E [Accidents and Emergency] visits and an operation eventually, but I think that really didn’t help my mental health because obviously if you’re in pain all the time then, it just drags you down, doesn’t it? So I wasn’t able to do my normal stuff, I wasn’t able to just carry on with life because I was in pain, I couldn’t sit and I felt like I couldn’t do mummy things.” – Mel .

Apart from the physical repercussions of pregnancy and childbirth, it was the trauma of giving birth and its psychological sequalae which triggered a marked deterioration in the mental health of several women in our sample.

“It was just sort of like you couldn’t expect it to happen, it was like a poor pregnancy and sort of felt like, you know, the birth went wrong as well.” – Hannah . “I had a premature baby. And I went on, I don’t know, like trauma response. Like totally numb. I suppose the adrenalin, the shock, everything…” – Liv .

Invalidation of identity and self-sacrifice

Almost all respondents encountered negative experiences with healthcare professionals at some point during pregnancy or the postnatal period and felt invalidated and dismissed by these. Women reported they were not seen as a person, with a complete identity, but reduced to a vessel for their baby, with little consideration given to their own feelings. This led to a profound loss of identity, exacerbating feelings of being invisible, inadequate and unimportant.

“It was never about me. And I know it’s not all about me, but when I’m wanting to commit suicide, it is very much about me and not one person asked me if I was alright, they were more concerned if the baby was alright, which I was as well, but they just completely bypassed that there was any reason I would do it.“ – Selina .

There seemed to be a lack of professional inquisitiveness to understand why a mother(-to-be) would consider suicide. Instead, all attention was directed towards the well-being of the baby, leading to multiple missed opportunities for timely care and support. In some cases, women reached out but their calls for help were simply ignored while their mood was rapidly deteriorating. These experiences would have devastating consequences on their further help-seeking behaviour.

“What really killed me, what was like the punch in the face that I needed was when I had my midwife appointment at, I don’t know, eight, ten weeks, something like that, and I told her ‘you know what, I’m not feeling right. There’s something bubbling inside me that is not alright, is not correct. I feel more anxious than normal, I can’t sleep, it’s all very weird’. And she just said ‘okay, I’m going to pin that down here to talk about in your next appointment. But we’re not going to do anything right now’. I never saw her again, by the way.” – Liv .

Invalidating encounters like the one described above would have a profound impact on how women viewed healthcare professionals as a source of support and whether they would reach out to them and share the extent of their mental health problems.

“I just felt like nobody was listening at all, just not heard one bit.” – Anna .

For some, the invalidating experience would almost become a motivator to succeed in their suicide plans, as they felt the severity of their mental health problems was brushed under the carpet. One participant sought help after a first suicide attempt through a medication overdose and shared the following:

“So then I think a few more weeks went by and I went back to the doctor’s. I said to the doctor, ’I want to kill myself’. My medication and stuff, I was honest with him, I said the medications and stuff that he was put… I think he tried me on Zopiclone as well with not sleeping and he said, ‘Well if you wanted to kill yourself, you would have done it by now’. I was just… I sort of felt then I’ve got something to prove.” – Hannah .

The loss of identity made respondents feel invisible to healthcare professionals and went hand in hand with exhausting themselves to be the best possible mother for their baby. Women described feelings of total self-sacrifice to meet this perceived standard of ‘the perfect mother’.

“I think I sort of went into supermum mode when I came home, like I had something to prove, and again, it’s that background of failure. I think I’m quite hard on myself anyway and I’m quite… If something goes wrong, I’m probably harder on myself in my head than somebody else would be and I maybe got a bit of a perfectionist trait, so I really didn’t want to rely on anybody, I didn’t ask for help with anything regarding my little boy, and I had a really, really strong bond with him which was really positive, but I think I was sort of going like overkill with not asking for help.” – Hannah .

However, as women started to experience the hard reality of caring for a newborn, they felt unable to meet this impossible standard. The perceived pressure to achieve (unrealistic) goals as well as their feelings of failure to do so started to take a significant strain on their mental health.

“No one had ever told me that before. No one had ever said that you don’t just have to drop everything and run to your child. Because I thought that that was what a secure bond was; and obviously now I’ve learnt about attachment theory and things. I thought that, for her to be securely bonded with me, I had to give every last drop of myself to be her mum.” – Sam .

‘It wasn’t like starry-eyed love’

Closely linked with the previous sub-theme, was the realisation for many women that they did not feel an instant rush of love for their baby. Several women reported feeling unsettled and flawed as a mother when they felt distant and detached from their baby. Women tried their very best to ‘act as a mother’ and do whatever their baby required, but this did not mean they also ‘felt like a mother’.

“So, at the beginning it was very strange. It, because like I said, I was determined to do anything in my power to get that baby out of NICU [Neonatal Intensive Care Unit]. Like whatever it takes, whatever the cost. So it never felt like oh, it’s my baby. I would have jumped in front of a train for him but it was not like a starry-eyed love. And that kept going.” – Liv . “In terms of motherhood, yes, I don’t know whether I just felt I was failing at it or… [pause] I don’t know, I felt very not connected to the baby. I had felt very, very bonded and very connected, and then I wasn’t at all.” – Sarah .

Sadly, for some, this lack of bonding with their baby persisted for a long time, with enduring consequences on their mental health and family happiness, leading to feelings of guilt and shame with which they still are coming to terms with.

“I had no attachment to him probably for about five years, nothing at all, just this ongoing sense of regret and I remember thinking daily I’ve made such a massive mistake in my life and almost this like realisation you are never going to get back what you had before, so just this real hopelessness actually at life.” – Lauren . “I just couldn’t, I couldn’t bond with, I couldn’t. Even still now I love her to pieces but we’re not like mother and daughter, we’re not.” – Anna .

Theme 3: entrapment and despair

In the final phase leading up to the suicide attempt, women experienced an accumulation of stressors, unleashing an overwhelming feeling of hopelessness and entrapment, with seemingly no way out of the situation they found themselves in. The sub-themes identified under this theme of ‘Entrapment and Despair’ left women no breathing space or respite. A perfect storm was brewing, for which women only started to see one way out, and that was by taking their own life.

Feeling like a failure

All respondents expressed a pervasive feeling of utter failure, intersecting their different identifies as a woman, mother and partner. Their perceived inability to meet expectations, whether this related to giving birth, feeding their baby, or functioning as a mother and partner stood in sharp contrast with how they viewed other mothers, who seemed to be effortlessly successful in doing so.

“You sort of just blame yourself. So I can just remember looking at him when he was asleep thinking like, ’Oh you’ve failed, I can’t do this, I’ve already failed at being a mum, but I can’t do this’, and I can just remember just thinking that, looking at him. So I think even though I know it wasn’t my fault, you really felt like a failure and I felt like it was me, like there was something wrong with me, because a lot of women around me, like even family, they never really had experiences like that, they would have like a good pregnancy, like a vaginal birth, a normal birth, so I really felt like I had failed and I really blamed myself for that.” – Hannah .

This feeling of being a total failure created a sense of dread, leaving them fearful every day that their inability and incompetence as a mother would be further exposed.

“I remember seeing the light coming in through the curtains in the morning and just thinking “Oh my god, no, I can’t, I can’t do another day,” like my heart would go, and it was that dread, that whole dread would come over me and I’d think “I can’t do another day today, I just can’t do it. I can’t do it.” It was like a… Yes, it was really hard. I just felt like I don’t know, it felt like I just wasn’t good enough for her, I wasn’t good enough. […] It just felt like I wasn’t good enough to be her mum.” – Mel .

This overwhelming sense of incompetence erased feelings of love, enjoyment or hope and instilled a feeling that their baby and loved ones would be better off without them.

“So it just escalated. This what was going on in my head about, you know, me not being good enough, a failure, just escalated even more, that now I was thinking they are going to take him away, everyone will know how rubbish I am. So it was later that week where I still wasn’t sleeping and I just thought, do you know what, the both of them would be better off without me, because I’ve just failed, I’m just a failure. They will be better off without me.” – Simone . “…That just made me feel so, so low that I think that spiral of internalised feelings and negativity compounded with this sort of isolation and lack of sleep just led me to think they’d be better off without me around, they’d have a parent maybe or a family that would be able to meet their needs.” – Rosy .

Intense intrusive thoughts and abnormal experiences

More than half of the women in our sample reported intrusive ideas or unsettling experiences in the period preceding their suicide attempt. For many, this came as a total surprise as they were unaware this could happen and they felt unable to express the extent of their intrusive thoughts to anyone.

“I remember getting up and going to the bathroom to brush my teeth and then started hearing voices. So this voice, I didn’t recognise it, was just chanting, ‘stinky [name of baby], stinky [name of baby]’, which is my baby’s name and I was like why’s that happening? I don’t understand. Where’s that coming from? And then later that day I remember looking at my husband and thinking you’re the father of this baby, but I’m not its mother. It was a really odd thought, because I was like I know I’ve been pregnant and I know I’ve just been through all that labour, but I look at this baby and it’s not mine, but I know you are the dad. It was really odd.”- Simone . “They [the intrusive thoughts] were really, really scary. And totally uncontrollable as well. They were so vivid and they used to make me feel really upset because they happened quite early on, probably when she was only a few weeks old and I remembering googling them and reading loads of things about it didn’t mean that you were not coping, it didn’t meant that you were going to hurt your baby, it didn’t mean that you were depressed, but I think maybe I should have perhaps seen that as a bit of a sign that I needed to get some help because it was weeks and weeks later that I finally did. But yes, they did upset me and I only told my mum, I didn’t tell anybody else because I just felt as though are people going to think that I’m going to hurt her? Am I going to hurt her if I talk about it more? Yes, they were really scary.” – Rosy .

For some, these ideas were extremely horrific and a symptom of their psychotic illness at the time. Unfortunately, this was left undiagnosed and untreated, leaving them totally desperate and isolated while these unsettling thoughts became their lived reality.

“[…] I started to think ‘oh I’ve committed all these awful crimes in my life’ and I was kind of struggling to process what they were and I was thinking have I killed people and maybe buried them and I don’t know where they are or have I kind of done a big theft or something but not been able to quite work out where I’d stolen the money from. But I was kind of panicking that I’d either buried these bodies or hidden this money and I couldn’t remember where they were, so I was panicking someone else is going to find them and then I’m going to be put in prison. So I had this kind of I want to die because I’m scared I’m going to go to prison because I’ve done all these awful things. And I just felt absolutely desperate.” – Lauren .

Alone in this world

While these distressing experiences of failure and intrusive thoughts invaded women’s mindset, women felt profoundly alone and isolated. Social isolation was reported as a catalyst for their suicide attempt by every woman in the sample. For some, it was a continuation of the situation they had already been in, but during this stage everything felt more desperate, more alone.

“I think by that point I wasn’t talking to anybody at all, not family, certainly not the kids’ dad. The kids’ dad… […] I just totally blocked his number and I wasn’t seeing anybody else. And actually, in some ways, I don’t think anybody wanted to see me because they were just like, “Why have you had another kid?” So the only people that I saw were my own kids, maybe the odd school teacher at pickup but that was it. No one from work. No friends really.” – Lauren .

For others, it was the absence of their partner, who had to return to work after paternity leave, that served as a lever for an acute deterioration of their mental health.

“Everything was fine until about three weeks after the birth and we were back at home, and my husband went back to work; it was him going back to work and I just, yes, fell apart.” – Sarah .

Some respondents had their baby during one of the COVID-19 pandemic lockdowns, when social restrictions meant they were unable to meet with friends or family or seek peer support from other mothers. Instead, they felt cooped up inside their house, alone and isolated, with their suicidal thoughts.

“Completely isolated. Not being able to, like I could have been going to, I don’t know, prenatal yoga. Or breastfeeding groups or toddler groups. Anything else that would take me out of that loop. So I think obviously that made it a lot worse. I don’t think that it would have been… – I don’t know.” – Liv . “So she was three or four months old when Covid hit and it was the whole lockdown and yes, everything just got ten times worse because I couldn’t do anything then; I couldn’t go and talk to my mum, I couldn’t go out, I couldn’t even have doctor’s appointments, I couldn’t have hospital appointments which made me worry even more, and my husband’s a key worker so I was just on my own all the time. Yes, and I think that’s when it got to the point where I just felt like I couldn’t cope anymore.” – Mel .

Several respondents recalled how this feeling of loneliness instilled a determination in them to retreat into isolation further. This meant they no longer wanted to speak to or be around others, even when they had a supportive network in place. An unstoppable cycle of isolation and socially avoidant behaviour was set in motion.

“I just stopped talking to people. That’s when I stopped talking to anybody and I got really ill with my mental health because of it, but I thought “Well, why am I going to talk to people when they don’t listen to me anyway?”- Selina . “I knew exactly what I was doing. I knew how I was going to do it. I just wanted it done. So I thought I have to tell him. I have to tell him. But I couldn’t tell him that I was off to kill myself.” – Simone .

‘Tired’ and ‘wired’

All but two respondents mentioned sleep deprivation as a major contributing factor to the accumulation of despair in the days or weeks before the suicide attempt. The sheer exhaustion they felt prevented them from thinking clearly or having the energy to face their circumstances and get better.

“My little boy slept really well from, gosh, about three weeks, maybe less than that, he would sleep through the night which was really, really lucky, but I couldn’t sleep and I think, yes, the problems of not sleeping had a snowball effect.” – Hannah .

This level of hypervigilance and restlessness was for many women the reason why they were unable to sleep. While women reported to feel exhausted on one hand, they also reported to experience an unhealthy level of drive, anger or arousal, leaving them ‘tired and wired’.

“I stopped sleeping entirely; I was so angry all the time – it’s all the textbook depression symptoms, but I was so angry all the time. I was so tired all the time, but just wired, couldn’t sleep.”- Sam . “I remember thinking I’m just so tired, I just want to go to sleep. I just want to be asleep and not be disturbed. But my mind was just so busy.” – Simone .

Some displayed agitated and manic behaviour to such an extent that they struggled to understand how this went unnoticed.

“I live three miles from the hospital and after they sent me home the next day, I walked back to the hospital with [the] kids and I was mowing the lawn five days after he was born and cleaning the house from top to bottom and driving all over the city after a [caesarean] section and you kind of just think like why did nobody notice? How can you think that that’s normal behaviour? Because I just felt this constant need, like I’ve got to be constantly doing things, constantly cleaning things, constantly walking places or doing things, alongside this absolute anger.” – Lauren .

The irreversibility of motherhood

A majority of respondents described they came to a very agonising realisation that they were unable to get out of being a mother and that they found themselves in an irreversible situation, with no going back. The feeling of being ‘stuck’ was so pervasive, that many expressed they wanted either the pregnancy to end, or to not wake up. The irreversibility of motherhood was surrounded by feelings of deep regret and an admission that this had been their own fault and responsibility.

“I remember actually hoping he would be stillborn towards the end, I think after the bridge. I just really wanted for him to be stillborn because if he was then it would all be over but it wouldn’t be my fault, and then I couldn’t go back. I think there was this constant sense of wanting to go back before any of it had happened and I just have my [older] children and I was working and I was happy and I kept seeking these ways just to go back and there weren’t any and I just got more and more desperate as time went on.” – Lauren .

Many respondents shared their conflicting emotions towards their baby, who they viewed as the cause of their distress on the one hand, and as the reason to stay alive on the other.

“[…] I simply could not do it anymore. Help, or don’t help. Whatever. I’m just not going to be around. And it’s almost like this feeling of, you want someone to take the baby off you, so that the baby’s not around, or that’s how I felt. The baby is your reason to stay alive, but the baby’s also the thing that’s causing you so much anguish. And that conflict is just so hard.” – Sam .

Women were desperate to get a grip on the situation, yet it all felt in vain, with no improvement in sight. An overwhelming feeling of hopelessness took over, leaving women with no light at the end of the tunnel and only one option: taking their own life.

“I don’t know how to explain it. I was feeling like all the things that I had to do were like water in my hands. I could see it. I could feel it. I could hold it. But it was coming through my fingers and I couldn’t do anything about it.” – Liv .

Our study identified three overarching themes, marking different phases during which women’s mental health gradually deteriorated. Whilst not all sub-themes under these themes were necessarily reported by every respondent, they paint a comprehensive picture of the distressing feelings and contributing factors that women experienced in the days and weeks prior to their suicide attempt. Nearly half of our sample undertook a suicide attempt during pregnancy. This is in line with evidence suggesting antepartum suicide attempts are an important complication of pregnancy [ 2 ] and act as a strong predictor for postnatal suicidal behaviour, including completed suicide [ 41 ]. In addition, participants in our sample whose suicide attempt occurred during the postnatal period reported suicidal ideation had started during pregnancy, making the antenatal period a critical period for both antenatal and postnatal suicide prevention.

Our first theme, ‘Trauma and adversities’, captures vulnerabilities prior to conception and during pregnancy and has two key elements: (1) psycho-social adversities, including grief and trauma and (2) having a family history of perinatal mental health difficulties. Women with previous mental health difficulties, in particular those with a history of depression and mood disorders, are known to have an increased risk of fatal and non-fatal perinatal suicide attempts [ 3 , 42 , 43 ]. In addition, previous adverse life events and abuse, especially when these occurred during childhood, [ 44 , 45 ], perinatal bereavement and infertility [ 46 ], comorbid substance use disorders and intimate partner violence [ 47 ], have also been associated with an increased risk of perinatal suicidal thoughts and suicidal behaviour. While the need for trauma-informed maternity services has become a public health priority [ 37 ], it is not always matched by a general awareness of the importance to raise these issues during pregnancy or the postnatal period [ 48 ]. This is reflected in our findings, where several of the respondents had experienced significant trauma and adverse life events prior to becoming pregnant but did not feel this was particularly relevant. Similarly, for some respondents a significant family history of perinatal mental health problems was unbeknown to them until their own mental health deteriorated. In contrast, those respondents who started pregnancy with an alertness of the risk of perinatal mental health problems in light of their own previous mental health difficulties or those of close relatives, reported to have prophylactic support measures in place, for instance by accessing a community perinatal mental health service during pregnancy. While this did not prevent their mental health from deteriorating, it did shorten the referral and escalation times when they reached a point of crisis. Having meaningful conversations about the prevalence of perinatal mental ill-health early on in pregnancy and undertaking a thorough assessment of mental health-related risk factors, such as previous mental health history, domestic abuse, substance misuse, previous trauma, among others, at every contact with maternity services is therefore essential to mitigate these pre-existing vulnerabilities [ 49 ].

In our second theme, ‘Disillusionment with Motherhood’, we identified a range of triggering factors that caused women’s mental health to decline. A first and often overlooked sub-theme that we identified was the impact of a physically and mentally challenging pregnancy and birth and their role in a subsequent mental health deterioration. This was often exacerbated when women received unkind, disrespectful care, which made them feel invisible. Whilst there are no studies to our knowledge that directly associate birth trauma with an increased risk of perinatal suicide, the association between birth trauma and postpartum post-traumatic stress disorder (PTSD) is well established [ 50 , 51 , 52 , 53 ]. Postpartum PTSD in turn is associated with poor coping and stress and highly co-morbid with depression [ 50 ]. Less evidence is available on the association between pregnancy and birth complications and perinatal suicide risk. One study found no association between maternal complications in pregnancy and during birth with hospitalisation for a suicide attempt [ 54 ]. Yet, as illustrated by our study sample, not all suicide attempts will result in an admission to a general hospital for medical treatment. Thus, further evidence is needed to understand the role of physical health complications, both during pregnancy, childbirth and the postnatal period, and their role in mood deterioration.

The subsequent sub-themes of ‘Invalidation of identify and self-sacrifice’ and ‘It wasn’t like starry-eyed love’ are closely intertwined and bring the complexity of women’s conflicting emotions towards motherhood to light [ 55 ]. The desire to be a good mother as a newly found identify often came to the detriment of their own personal self, with many women reporting situations of total self-sacrifice [ 56 ]. These daily struggles, of trying to be the perfect mother on the one hand, while trying to bond with their baby on the other hand, was in many cases fertile soil to start feeling obsolete as a person and feeling disillusioned in motherhood. Our findings build on previous work from Reid et al. (2022), who identified key factors in the context of a perinatal suicide attempt, such as a strained mother-infant bond, lack of social support, loneliness and hopelessness [ 44 ]. This resonates with our sub-themes of “Feeling like a failure”, “Alone in this world” and “Irreversibility of motherhood”. Our final theme “Entrapment and Despair” is in line with Reid et al. (2022)’s final phase, called ‘Darkness Descends’ [ 23 ] and is marked by pervasive feelings of hopelessness and failed motherhood. Under this theme, a turbulent accumulation of negative factors resulting in a fast deterioration of their mental health was reported by all respondents. These feelings of hopelessness and being totally entrapped were so all-encompassing, that participants felt no other way out than by attempting to take their own life. However, in this third stage, women did not just feel disillusioned, they felt totally incompetent as a mother, to a point they believed their baby and family would be better off without them. The finality of motherhood, with no way to turn back time or to escape their fate (‘Irreversibility of Motherhood’), drove them further to despair [ 55 ]. The MBRRACE-UK reports have repeatedly raised such feelings of incompetence as a mother and estrangement of the infant as a ‘red flag’ which should be taken seriously to prevent future maternal deaths by suicide [ 1 , 13 , 57 ].

Another factor we identified in this phase was the occurrence of intrusive thoughts and unsettling (psychotic) experiences, brought together in the subtheme ‘Intense intrusive thoughts and abnormal experiences’. The majority of our respondents reported abnormal experiences that were very unsettling to them. For some, these could be described as intrusive thoughts in the context of Obsessive Compulsive Disorder. Although intrusive thoughts are common among new parents, such experiences are often misunderstood, surrounded by stigma, and sometimes being misdiagnosed or over-normalised and dismissed, preventing timely and effective intervention [ 58 ]. For others in our sample, these experiences may have been delusions or hallucinations as part of a psychotic presentation. For all respondents who had them, the experiences were intense, frightening and difficult to understand at the time. Practitioner knowledge, sensitive risk assessment and careful diagnostic consideration about the nature and type of internal experiences is fundamental to appropriately treat women experiencing these upsetting experiences [ 59 ]. Yet equally important is increased public awareness on the occurrence and impact of such experiences, so women can seek timely support when they experience these frightening thoughts or delusions.

A third common factor we identified was sleep deprivation during pregnancy and the postnatal period and its profound impact on women’s mental health. Sleep disturbance is very common in relation to mental illness, and was highlighted in the most recent MBRRACE-UK report as marked and persistent in those women who died by suicide, even when treated with hypnotic medication [ 1 ]. A recent systematic review by Palagini et al. (2023) showed insomnia and poor sleep quality increased the odds of suicidal risk in pregnant and postpartum women by more than threefold, independently from psychiatric comorbidity [ 60 ]. Especially in a context of onset of psychotic illness, such as bipolar disorder, insomnia often precipitates other psychotic symptoms such as restlessness, irritability and rapid mood changes [ 61 ]. Unfortunately, as sleep loss is generally accepted as a common ‘side effect’ of pregnancy and having a newborn baby, its severity and potential devastating consequences are poorly understood and often minimised. Overall, the theme of ‘Entrapment and Despair’ captures the sheer hopelessness and inability to gain control over a rapidly escalating situation, in line with Klonsky and May’s Three-Step-Theory of suicide [ 62 ]. This theoretical model of suicide considers three steps to suicide. Being in pain and hopelessness leads to suicidal ideation (Step 1), which can be exacerbated by isolation or countered by connectedness (Step 2). The final step is marked by one’s capability of attempting suicide (Step 3). The pervasive feeling of hopelessness and lack of control gradually paved the way for a solid belief it would be better to no longer be here. Participants in our sample shared how they accepted this belief and waited for an opportunity to carry out their suicide plan. This combination of hopelessness and rejection of motherhood, a belief that death would be preferred and an opportunity to act on these thoughts has been previously theorised as a culmination of factors for perinatal suicide [ 23 ]. In line with findings from previous MBRRACE-UK reports, the vast majority of respondents in our sample turned to violent methods for suicide, such as jumping, hanging, suffocation, using sharp objects or stepping in front of traffic, reflecting the high level of distress women found themselves in and the determination with which they wanted to carry out their plan.

Strengths and limitation

Our study is the first to our knowledge to focus on suicide attempts during the perinatal period and offers a rich understanding of women’s experiences surrounding these highly distressing events. A strength of this study is the recruitment of participants across the UK, rather than one geographical area, with diversity in the sample regarding age, parity, psychiatric morbidity, social support, educational attainment and socio-economic status. Significant efforts were made to recruit women from diverse ethnic, cultural, and religious backgrounds, through invitations and meetings with community leaders and designated support groups. Despite our efforts, we did not achieve diversity regarding ethnic and cultural background, one of the limitations of this study. Ethnicity data from the latest MBRRCACE-UK report showed that women who died by suicide were predominately white (86%), with no further ethnicity details on the remaining 14% [ 1 ]. As a result, although this was never our intention, we are aware our study findings are focusing on the experiences of White women in the UK and not transferrable to an ethnically and culturally more diverse sample, or to other countries across the globe. In addition, our sample consisted predominantly of participants with higher educational qualification, in positions of employment. Therefore, our analysis was unable to explore the impact of poverty on women’s suicidality, which is known to be an important driver of poor (perinatal) mental health [ 63 , 64 ]. We are aware a more ethnically, culturally, religiously and socio-economically heterogenous sample is likely to represent a diversity of perspectives, highlighting these issues. Another limitation was the design of the demographic survey, which did not specifically differentiate between mental health diagnosis given during the life course or specifically at the time of the suicide attempt. Suicide research, especially in a perinatal context, is notorious for its recruitment challenges. Saturation for all themes and sub-themes was achieved well within the available sample and is one of the strengths of this study. Another strength of our study is the sensitivity and rigour of patient and public involvement throughout the various phases of the study. This was crucial to do justice to the courage which participants had shown by sharing their stories and to keep respondents safe throughout their research participation.

Implications for clinical practice and care and future research

Our study highlights the importance of routine inquiry of previous mental health difficulties and family history of perinatal mental health problems at the first encounter during pregnancy. Yet, such an assessment needs to be more comprehensive than a tick-box exercise and should be accompanied by a personalised conversation about prevalence of perinatal mental health problems and potential triggers, including trauma and grief. Professionals should be given adequate time during antenatal encounters to explore this in depth and, where required, receive additional training in perinatal mental health to build confidence in doing so. The perinatal period is often described as a ‘window of opportunity’, but this goes both ways: While every encounter creates opportunity for screening, detection and support, it also has the potential for invoking or deepening trauma. Our study revealed the devastating and long-lasting impact of unkind, careless and dismissive remarks by healthcare professionals on women’s mental health, thus instilling a feeling of failure by throw-away comments that would ripple on weeks and months after they were uttered. Perinatal healthcare professionals need to understand the weight of their words, how they can provide hope when women are struggling, but equally how they can push women further into isolation and despair. Culturally aware and trauma-informed clinical practice is essential to achieve this, whilst also recognising the impact of burn-out and carer’s fatigue in an overstretched and under-resourced healthcare service. Healthcare professionals need to be cautious about the difference between normalising and dismissing distressing feelings. In addition, professionals need to fully understand the profound impact of physical, social and psychological risk factors as identified by our study. The physical and mental challenge of pregnancy and childbirth, often in combination with a traumatic birth experience should not be underestimated. An impaired mother-infant dyad, feelings of resentment of motherhood, and the discrepancy between women’s expectations and their lived reality are all key triggers that should be discussed, identified and addressed at the earliest opportunity, in a non-judgemental and sensitive way to avoid further escalation. Women need to be validated and reassured by professionals when disclosing these feelings, and be informed that support is available to help them transition into motherhood. Continuity of care throughout the perinatal period, if done with sensitivity and person-centredness, can foster trusting relationship so women feel safe and supported to disclose distressing feelings. Similarly, insomnia and sleep disturbance, albeit in combination with restlessness and irritability, intrusive thoughts and feelings of lack of control and failure are red flags for severe and rapid mental health deterioration that required prompt and effective action. More than anything, women need to feel safe and listened to, so they can share their feelings with healthcare professionals without fear of judgement, shame and stigma. Our study showed that women will often retreat into silence prior to a suicide attempt and in that moment more than ever rely on attentive, educated and compassionate support networks to avoid a suicide attempt.

Future research into perinatal suicide attempt should focus on developing effective preventative interventions and public health strategies, both in an antenatal and postnatal context, with their distinct healthcare professionals’ involvement and resource challenges. By using implementation science methods, these interventions should be tested and evaluated on their efficacy and effectiveness, in order to reduce future maternal suicides.

This study is the first UK-based qualitative study looking at suicide attempts during the perinatal period. Our findings identified three themes with several contributing factors which led women to undertake a suicide attempt. It is important to understand the impact of previous trauma and life adversity when going through pregnancy and the postnatal period. Feelings of disillusionment with motherhood and feeling entrapped in a hopeless situation were key phases women experienced in the lead-up to their suicide attempt. Our study findings have important implications for clinical practice and healthcare professionals should be aware of warning signs, to improve timely detection and facilitate meaningful inquiry, in order to improve care and prevent future maternal suicide deaths.

Data availability

The datasets generated and analysed during the current study are not publicly available due to the privacy of the participants in the study and the sensitive nature of the data. Further inquiries can be directed to the corresponding author ([email protected]).

We acknowledge not all people who give birth and go through the perinatal period identity as women, female or mothers. While this paper utilises predominantly the terms women and mothers, we aim to include also those who identify as transgender, non-binary or any other gender identity.

Knight M, Bunch K, Patel R, Shakespeare J, Kotnis R, Kenyon S, Kurinczuk J. Saving lives, improving mothers’ Care Core Report - lessons learned to inform maternity care from the UK and Ireland Confidential enquiries into maternal deaths and morbidity 2018-20. In. Oxford: National Perinatal Epidemiology Unit, University of Oxford; 2022.

Google Scholar  

Rao WW, Yang Y, Ma TJ, Zhang Q, Ungvari GS, Hall BJ, Xiang YT. Worldwide prevalence of suicide attempt in pregnant and postpartum women: a meta-analysis of observational studies. Soc Psychiatry Psychiatr Epidemiol. 2021;56(5):711–20.

Article   PubMed   Google Scholar  

Howard LM, Khalifeh H. Perinatal mental health: a review of progress and challenges. In: World Psychiatry vol. 19; 2020: 313–327.

Gold KJ, Singh V, Marcus SM, Palladino CL. Mental health, substance use and intimate partner problems among pregnant and postpartum suicide victims in the National Violent Death Reporting System. Gen Hosp Psychiatry. 2012;34(2):139–45.

Stein A, Pearson RM, Goodman SH, Rapa E, Rahman A, McCallum M, Howard LM, Pariante CM. Effects of perinatal mental disorders on the fetus and child. Lancet. 2014;384(9956):1800–19.

Letourneau NL, Dennis C-L, Benzies K, Duffett-Leger L, Stewart M, Tryphonopoulos PD, Este D, Watson W. Postpartum Depression is a Family Affair: addressing the impact on mothers, fathers, and children. Issues Ment Health Nurs. 2012;33(7):445–57.

Bauer A, Parsonage M, Knapp M, Iemmi V, Adelaja B. The costs of perinatal mental health problems. Lond School Econ 2014.

Chin K, Wendt A, Bennett IM, Bhat A. Suicide and maternal mortality. Curr Psychiatry Rep. 2022;24(4):239–75.

Article   PubMed   PubMed Central   Google Scholar  

Diguisto C, Saucedo M, Kallianidis A, Bloemenkamp K, Bodker B, Buoncristiano M, Donati S, Gissler M, Johansen M, Knight M, et al. Maternal mortality in eight European countries with enhanced surveillance systems: descriptive population based study. BMJ. 2022;379:e070621.

Cantwell R. Perinatal mental health service development across the UK – many achievements, growing challenges. Ir J Psychol Med 2022:1–4.

Knight M, Bunch K, Tuffnell D, Patel R, Shakespeare J, Kotnis R, Kenyon S, Kurinczuk JJ. Saving Lives, Improving Mothers’ Care - Lessons learned to inform maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2017-19. In. Oxford; 2021.

Knight M, Nair M, Tuffnell D, Shakespeare J, Kenyon S, Kurinczuk JJ. Saving Lives, Improving Mothers’ Care Lessons learned to inform maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2013-15 Maternal, Newborn and Infant. Clinical Outcome Review Programme; 2017.

Knight M, Bunch K, Tuffnell D, Jayakody H, Shakespeare J, Kotnis R, Kenyon S, Kurinczuk JJ. Saving Lives, Improving Mothers’ Care Maternal, Newborn and Infant Clinical Outcome Review Programme; 2018.

Knight M, Bunch K, Cairns A, Cantwell R, Cox P, Kenyon S, Kotnis R, Lucas N, Lucas S, Marshall L, et al. Saving Lives, Improving Mothers’ Care Rapid report: Learning from SARS-CoV-2-related and associated maternal deaths in the UK Maternal. Newborn and Infant Clinical Outcome Review Programme; 2020.

Department of Health and Social Care. Suicide prevention in England: 5 year cross-sector strategy. In.; 2023.

Orsolini L, Valchera A, Vecchiotti R, Tomasetti C, Iasevoli F, Fornaro M, De Berardis D, Perna G, Pompili M, Bellantuono C. Suicide during Perinatal Period: epidemiology, risk factors, and clinical correlates. Front Psychiatry. 2016;7:138.

Gandhi SG, Gilbert WM, McElvy SS, El Kady D, Danielson B, Xing G, Smith LH. Maternal and neonatal outcomes after attempted suicide. Obstet Gynecol. 2006;107(5):984–90.

Schiff MA, Grossman DC. Adverse perinatal outcomes and risk for postpartum suicide attempt in Washington state, 1987–2001. Pediatrics. 2006;118(3):e669–675.

Crosby A, Ortega L, Melanson C. Self-directed violence surveillance; uniform definitions and recommended data elements. In.: National Center for Injury Prevention and Control (U.S.). Division of Violence Prevention; 2011.

Brown GK, Beck AT, Steer RA, Grisham JR. Risk factors for suicide in psychiatric outpatients: a 20-year prospective study. J Consult Clin Psychol. 2000;68(3):371–7.

Article   CAS   PubMed   Google Scholar  

Douglas J, Cooper J, Amos T, Webb R, Guthrie E, Appleby L. Near-fatal deliberate self-harm: characteristics, prevention and implications for the prevention of suicide. J Affect Disord. 2004;79(1):263–8.

Johannsen BM, Larsen JT, Laursen TM, Ayre K, Howard LM, Meltzer-Brody S, Bech BH, Munk-Olsen T. Self-harm in women with postpartum mental disorders. Psychol Med. 2020;50(9):1563–9.

Reid H, Pratt D, Edge D, Wittkowski A. What makes a perinatal woman suicidal? A grounded theory study. BMC Psychiatry. 2022;22(1):386.

Al-Halabi S, Garcia-Haro J, de la Fe Rodriguez-Munoz M, Fonseca-Pedrero E. Suicidal behavior and the perinatal period: taboo and misunderstanding. Psychol Papers. 2021;42(3):161–9.

Silverio SA, Sheen KS, Bramante A, Knighting K, Koops TU, Montgomery E, November L, Soulsby LK, Stevenson JH, Watkins M, et al. Sensitive, challenging, and difficult topics: experiences and practical considerations for qualitative researchers. Int J Qualitative Methods. 2022;21:16094069221124739.

Article   Google Scholar  

Hjelmeland H, Knizek BL. Why we need qualitative research in Suicidology. Suicide Life-Threatening Behav. 2010;40(1):74–80.

O’Mahoney J. Critical realism and qualitative research: an introductory overview. In, edn.; 2016.

Williams R. The epistemology of knowledge and the knowledge process cycle: beyond the objectivist vs interpretivist. J Knowl Manage. 2008;12(4):72–85.

Article   CAS   Google Scholar  

Boyatzis RE. Transforming qualitative information: thematic analysis and Code Development. Thousand Oaks, CA: Sage; 1998.

Braun V, Clarke V. Reflecting on reflexive thematic analysis. Qualitative Res Sport Exerc Health. 2019;11(4):589–97.

Braun V, Clarke V. Using thematic analysis in psychology. Qualitative Res Psychol. 2006;3(2):77–101.

Wiltshire G, Ronkainen N. A realist approach to thematic analysis: making sense of qualitative data through experiential, inferential and dispositional themes. J Crit Realism. 2021;20(2):159–80.

Fryer T. A critical realist approach to thematic analysis: producing causal explanations. J Crit Realism. 2022;21(4):365–84.

Vasileiou K, Barnett J, Thorpe S, Young T. Characterising and justifying sample size sufficiency in interview-based studies: systematic analysis of qualitative health research over a 15-year period. BMC Med Res Methodol. 2018;18(1):148.

De Backer K, Newburn M, Hildersley R, Easter A. Conducting a sensitive research study on perinatal suicide attempts — the power of patient and public involvement and Engagement (PPIE). MIDIRS Midwifery Digest. 2023;33(2):115–8.

Martinez Dy A, Martin L, Marlow S. Developing a critical Realist positional Approach to Intersectionality. J Crit Realism. 2014;13(5):447–66.

Law C, Wolfenden L, Sperlich M, Taylor J. A good practice guide to support implementation of trauma-informed care in the perinatal period. In.; 2021.

Gibson S, Benson O, Brand SL. Talking about suicide: confidentiality and anonymity in qualitative research. Nurs Ethics. 2013;20(1):0969733012452684.

Johnson B, Clarke JM. Collecting Sensitive Data: the impact on researchers. Qual Health Res. 2003;13(3):421–34.

Kiyimba N, O’Reilly M. An exploration of the possibility for secondary traumatic stress among transcriptionists: a grounded theory approach. Qualitative Res Psychol. 2016;13(1):92–108.

Lindahl V, Pearson JL, Colpe L. Prevalence of suicidality during pregnancy and the postpartum. Arch Womens Ment Health. 2005;8(2):77–87.

Gressier F, Guillard V, Cazas O, Falissard B, Glangeaud-Freudenthal NMC, Sutter-Dallay A-L. Risk factors for suicide attempt in pregnancy and the post-partum period in women with serious mental illnesses. J Psychiatr Res. 2017;84:284–91.

Taylor CL, Broadbent M, Khondoker M, Stewart RJ, Howard LM. Predictors of severe relapse in pregnant women with psychotic or bipolar disorders. J Psychiatr Res. 2018;104:100–7.

Reid H, Pratt D, Edge D, Wittkowski A. Maternal suicide ideation and Behaviour during pregnancy and the First Postpartum Year: a systematic review of psychological and psychosocial risk factors. Front Psychiatry 2022, 13.

Bright AM, Doody O, Tuohy T. Women with perinatal suicidal ideation-A scoping review of the biopsychosocial risk factors to inform health service provision and research. PLoS ONE. 2022;17(9):e0274862.

Article   CAS   PubMed   PubMed Central   Google Scholar  

Weng S-C, Chang J-C, Yeh M-K, Wang S-M, Lee C-S, Chen Y-H. Do stillbirth, miscarriage, and termination of pregnancy increase risks of attempted and completed suicide within a year? A population-based nested case–control study. BJOG: Int J Obstet Gynecol. 2018;125(8):983–90.

Forray A, Yonkers KA. The Collision of Mental Health, Substance Use Disorder, and suicide. Obstet Gynecol. 2021;137(6):1083–90.

Cull J, Thomson G, Downe S, Fine M, Topalidou A. Views from women and maternity care professionals on routine discussion of previous trauma in the perinatal period: a qualitative evidence synthesis. PLoS ONE. 2023;18(5):e0284119.

National Institute for Health Care Excellence. Antenatal and postnatal mental health: Antenatal and postnatal mental health: clinical management and service clinical management and service guidance guidance clinical guideline. In.; 2014.

Ayers S, Bond R, Bertullies S, Wijma K. The aetiology of post-traumatic stress following childbirth: a meta-analysis and theoretical framework. Psychol Med. 2016;46(6):1121–34.

Sheen K, Slade P. The efficacy of ‘debriefing’ after childbirth: is there a case for targeted intervention? J Reproductive Infant Psychol. 2015;33:308–20.

Sheen K, Slade P. Examining the content and moderators of women’s fears for giving birth: a meta-synthesis. J Clin Nurs. 2018;27(13–14):2523–35.

Jomeen J, Martin CR, Jones C, Marshall C, Ayers S, Burt K, Frodsham L, Horsch A, Midwinter D, O’Connell M, et al. Tokophobia and fear of birth: a workshop consensus statement on current issues and recommendations for future research. J Reprod Infant Psychol. 2021;39(1):2–15.

Schiff M, Grossman D. Adverse perinatal outcomes and risk for postpartum suicide attempt in Washington State, 1987–2001. Pediatrics. 2006;118(3):e669–75.

Nicolson P. Loss, happiness and postpartum depression: the ultimate paradox. Can Psychol. 1999;40:162–78.

Staneva AA, Bogossian F, Wittkowski A. The experience of psychological distress, depression, and anxiety during pregnancy: a meta-synthesis of qualitative research. Midwifery. 2015;31(6):563–73.

Knight M, Bunch K, Tuffnell D, Shakespeare J, Kotnis R, Kenyon S, Kurinczuk JJ. Saving Lives, Improving Mothers’ Care Maternal, Newborn and Infant Clinical Outcome Review Programme. In. Oxford; 2020.

Fairbrother N, Woody SR. New mothers’ thoughts of harm related to the newborn. Arch Womens Ment Health. 2008;11(3):221–9.

Challacombe FL, Bavetta M, DeGiorgio S. Intrusive thoughts in perinatal obsessive-compulsive disorder. BMJ. 2019;367:l6574.

Palagini L, Cipriani E, Miniati M, Bramante A, Gemignani A, Geoffroy PA, Riemann D. Insomnia, poor sleep quality and perinatal suicidal risk: a systematic review and meta-analysis. J Sleep Res 2023:e14000.

Sharma V, Mazmanian D. Sleep loss and postpartum psychosis. Bipolar Disord. 2003;5(2):98–105.

Klonsky ED, May AM, 3ST). The Three-Step Theory (: A New Theory of Suicide Rooted in the Ideation-to-Action Framework. International Journal of Cognitive Therapy 2015, 8(2):114–129.

Mathieu S, Treloar A, Hawgood J, Ross V, Kõlves K. The role of unemployment, Financial Hardship, and economic recession on suicidal behaviors and interventions to mitigate their impact: a review. Front Public Health. 2022;10:907052.

Parra-Saavedra M, Miranda J. Maternal mental health is being affected by poverty and COVID-19. Lancet Global Health. 2021;9(8):e1031–2.

Download references

Acknowledgements

We would like to thank all the women and birthing people who took part in this study, for their time, their bravery and the honesty with which they shared their story. Their commitment to improve care for others who find themselves in a similar position was a privilege to witness. We thank Dr Clare Dolman, the Patient Advisory Group at the Section for Women’s Mental Health at King’s College London, the South London Applied Research Collaboration Maternity and Perinatal Mental Health theme Patient and Public Involvement and Engagement group for their suggestions and feedback throughout the different stages of this study. We also like to thank the third sector partners that were closely involved in the study journey, such as Maternal Mental Health Alliance, Mothers for Mothers, the Institute of Health Visiting, the Motherhood Group, REFORM, National Childbirth Trust (NCT), and Maternity Action.

This work was supported by the National Institute for Health and Care Research (NIHR) South London Applied Research Collaboration (NIHR200152). Patient and public involvement engagement activities undertaken for this study were funded through a King’s Engaged Research Network (KERN) Public Engagement Small Grant Award. Kaat De Backer, Sergio A. Silverio, Professor Jane Sandall and Dr Abigail Easter are supported by the NIHR Applied Research Collaboration South London (NIHR ARC South London) at King’s College Hospital NHS Foundation Trust. Kaat De Backer (King’s College London) is also in receipt of an NIHR Doctoral Research Fellowship (NIHR302565). Sergio A. Silverio (King’s College London) is currently in receipt of a Personal Doctoral Fellowship from the NIHR ARC South London Capacity Building Theme [NIHR-INF-2170]. The views expressed are those of the authors and not necessarily those of the NIHR or the Department of Health and Social Care.

Author information

Authors and affiliations.

Department of Women & Children’s Health, School of Life Course and Population Sciences, Faculty of Life Sciences & Medicine, King’s College London, 10th Floor North Wing, St. Thomas’ Hospital, Westminster Bridge Road, Lambeth, London, SE1 7EH, UK

Kaat De Backer, Alexandra Pali, Jane Sandall & Abigail Easter

Department of Clinical Psychological Science, Faculty of Psychology and Neuroscience, Maastricht University, Maastricht, The Netherlands

Alexandra Pali

Section of Women’s Mental Health, Institute of Psychiatry, Psychology, and Neuroscience, King’s College London, Denmark Hill, 16 De Crespigny Park, London, SE5 8AF, England

Fiona L. Challacombe, Rosanna Hildersley & Louise M. Howard

Patient and Public Involvement and Engagement Lead for ARC South London, Maternity and Perinatal Mental health theme, Department of Women & Children’s Health, School of Life Sciences and Medicine, King’s College London, 10th Floor North Wing, St. Thomas’ Hospital, Westminster Bridge Road, Lambeth, London, SE1 7EH, UK

Mary Newburn

Department of Women & Children’s Health, School of Life Course & Population Sciences, Faculty of Life Sciences & Medicine, King’s College London, 6th Floor Addison House, Great Maze Pond, Southwark, London, SE1 1UK, UK

Sergio A. Silverio

School of Psychology, Faculty of Health, Liverpool John Moores University, Liverpool, Merseyside, L3 3AF, UK

You can also search for this author in PubMed   Google Scholar

Contributions

AE, LMH, JS, RH, KDB conceived the work and designed the study. SAS and MN contributed to the development of the design. MN led the Public and Patient Involvement and Engagement. KDB, AP, AE, FLC contributed to data acquisition. KDB, AP, AE, FLC interpreted the data. KDB drafted the manuscript and incorporated revisions from all other authors. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Abigail Easter .

Ethics declarations

Ethical approval and consent to participate.

Ethical approvals were sought and granted by the King’s College London Health Faculties Research Ethics Committee, in January 2021 (reference HR-20/21-20092), with a further amendment in June 2022, after further feedback from the advisory panel and stakeholder meeting (reference MOD-21/22-20092). The authors assert that all procedures contributing to this work comply with the ethical standards of the relevant national and institutional committees on human experimentation and with the Helsinki Declaration of 1975, as revised in 2008.

Consent for publication

Written informed consent was obtained from all participants in the study. Participants were also invited to proof-read the manuscript to ensure they were satisfied with selection of quotations.

Competing interests

The authors declare no competing interests.

Additional information

Publisher’s note.

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

Electronic supplementary material

Below is the link to the electronic supplementary material.

Supplementary Material 1

Rights and permissions.

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/ . The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/ ) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Cite this article.

De Backer, K., Pali, A., Challacombe, F.L. et al. Women’s experiences of attempted suicide in the perinatal period (ASPEN-study) – a qualitative study. BMC Psychiatry 24 , 255 (2024). https://doi.org/10.1186/s12888-024-05686-3

Download citation

Received : 22 December 2023

Accepted : 14 March 2024

Published : 03 April 2024

DOI : https://doi.org/10.1186/s12888-024-05686-3

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Qualitative research
• Women’s mental health

BMC Psychiatry

ISSN: 1471-244X

• Submission enquiries: [email protected]
• General enquiries: [email protected]

• Open access
• Published: 05 April 2024

Barriers and facilitators to guideline for the management of pediatric off-label use of drugs in China: a qualitative descriptive study

• Min Meng 1 , 2 , 3 , 4   na1 ,
• Jiale Hu 5   na1 ,
• Xiao Liu 6 ,
• Min Tian 4 ,
• Wenjuan Lei 4 ,
• Enmei Liu 2 , 3 ,
• Zhu Han 7 ,
• Qiu Li 2 , 3 , 8 &
• Yaolong Chen 1 , 2 , 3 , 9 , 10 , 11  

BMC Health Services Research volume  24 , Article number:  435 ( 2024 ) Cite this article

Metrics details

Despite being a global public health concern, there is a research gap in analyzing implementation strategies for managing off-label drug use in children. This study aims to understand professional health managers’ perspectives on implementing the Guideline in hospitals and determine the Guideline’s implementation facilitators and barriers.

Pediatric directors, pharmacy directors, and medical department directors from secondary and tertiary hospitals across the country were recruited for online interviews. The interviews were performed between June 27 and August 25, 2022. The Consolidated Framework for Implementation Research (CFIR) was adopted for data collection, data analysis, and findings interpretation to implement interventions across healthcare settings.

Individual interviews were conducted with 28 healthcare professionals from all over the Chinese mainland. Key stakeholders in implementing the Guideline for the Management of Pediatric Off-Label Use of Drugs in China (2021) were interviewed to identify 57 influencing factors, including 27 facilitators, 29 barriers, and one neutral factor, based on the CFIR framework. The study revealed the complexity of the factors influencing managing children’s off-label medication use. A lack of policy incentives was the key obstacle in external settings. The communication barrier between pharmacists and physicians was the most critical internal barrier.

To our knowledge, this study significantly reduces the implementation gap in managing children’s off-label drug use. We provided a reference for the standardized management of children’s off-label use of drugs.

Peer Review reports

Introduction

Off-label drug use in pediatrics is a global public health issue [ 1 ], particularly in China [ 2 , 3 ]. According to a systematic review, pediatric off-label medicine prescription rates ranged from 22.7% to 51.2% in outpatient settings and 40.48% to 78.96% in hospitalized children in China [ 4 ]. However, there are numerous unreasonable examples of off-label drug use in children, posing significant risks to children’s safety [ 5 , 6 ]. As a result, the Guideline for the Management of Pediatric Off-label Use of Drugs in China (i.e., the Guideline) was developed in 2021 by the Chinese Society of Pediatric Clinical Pharmacology, the Chinese Medical Association, and the National Clinical Research Center for Child Health and Disorders (Children’s Hospital of Chongqing Medical University), in collaboration with the Chinese GRADE Center [ 7 ].

However, translating evidence from clinical practice guidelines (i.e., CPG) into practice, also known as implementation [ 8 , 9 ], is a complex process influenced by various factors such as political and social, the health organizational system, the CPG context, healthcare professionals, and patients [ 10 ]. For example, only about half of Chinese healthcare professionals follow the recommendations and understand the clinical practice guidelines, which range from 3 to 86% [ 9 ].

To enhance guideline adherence among healthcare professionals, it is necessary to identify the facilitators and barriers to guideline implementation [ 11 ]. In addition, theory-based guideline implementation research can assist implementers in avoiding potential pitfalls that may hinder their effectiveness [ 12 ]. Consequently, identifying factors that influence the implementation of recommendations, that is, implementation barriers and facilitators [ 10 ], is essential for the early clinical translation of guidelines to implement strategies tailored to anticipated barriers [ 13 ] and to optimize the implementation of interventions [ 14 ].

Off-label use of drugs in children is a complex aspect of clinical practice [ 15 ]. Only a small number of studies have demonstrated that the following are obstacles to the management of pediatric off-label use in China: lack of time to offer sources of information and evidence of off-label use, no available expert panel on off-label use, no adverse drug reaction monitoring system, no database of off-label drugs, no ethics council or pharmacy administration committee, difficulties in gaining written agreement from parents or guardians, and absence of a unified regulatory framework [ 16 , 17 , 18 ]. In addition, doctors’ awareness prescription of off-label drugs [ 19 , 20 , 21 , 22 ], their fear of legal repercussions [ 23 ], and they are less of informing parents about off-label drugs [ 21 , 24 ] were obstacles to managing children’s off-label drug use. However, none of the present research is theoretically based on guideline implementation studies and hence may lack systematicity in identifying factors influencing off-label drug use management in children. In addition, implementation strategies for managing pediatric off-label drug use are understudied.

Implementation strategies tailed based on the implementation contextual factors can promote adherence among healthcare professionals [ 25 ]. The Consolidated Framework for Implementation Research (CFIR), a well-known implementation science framework, has been extensively used as a framework in recent research on strategies for implementing guidelines, and it has successfully identified the influencing factors for guidelines’ implementation [ 26 , 27 , 28 , 29 , 30 , 31 ].Therefore, this study used CFIR for guiding data collection, data analysis, and findings interpretation to implement interventions across healthcare settings and aimed to understand professional health managers’ perspectives on implementing the Guideline in hospitals and determine the Guideline’s implementation facilitators and barriers. Also, the suggestions for implementing the Guideline were created by mapping the identified barriers to the Expert Recommendations for Implementing Change (ERIC) and selecting the appropriate strategies for implementation [ 26 , 32 ].

Research design

A qualitative descriptive study design was used in this study to understand professional health managers’ perceived barriers and facilitators to implementing the Guideline in hospitals [ 33 ]. In the previous study, 896 healthcare professionals from mainland China were invited to complete a questionnaire to rate the urgency and difficulty of implementing each of the 21 recommendations in the Guideline, ranking the recommendations according to combined scores, and selecting the top five of them (See Table  1 ).

Setting and sample

The study was conducted collaboratively by the Clinical Pharmacology Group of the Pediatric Society of the Chinese Medical Association and the National Clinical Research Center for Child Health (Children’s Hospital of Chongqing Medical University). Pediatric directors, pharmacy directors, and medical department directors from secondary and tertiary hospitals across the country were recruited voluntarily through the members’ units for online interviews via Tencent Meeting ( https://meeting.tencent.com ).

Reading available studies and performing some initial research helped create an interview framework [ 16 , 17 , 34 , 35 , 36 ]. Before the formal interviews started, a pharmacy director was recruited to participate in the pretest, and the interview plan was modified to consider the pretest results. The formal interviews were performed between June 27 and August 25, 2022, and participants were recruited using the convenience sampling approach. All the professionals with at least one year of management experience in pediatric off-label drug use were included. All experts invited to present were encouraged to participate and were given comprehensive information on the study via WeChat. They were instructed to read the Guideline in detail and ask the guideline developers to explain any questions accordingly [ 7 ]. Detailed interview times and locations were negotiated after signing an electronic informed consent. The sample size for this investigation was determined based on data coding, data saturation, and study feasibility [ 37 ].

Data collection

A semi-structured interview outline was created, with all questions revolving around the CFIR. The conversation will focus on potential contributing elements and obstacles to the Guideline’s implementation (See Supplementary Material 2 ). The CFIR framework and pre-interview were used to determine the validity of a structured interview in this qualitative research.

Data collection and analysis were repeated to discover new insights from early interviews that would guide later interviews and data collection [ 33 ]. We used Tencent Conferences ( https://meeting.tencent.com ) for audio recording and Xunfeitingjian Software ( https://www.iflyrec.com/ ) for transcriptions. Each interview was recorded with a particular interviewer label and then transcribed verbatim. All interviewees had the chance to examine the interview recordings to increase credibility and reliability.

Data analysis

The facilitators and barriers of the Guideline were investigated explicitly in the qualitative content analysis of expert interview data [ 38 ]. Both inductive and deductive methods were used to identify facilitators, barriers, and neutral factors [ 39 ]. A neutral influence has no positive or negative consequences or both positive and negative consequences but is overall neutral [ 40 ]. Meaningful text units, such as sentences, paragraphs, and words, were inductively extracted into coding and then subjected to CFIR framework analysis. These codes were then classified into subcategories and generic categories for further evaluation [ 41 ]. Information extraction and coding in Chinese were carried out independently by two researchers (MM and LX), and any discrepancies were resolved through discussion. The final findings were translated into English and further discussed by the research team to enable researcher triangulation and to reach a consensus on the results [ 42 ].

Role of the funding sources

The funder provided support for expert consultation fees and research publication costs. The study’s design and execution were not influenced by the research funding.

Characteristics of participants

Individual interviews were conducted with 28 healthcare professionals. The interviews ranged from 21 to 56 min. Half of the participants had a bachelor’s degree, and 60.7% were male. Among the participants, pediatric directors, pharmacy directors, and medical department director were ten, nine, and nine, correspondingly. About 40% of participants had more than 20 years of experience, 27 were in senior positions, and one was in an intermediate position. There were 15 from tertiary hospitals and 13 from secondary hospitals, respectively. Twenty of the professionals interviewed were dissatisfied with the current management of off-label drug use in children. Participants came from all across the Chinese mainland (see Table  2 ).

Identified influencing factors

According to the findings of the interviews, there are 57 factors influencing the implementation of the Guideline in China, including 27 facilitators, 29 barriers, and one neutral factor. These contributing factors were spread throughout 29 constructs in the four CFIR domains studied for the guidelines (see Table  3 and Supplementary Material 1 ). The most influential factors were found in the internal setting, and the fewest influences were found in the intervention characteristics, which was 24 and ten, respectively. Following the CFIR framework, including intervention characteristics, external setting, internal setting and individual characteristics, we will present the following descriptions of all influential factors.

Intervention characteristics

In seven of the eight constructs in the CFIR domain of intervention characteristics, three facilitators and seven barriers were identified (see Table  3 and Supplementary Material 1 ). Many experts supported the implementation of the Guideline and praised the quality and strength of the evidence in terms of facilitators. The Guideline’s key relative strengths were the Guideline developed by a pediatric specialty hospital, which was in charge of developing pharmaceuticals for pediatrics, including national interdisciplinary specialists with more impact. It is more advantageous than comparable existing guidelines in China.

The barriers included a lack of practicality, unnecessary clinical practice, a need for context-specific adaptation, poor trialability in non-children’s hospitals, poor feasibility in primary hospitals, some complicated recommendations, and a need for some cost. The participant said, “With or without this guideline, it has little impact on clinical practice; it is just an additional option to consider.” which showed the Guideline is not particularly meaningful. The absence of emergency response capacity, the shortage of pediatricians, and the inability to accurately estimate adverse drug reactions are the key barriers to implementation in primary care facilities. The adaptations to the guidelines that are required to fit the implementing setting include suiting the primary level, renaming off-label drug use to expanded drug use, managing pediatric population subgroups differently (neonates, infants, children, and adolescents), improving process management, and simplifying clinical practice. The management of off-label use of drugs should be implemented for all patients while managing the pediatric population, according to the broad view of non-children’s hospital managers who believe that the pediatric population is too small. Costs that need to be considered include the cost of purchasing, maintaining, and updating the database, the cost of recruiting assessment experts, the cost of legislation, training, and dissemination, as well as the time clinicians must spend managing off-label drugs.

External setting

In the four constructs of the external setting, a total of 12 influencing factors were included, with five facilitating factors, six barrier factors, and one neutral factor (see Table  3 and Supplementary Material 1 ). In terms of facilitating factors, the Guideline can meet children’s treatment needs, pharmaceutical companies participate in and promote clinical trials, the Physicians Law of the People’s Republic of China encourages the management of off-label drug use in children, the occurrence of off-label drug use disputes in children raises concerns in this area, and unique improvement campaigns. Neutral influences include the Guangdong Pharmaceutical Society, the Shandong Pharmaceutical Society, and similar guidelines from other countries.

The barriers included a lack of patient understanding, pharmaceutical industry off-label promotion, too many choices, non-reimbursement by health insurance, risk of legal conflicts, and a lack of administrative or policy promotion. Although clinicians may have some authority, they will still have to deal with the problem and risk of off-label use of drugs because patients frequently lack comprehension of their use. " Well-known professionals collect a variety of evidence and then inform the patient of any potential adverse effects,, the parents will claim, ‘I signed the informed permission, but I do not know the medicine and saw the instructions did not include this use. You are a doctor, and you know whether to use it.' if the accident occurs.” In China, the health insurance reimbursement system has a direct impact on clinicians’ treatment behavior, and “there is a big problem with not being reimbursed for any medications that are used off-label. " In addition, the possibility of legal disputes arising from the off-label use of medications in children worries many doctors. A participant said,” After all, there is no particular legislation, and while the Physician Law specifies that off-label drug use is subject to standards and guidelines, there are still risks in practice. " Furthermore, the lack of administrative or policy impetus for the guideline is an essential barrier, “Regarding the current context of hospital medication use in China, the power of professionals is constantly pushed by the force of administration or policy. “

Internal setting

The 14 structures of the internal setting in CFIR contained the most influencing elements, with 15 facilitators and nine barriers (see Table  3 and Supplementary Material 1 ). The facilitators included graded management, a dedicated person to drive, the addition of prescription review rules, promotion by societies or associations, promotion by medical associations, cultural alignment with the hospital, high urgency, fitting firmly with the hospital’s management, availability of punishments, alignment with hospital management goals, a better learning environment, proper off-label drug coverage by the hospital, a team of off-label drug management, a database, and clinical pharmacists’ support of off-label drug use. Off-label drugs are not reimbursed by Medicare but are covered by some hospitals. " The hospital will pay for reasonable off-label drugs that are approved by the hospital but are not paid for by health insurance.” Furthermore, many hospitals are prepared to implement off-label management in children, and interview experts believe that clinical pharmacist support can help manage the off-label use of drugs. A participant said, “Our clinical pharmacists are our most important resource for explaining off-label drug use. The combination of clinicians and clinical pharmacists coming together to assess the safety and efficacy of the drugs is particularly good.”

The barriers included the low priority of pediatrics in non-children’s hospitals, the unfavorable social environment, the conflict between clinicians and patients, the lack of communication between pharmacists and clinicians, a lack of priority in comparison to other daily work, a lack of personal gain, low-level physician compliance, complex management procedures, a lack of attention from hospital leadership, and a lack of specialized training. According to many experts, managing pediatric off-label drug use does not prioritize daily work since it is only a small component of rational medication management or daily diagnosis and treatment. A participant said, " Off-label drugs for children are just a minor part of clinical treatment. In the arduous clinical work, I must always prioritize the patient, making off-label drugs impossible to focus on”. Additionally, especially in primary hospitals, there is a lack of specialized training in using off-label medications in children.

Individual characteristics

In the four constructs of the individual characteristics, a total of 11 influencing factors were included, with four facilitating factors and seven barrier factors (see Table  3 and Supplementary Material 1 ). The facilitators included an alignment with personal beliefs, physician confidence, a willingness to promote, and a high degree of professional restraint and self-defense of pediatric doctors. The transmission and promotion of guidelines with coworkers, classmates, and some network contacts were mentioned by experts as methods. Furthermore, some interviewers considered pediatricians more self-aware and disciplined than adult physicians.

The barriers included a lack of understanding of the Benefit and Risk Assessment framework, low titles, a lack of passion and innovation on the part of pharmacists, a wide range of technical competence, a few physicians’ poor ethical principles, an ignorance of physicians’ management of off-label use drugs, and a physicians’ empiricism with drug use. Recommendation 4.1’s benefit and risk assessment framework confused many medical professionals. They offered some solutions, such as “I hope to use it as a quantitative adjustment of a scale,” “make it a scoring system,” “make its voice recognizable,” or “make it as intelligent standard operating procedures.” The more considerable barriers are physicians’ empirical use of drugs and a lack of awareness about off-label drug management. “Clinically, there isn’t a clear line between right and wrong, and I think that after the recommendations are put into place, there will be a lot of resistance to changing doctors’ habits if they need to.”

Role differences

Conflicting views exist among experts on the interaction between clinical pharmacists and physicians. A pharmacist said, “The most challenging component of communicating with clinicians is clinical department chiefs, in particular. Some medical professionals will collect books, manuals, guidelines, and other information to prove their point to you. We must explain that any use not listed in the drug manual is considered off-label, but it may not be irrational. Additionally, you must carefully and exhaustively offer evidence when introducing each form of an off-label drug one at a time. With the medical department, communication is still quite simple.” In contrast, doctors contended that “prescriptions are frequently evaluated by the hospital’s pharmacy department, for example, in the case of incorrect dosage. Then a deduction is required, and much work and time must be spent on fighting and appealing each time.” Clinicians expect pharmacists to devote their time and energy as the driving force behind the off-label use of drugs for children, even though the varied feedback from the roles for communication may be related to the various goals of the different roles for managing off-label drugs for children. A participant said, “Pharmacy is expected by medical departments to offer a catalog or to advance scientific management, but their primary goal is self-preservation and minimizing dangers to clinicians during treatment. Clinicians are also extremely hopeful that pharmacies will become more clinically friendly through constant appeal and standardization, some actions to support the development of a reliable system, and a social environment. However, clinicians might not invest much time or effort in this area.”

Conflicting influential factors

Some interview experts viewed clinical pharmacists as facilitators, but some believed that they made managing children’s off-label drug use more difficult. “It is appropriate for clinical pharmacists to direct the clinical use of medications because they are more knowledgeable about drug toxicology and adverse effects. But the current situation of over-centralization of clinical pharmacist rights and restriction of clinical use of medications to clinicians, as well as the lack of personal competence of clinical pharmacists, may hinder the rational clinical use of medications, including off-label use in children,” one medical director stated.

Many experts regarded the Law on Doctors of the People's Republic of China as a facilitating factor, but some experts still think there are legal concerns involved in putting the Guidelines into practice. An expert said, “The Physicians’ Law contains 67 items, including four on the use of off-label drugs, which is considerable progress for the management of off-label use of drugs. However, there is no targeted legislation. Clinicians are at higher risk of experiencing adverse side effects from using off-label drugs.” The experts regard the guidelines’ implementation as urgent but not a priority. An interviewer said, “As a result of our current inadequate drug supply and the urgent demand for pediatric medications, experts stressed the urgent necessity to address the issue of off-label prescriptions for children.” However, according to experts, it is not given the highest priority for implementation, primarily due to the busy and complex clinical work and the concern about off-label use of drugs making up a tiny portion of daily work. Additionally, managing children’s off-label drug use is also not a standard component of hospital assessments, and medical staff typically puts the hospital’s assessment requirement first.

According to our knowledge, this is the first study conducted by Chinese guideline developers to tailor the implementation strategy of the guidelines. Key stakeholders in the implementation of the Guideline for the management of pediatric off-label use of drugs in China (2021) were interviewed to identify 57 influencing factors, including 27 facilitators, 29 barriers, and one neutral factor, based on the implementation science CFIR framework and using one-on-one expert in-depth interviews. Based on mapping the critical barriers to the CFIR-ERIC [ 26 , 32 ], recommendations for implementation strategies were made, such as tailoring strategies, encouraging adaptability, inquiring of national health administrations to promote recommendations, and establishing networks for communication between clinicians and pharmacists. The study revealed the complexity of the factors influencing managing children’s off-label medication use. We will update the Guideline to address the lack of patient awareness, and a lack of policy incentives (non-reimbursement by health insurance and a lack of administrative or policy promotion) were the key obstacles in external settings. The communication barriers between pharmacists and physicians were found to be the most critical internal barriers. Regarding individual characteristics, the main barriers were pharmacists’ varying technical competence and physicians’ empiricism with medication use. Additionally, this study discovered that even though the PRC Physicians Law’s enforcement helped implement and promote the Guideline, it still needs to relieve the issue of legal dangers for medical staff completely. The difference in the barriers to implementing the Guideline for different roles of medical staff is the communication barrier between pharmacists and physicians.

According to this qualitative study, the Guideline was viewed as having less applicability for primary hospitals by many experts. The findings were consistent with a 2017 study on managing children’s off-label drug use, which also found a significant difference between the management of children’s off-label drug use in secondary and tertiary hospitals [ 17 ]. In China, each hospital grade has a unique set of medical duties, and the higher the grade, the greater the capacity for treatment [ 43 , 44 ]. As map CFIR-ERIC suggests, we should tailor strategies [ 26 , 32 ]. It is advised that guideline developers should take into account the creation of implementation strategies for various hospital grades [ 14 ]. Additionally, many experts feel that the Benefit and Risk Assessment Framework in recommendation 4.1 is difficult to comprehend and would like to quantify and improve the framework’s operability to help physicians make speedy and accurate decision-making. Intelligent assisted decision-making technologies have been created globally and deployed in clinical practice [ 45 , 46 , 47 ]. Artificial intelligence-based and scientifically sound assisted decision-making systems for children’s off-label drug use to have some shortcomings [ 45 ]. As map CFIR-ERIC suggests, we should promote adaptability and suggest researchers should develop a more practical framework for monitoring the use of off-label drugs in children or a scientifically validated off-label medication-assisted decision-making system to make it easy to follow [ 26 , 32 ].

As our findings show, in China, the lack of policy incentives and Medicare not covering off-label medicine costs are severe barriers to managing off-label drug use in children [ 48 , 49 ], Belgium [ 50 ], the Czech Republic [ 51 ], Germany [ 52 ], Italy [ 53 ], Switzerland [ 53 ], the United States [ 54 , 55 ], Slovakia [ 55 ], Greece [ 5 ], and Poland [ 56 ], were currently capable of paying for certain off-label drugs by general health insurance. As a result, it is proposed that China’s health insurance department consider establishing a national essential specified reimbursement catalog for off-label drugs based on the relevant experience of the countries mentioned above. Also, we find that a lack of administrative & policy promotion is a barrier. Policies are the most influential drivers of medical practice improvement in China. For example, the Chinese Special Rectification Activity on Clinical Antibiotic Use (CSRA), launched in 2011, has been implemented by hospitals and promoted by policy. Numerous studies have demonstrated its rapid and long-term implementation effect [ 57 , 58 , 59 ]. Alter incentive/allowance structures, involve executive boards, and build a coalition were mapped by CFIR-ERIC [ 26 , 32 ]; consequently, the national health administration is called upon to promote implementing off-label drug use management in children.

Although the Law on Doctors of the People's Republic of China was a reasonable basis for off-label use, physicians and hospitals face potential legal risks in practice, according to our research, which may be because of its implementation challenges [ 59 ]. According to Chinese Physicians Law, “in special cases where effective therapies are not yet available, a physician may, after obtaining the patient’s explicit informed consent, use a drug that is not stated in the drug’s instructions but has evidence to support its use,” which indicates that there are two conditions for using drugs off-label. First, obtain the patient’s informed consent. Second, there is evidence supported. Clinical challenges exist in obtaining informed permission from parents of children, primarily because of their lack of comprehension of the concept of off-label use of drugs [ 19 , 60 ] and an increased risk of adverse reaction [ 60 ], which is further worsened by the crisis in doctor-patient trust crisis [ 61 ]. Additionally, the current inaccessibility of evidence, mainly because of the shortage of locally evidence-based data for pediatrics [ 62 , 63 ], the shortage of evidence-based specialists [ 64 ], and the ignorance of “evidence-based medicine” and its critical databases among doctors both domestically and internationally [ 65 ]. As a result, the following two suggestions are recommended: On the one hand, information sharing and disease-specific education [ 66 ] can help doctors and patients communicate more effectively. The Guideline’s developers should create patient and public versions of the Guidelines [ 67 , 68 ] to “translate” the rationale and recommendations into a format that patients and the general public can understand and use, as well as to assist parents of children in understanding the meaning and necessity of off-label drugs in a friendly manner. Parents will have a better grasp of why off-label drug use is necessary. On the other hand, the authors of the recommendations should invite evidence-based specialists to regularly update the “list of common types of pediatric off-label use of drugs, evidence levels, and recommendations” in Recommendation 1.2, making it easy for clinicians to access the evidence-based information regarding the use of drugs off-label in children.

Clinical pharmacists actively contribute to managing off-label drugs in children, as the experts indicated in their interviews [ 69 , 70 , 71 , 72 ]. However, the study identified communication barriers between pharmacists and physicians, which is consistent with the findings [ 73 ]. On the one hand, the idea of the doctor as a leader is ingrained in the medical profession. The power gap between doctors and pharmacists makes doctors seem unapproachable to pharmacists [ 74 , 75 ]. On the other, most clinical pharmacists in China originally trained as ordinary pharmacists and went on to finish a year of continuing clinical pharmacy education [ 76 , 77 ]. A need for more clarity of duty and role conflict among clinical pharmacists is frequently the result of shorter training programs and quick duty transitions [ 76 ]. The wide range mainly demonstrates this in clinical pharmacist competence [ 78 ], which has caused physicians to need more faith in their expertise [ 73 ]. In order to improve the communication effectiveness of pediatric off-label use of drug management, it is suggested to investigate appropriate communication strategies and establish networks for communication between doctors and pharmacists according to the CFIR-ERIC map [ 26 , 32 ]. For instance, physician-pharmacist-patient communication has become more effective and satisfying thanks to the situation-background-assessment-recommendation (SBAR) standardized communication model [ 79 , 80 ].

To our knowledge, this study significantly reduces the implementation gap in managing children’s off-label drug use. We systematically identified and analyzed the “Guideline for the Management of Pediatric Off-Label Use of Drugs in China” implementation challenges using the CFIR framework and gave suggestions for implementing the Guideline. In this study, we investigated the perspectives of healthcare professionals in various hospital roles on the management of children’s off-label drug use. We provided a reference for the standardized management of children’s off-label use of drugs.

Limitations

The study also has some limitations. Firstly, only the key stakeholders in the Guideline—the head of pediatrics, the head of the pharmacy, and the medical department director were included in the study, whichmeans that not all influencing factors were identified. Still, since all participants have rich experience in the field and experience managing off-label drug use in children, we believe they are more representative. Second, quotations with codes were translated into English from the expert interviews and data analysis done in Chinese. Although no researchers of the international collaborative team had read the original transcripts, a consensus was reached through an iterative process and triangulation to ensure the objectivity of the data collection and analysis.

Implications for further research and clinical practice

Planning the implementation of guidelines, including a good fit between implementation strategies, relevant interventions, and contexts, is more complicated and demanding [ 81 ]. The findings of this study indicate that future complex interventions for the Guideline will be necessary because of several influencing factors. It is advised that future intervention studies be designed using the new framework for complex interventions, which includes intervention development or identification, feasibility, assessment, and implementation [ 82 ]. Partnership, target population-centered, evidence, and theory-based, implementation-based, efficiency-based, stepped or phased, intervention-specific, and combination are currently recommended intervention development and design methodologies [ 83 ]. Combining the Chinese implementation settings will be possible concerning numerous implementation strategies, such as workflow and regulation optimization, assessment tool development, resource input, or multidisciplinary collaboration [ 84 ]. Consequently, complex interventions may be established to encourage the implementation of guidelines at various levels of the hospital setting. In addition, appropriate process evaluation methods should be adopted to comprehend and better understand the causal mechanisms and contextual factors associated with outcome change [ 85 , 86 ].

Despite being a global public health concern, there is a research gap in analyzing implementation strategies for managing off-label drug use in children. In the future, the Guideline will be updated based on facilitators and barriers, and interventions will be created in various settings to advance guidelines’ implementation by guideline developers. Additionally, the findings in this study are regarded as a baseline for comparison with the barriers and facilitators evaluated during and after implementing an intervention to improve the use of off-label drug management strategies.

Data availability

To preserve the anonymity of interviewees, the transcribed interviews are not available for sharing. The remaining data generated or analysed during this study are included in this published article and its supplementary information file.

Frattarelli DA, Galinkin JL, Green TP, Johnson TD, Neville KA, Paul IM, Van Den Anker JN. Off-label use of drugs in children. Pediatrics. 2014;133(3):563–7.

Article   PubMed   Google Scholar  

Allen HC, Garbe MC, Lees J, Aziz N, Chaaban H, Miller JL, Johnson P, DeLeon S. Off-label medication use in children, more common than we think: a systematic review of the literature. J Okla State Med Assoc. 2018;111(8):776–83.

PubMed   PubMed Central   Google Scholar  

Balan S, Hassali MAA, Mak VSL. Two decades of off-label prescribing in children: a literature review. World J Pediatrics: WJP. 2018;14(6):528–40.

Li Y, Jia L, Teng L. A systematic review of off-label drug use at home and abroad for pediatrics. Chin J Hosp Pharm. 2016;36(23):2114–9.

CAS   Google Scholar  

Schrier L, Hadjipanayis A, Stiris T, Ross-Russell RI, Valiulis A, Turner MA, Zhao W, De Cock P, de Wildt SN, Allegaert K, et al. Off-label use of medicines in neonates, infants, children, and adolescents: a joint policy statement by the European Academy of Paediatrics and the European society for Developmental Perinatal and Pediatric Pharmacology. Eur J Pediatrics. 2020;179(5):839–47.

Article   Google Scholar  

Cui J, Zhao L, Liu X, Liu M, Zhong L. Analysis of the potential inappropriate use of medications in pediatric outpatients in China. BMC Health Serv Res. 2021;21(1):1273.

Article   PubMed   PubMed Central   Google Scholar  

Meng M, Liu E, Zhang B, Lu Q, Zhang X, Ge B, Wu Y, Wang L, Wang M, Luo Z et al. Guideline for the management of pediatric off-label use of drugs in China (2021). BMC Pediatr. 2022;22(1):442.

Rabin BA, Brownson RC, Haire-Joshu D, Kreuter MW, Weaver NL. A glossary for dissemination and implementation research in health. J Public Health Manag Pract. 2008;14(2):117–23.

Liu M, Zhang C, Zha Q, Yang W, Yuwen Y, Zhong L, Bian Z, Han X, Lu A. A national survey of Chinese medicine doctors and clinical practice guidelines in China. BMC Complement Altern Med. 2017;17(1):451.

Correa VC, Lugo-Agudelo LH, Aguirre-Acevedo DC, Contreras JAP, Borrero AMP, Patiño-Lugo DF, Valencia DAC. Individual, health system, and contextual barriers and facilitators for the implementation of clinical practice guidelines: a systematic metareview. Health Res Policy Syst. 2020;18(1):74.

Houghton C, Meskell P, Delaney H, Smalle M, Glenton C, Booth A, Chan XHS, Devane D, Biesty LM. Barriers and facilitators to healthcare workers’ adherence with infection prevention and control (IPC) guidelines for respiratory infectious diseases: a rapid qualitative evidence synthesis. Cochrane Database Syst Rev. 2020;4(4):CD013582.

PubMed   Google Scholar  

McArthur C, Bai Y, Hewston P, Giangregorio L, Straus S, Papaioannou A. Barriers and facilitators to implementing evidence-based guidelines in long-term care: a qualitative evidence synthesis. Implement Sci. 2021;16(1):70.

Fischer F, Lange K, Klose K, Greiner W, Kraemer A. Barriers and strategies in Guideline Implementation-A scoping review. Healthc (Basel Switzerland). 2016;4(3):36.

Baker R, Camosso-Stefinovic J, Gillies C, Shaw EJ, Cheater F, Flottorp S, Robertson N, Wensing M, Fiander M, Eccles MP et al. Tailored interventions to address determinants of practice. Cochrane Database Syst Rev. 2015;2015(4):CD005470.

Rusz C-M, Ősz B-E, Jîtcă G, Miklos A, Bătrînu M-G, Imre S. Off-Label Medication: From a Simple Concept to Complex Practical Aspects. Int J Environ Res Public Health. 2021;18(19).

Mei M, Wang L, Liu E, Li Z, Guo Z, Zhang X, Xu H. Current practice, management and awareness of pediatric off-label drug use in China-A questionnaire based cross-sectional survey. Chin J Evid Based Pediatr. 2017;12(04):289–94.

Google Scholar  

Mei M, Xu H, Wang L, Huang G, Gui Y, Zhang X. Current practice and awareness of pediatric off-label drug use in Shanghai, China -a questionnaire-based study. BMC Pediatr. 2019;19(1):281.

Zhang L, Li Y, Liu Y, Zeng L, Hu D, Huang L, Chen M, Lv J, Yang C. Pediatric off-label drug use in China: risk factors and management strategies. J Evid Based Med. 2013;6(1):4-18..

Balan S, Hassali MA, Mak VSL. Awareness, knowledge and views of off-label prescribing in children: a systematic review. Br J Clin Pharmacol. 2015;80(6):1269–80.

Article   CAS   PubMed   PubMed Central   Google Scholar  

Balan S, Ahmad Hassali MA, Mak VSL. Attitudes, knowledge and views on off-label prescribing in children among healthcare professionals in Malaysia. Int J Clin Pharm. 2019;41(4):1074–84.

AbuAlsaud Z, Alshayban D, Joseph R, Pottoo FH. Off-label medications use in the Eastern Province of Saudi Arabia: the views of General practitioners, pediatricians, and other specialists. Hosp Pharm. 2020;55(1):37–43.

Pérez RP, Antorán M, Solá CA, Riechmann ER, Pea MJM. [Results from the 2012–2013 paediatric national survey on off-label drug use in children in Spain (OL-PED study)]. Anales De Pediatría. 2014;81(1):16-21.

Wittich CM, Burkle CM, Lanier WL. Ten common questions (and their answers) about off-label drug use. Mayo Clin Proc. 2012;87(10):982–90.

Joret-Descout P, Bataille J, Brion F, Bourdon O, Hartmann JF, Prot-Labarthe S. [Attitudes and experiences of off-label prescribing among paediatricians in a French university teaching hospital]. Ann Pharm Fr. 2016;74(3):222–31.

Article   CAS   PubMed   Google Scholar  

Flodgren G, Hall AM, Goulding L, Eccles MP, Grimshaw JM, Leng GC, Shepperd S. Tools developed and disseminated by guideline producers to promote the uptake of their guidelines. Cochrane Database Syst Rev. 2016;2016(8):CD010669.

Waltz TJ, Powell BJ, Fernández ME, Abadie B, Damschroder LJ. Choosing implementation strategies to address contextual barriers: diversity in recommendations and future directions. Implement Sci. 2019;14(1):42.

Breimaier HE, Halfens RJ, Lohrmann C. Effectiveness of multifaceted and tailored strategies to implement a fall-prevention guideline into acute care nursing practice: a before-and-after, mixed-method study using a participatory action research approach. BMC Nurs. 2015;14:18.

McManus K, Cheetham A, Riney L, Brailsford J, Fishe JN. Implementing oral systemic corticosteroids for Pediatric Asthma into EMS Treatment guidelines: a qualitative study. Prehosp Emerg Care. 2023;27(7):886-892.

VanDevanter N, Kumar P, Nguyen N, Nguyen L, Nguyen T, Stillman F, Weiner B, Shelley D. Application of the Consolidated Framework for Implementation Research to assess factors that may influence implementation of tobacco use treatment guidelines in the Viet Nam public health care delivery system. Implement Sci. 2017;12(1):27.

Breimaier HE, Heckemann B, Halfens RJ, Lohrmann C. The Consolidated Framework for Implementation Research (CFIR): a useful theoretical framework for guiding and evaluating a guideline implementation process in a hospital-based nursing practice. BMC Nurs. 2015;14:43.

Hu J, Ruan H, Li Q, Gifford W, Zhou Y, Yu L, Harrison D. Barriers and facilitators to Effective Procedural Pain treatments for Pediatric patients in the Chinese context: a qualitative descriptive study. J Pediatr Nurs. 2020;54:78–85.

Powell BJ, Waltz TJ, Chinman MJ, Damschroder LJ, Smith JL, Matthieu MM, Proctor EK, Kirchner JE. A refined compilation of implementation strategies: results from the Expert recommendations for Implementing Change (ERIC) project. Implement Sci. 2015;10:21.

Moser A, Korstjens I. Series: practical guidance to qualitative research. Part 3: Sampling, data collection and analysis. Eur J Gen Pract.2018;24(1):9-18..

Stewart D, Rouf A, Snaith A, Elliott K, Helms PJ, McLay JS. Attitudes and experiences of community pharmacists towards paediatric off-label prescribing: a prospective survey. Br J Clin Pharmacol. 2007;64(1):90–5.

Mukattash T, Hawwa AF, Trew K, McElnay JC. Healthcare professional experiences and attitudes on unlicensed/off-label paediatric prescribing and paediatric clinical trials. Eur J Clin Pharmacol. 2011;67(5):449–61.

Zhang Qiuwen P, Dong H, Jiale, et al.:.Interpretation of the components of the Comprehensive Framework for Implementation Research (CFIR). Chin J Evidence-Based Med. 2021;21(03):355–60.

Hennink MM, Kaiser BN, Marconi VC. Code saturation versus meaning saturation: how many interviews are Enough? Qual Health Res. 2017;27(4):591–608.

Goodman LA. Snowball Sampling. Annals Math Stat. 1961;32(1):148–70.

Sacks D, Baxter B, Campbell BCV, Carpenter JS, Cognard C, Dippel D, Eesa M, Fischer U, Hausegger K, Hirsch JA, et al. Multisociety Consensus Quality Improvement revised Consensus Statement for Endovascular Therapy of Acute ischemic stroke. Int J Stroke. 2018;13(6):612–32.

Damschroder LJ, Lowery JC. Evaluation of a large-scale weight management program using the consolidated framework for implementation research (CFIR). Implement Sci. 2013;8(1):51.

Keith RE, Crosson JC, O’Malley AS, Cromp D, Taylor EF. Using the Consolidated Framework for Implementation Research (CFIR) to produce actionable findings: a rapid-cycle evaluation approach to improving implementation. Implement Sci. 2017;12(1):15.

Vermeulen J, Beeckman K, Turcksin R, Van Winkel L, Gucciardo L, Laubach M, Peersman W, Swinnen E. The experiences of last-year student midwives with high-fidelity Perinatal Simulation training: a qualitative descriptive study. Women Birth. 2017;30(3):253–61.

Ji S, Wang W, Zhang P, Zeng C, Li L, Yu F, Zhou X. Research on the rationality of hospital human resources allocation under the background of graded diagnosis and treatment. Chin J Evidence-Based Med. 2020;20(9):1004–11.

Wu C, Xie G. Differences in perceived professionalism of medical workers in different levels of hospitals and insights. Med Manage;2018;36):184–6.

Sharma M, Savage C, Nair M, Larsson I, Svedberg P, Nygren JM. Artificial Intelligence Applications in Health Care Practice: scoping review. J Med Internet Res. 2022;24(10):e40238.

Liao P, Hsu P, Chu W, Chu W. Applying artificial intelligence technology to support decision-making in nursing: a case study in Taiwan. Health Inf J. 2015;21(2):137–48.

Wu J, Gou F, Tan Y. A Staging Auxiliary Diagnosis Model for Nonsmall Cell Lung Cancer Based on the Intelligent Medical System. Comput Math Methods Med.2021;2021:6654946.

Zuo W, Sun Y, Liu R, Du L, Yang N, Sun W, Wang P, Tang X, Liu Y, Ma Y, et al. Management guideline for the off-label use of medicine in China. Expert Rev Clin Pharmacol. 2021;2022:1–16.

Liu R, Niu Z, Zuo W, Hu Y, Zhang B. Atitude and medical insurance coverage for of label use in various countries. Chin Hosptial Manage. 2021;37(10):838–41.

Dooms M, Cassiman D, Simoens S. Off-label use of orphan medicinal products: a Belgian qualitative study. Orphanet J Rare Dis. 2016;11(1):144.

Vostalová L, Mazelová J, Samek J, Vocelka M. Health Technology Assessment in Evaluation of Pharmaceuticals in the Czech Republic. Int J Technol Assess Health Care. 2017;33(3):339–44.

Seidenschnur KEK, Dressler C, Weller K, Nast A, Werner RN. Off-label prescriptions and decisions on reimbursement requests in Germany - a retrospective analysis. J Dtsch Dermatol Ges. 2017;15(11):1103–9.

Pauwels K, Huys I, Casteels M, De Nys K, Simoens S. Market access of cancer drugs in European countries: improving resource allocation. Target Oncol. 2014;9(2):95-110..

Teagarden JR, Dreitlein WB, Kourlas H, Nichols L. Influence of pharmacy benefit practices on off-label dispensing of drugs in the United States. Clin Pharmacol Ther. 2012;91(5):943–5.

Löblová O, Csanádi M, Ozierański P, Kaló Z, King L, McKee M. Patterns of alternative access: unpacking the Slovak extraordinary drug reimbursement regime 2012–2016. Health Policy. 2019;123(8):713–20.

Badora K, Caban A, Rémuzat C, Dussart C, Toumi M. Proposed changes to the reimbursement of pharmaceuticals and medical devices in Poland and their impact on market access and the pharmaceutical industry. J Mark Access Health Policy. 2017;5(1):1381544.

Wu X, Chen Y, Xu J. Effect of special rectification of antibiotics. Chin J Nosocomiology. 2014;24(22):5540–2.

Huang J, Wang D, Li J. Effect of special rectification on use intensity of before and after strict policy on use intensity of antimicrobial. Chin J Nosocomiology. 2014;24(1):99–101.

Qian X, Pan Y, Su D, Gong J, Xu S, Lin Y, Li X. Trends of Antibiotic Use and Expenditure after an intensified antimicrobial stewardship policy at a 2,200-Bed Teaching Hospital in China. Front Public Health. 2021;9:729778.

Guidi B, Parziale A, Nocco L, Maiese A, La Russa R, Di Paolo M, Turillazzi E. Regulating pediatric off-label uses of medicines in the EU and USA: challenges and potential solutions: comparative regulation framework of off label prescriptions in pediatrics: a review. Int J Clin Pharm. 2022;44(1):264–9.

Zhou M, Zhao L, Campy KS, Wang S. Changing of China׳s health policy and doctor–patient relationship: 1949–2016. Health Policy Technol. 2017;6(3):358–67.

Li J, Yan K, Kong Y, Ye X, Ge M, Zhang C. A cross-sectional study of children clinical trials registration in the world based on ClinicalTrials.gov establishment. Chin J Evidence-Based Pediatr. 2016;11(1):3–7.

Jiang J, Shen J, Li C, Qi L, Ni S. Development of pediatric clinical trials at home and abroad. J Clin Pediatr. 2020;39(8):636–40.

Li B, Yan Y, Lv M, Zhao G, Li Z, Feng S, Hu J, Zhang Y, Yu X, Zhang J, et al. Clinical epidemiology in China series. Paper 1: evidence-based medicine in China: an oral history study. J Clin Epidemiol. 2021;140:165–71.

Barzkar F, Baradaran HR, Koohpayehzadeh J. Knowledge, attitudes and practice of physicians toward evidence-based medicine: a systematic review. J Evid Based Med. 2018;11(4):246–51.

Georgopoulou S, Prothero L, D’Cruz DP. Physician-patient communication in rheumatology: a systematic review. Rheumatol Int. 2018;38(5):763–75.

Wang X, Chen Y, Akl EA, Tokalić R, Marušić A, Qaseem A, Falck-Ytter Y, Lee MS, Siedler M, Barber SL, et al. The reporting checklist for public versions of guidelines: RIGHT-PVG. Implement Sci. 2021;16(1):10.

About the G-I-N. PUBLIC Toolkit: patient and public involvement in guidelines [ https://g-i-n.net/toolkit ].

Zheng Z, Zeng Y, Huang H. Pharmacists’ role in off-label drug use in China. Eur J Hosp Pharm. 2018;25(2):116.

Deng T, Lin M, Zhang S, Yang X. Thinking and practice of clinical pharmacists participating in the treatment of Infectious diseases. Chin J Pharmacoepidemiology. 2022;31(3):178–83.

Li W, Zheng L, Luo X. Clinical pharmacist interventions in obstetrics and gynecology: off-label use of drugs. Herald Med. 2021;40(10):1435–8.

Li Y, Cai J, Jia M, Jia W, Liu J. Analysis of off-label use of anti-tumor drugs and clinical pharmaceutical intervention in a third-grade hospital in Xinjiang. Chin J Clin Ration Drug Use. 2019;14(9):1–4.

Cai F, Zhang J. Investigation and analysis of how to promote the clinical reasonable medication from doctors, clinical pharmacists and patients. China Med Pharm. 2015;5(4):122–46.

Thomas J, Kumar K, Chur-Hansen A. How pharmacy and medicine students experience the power differential between professions: even if the pharmacist knows better, the doctor’s decision goes. PLoS ONE. 2021;16(8):e0256776.

Baker L, Egan-Lee E, Martimianakis MAT, Reeves S. Relationships of power: implications for interprofessional education. J Interprof Care. 2011;25(2):98-104..

Li W, Lin G, Xu A, Huang Y, Xi X. Role ambiguity and role conflict and their influence on responsibility of clinical pharmacists in China. Int J Clin Pharm. 2020;42(3):879–86.

Zhao J, Zhou Y, Ma L, Sheng X, Cui Y. Current situation and enlightenment of clinical pharmacists training in Peking University First Hospital. Clin Medication J. 2017;15(3):86–8.

Tu D, Zhao L, Wang L, Huang Z. Thinking on improving pharmacists’clinical Pharmaceu⁃ Tical Care under the Transformation of pharmacists. Sci Educ Article Collects 2021(7):116–8.

Zhang J, Wang Y, Shi X, Bao Q, Shen G. Clinical practice for PIVAS pharmacists based upon SBAR communication model. Chin J Hosp Pharm. 2021;41(3):309–13.

Lo L, Rotteau L, Shojania K. Can SBAR be implemented with high fidelity and does it improve communication between healthcare workers? A systematic review. BMJ Open. 2021;11(12):e055247.

Schultes M-T, Albers B, Caci L, Nyantakyi E, Clack L. A modified implementation mapping methodology for evaluating and learning from existing implementation. Front Public Health. 2022;10:836552.

Rutter H, Savona N, Glonti K, Bibby J, Cummins S, Finegood DT, Greaves F, Harper L, Hawe P, Moore L, et al. The need for a complex systems model of evidence for public health. Lancet. 2017;390(10112):2602–4.

O’Cathain A, Croot L, Sworn K, Duncan E, Rousseau N, Turner K, Yardley L, Hoddinott P. Taxonomy of approaches to developing interventions to improve health: a systematic methods overview. Pilot Feasibility Stud. 2019;5:41.

Zhao J, Bai W, Zhang Q, Su Y, Wang J, Du X, Zhou Y, Kong C, Qing Y, Gong S, et al. Evidence-based practice implementation in healthcare in China: a living scoping review. Lancet Reg Health West Pac. 2022;20:100355.

Quasdorf T, Clack L, Laporte Uribe F, Holle D, Berwig M, Purwins D, Schultes M-T, Roes M. Theoretical approaches to process evaluations of complex interventions in health care: a systematic scoping review protocol. Syst Rev. 2021;10(1):268.

Brown CH, Curran G, Palinkas LA, Aarons GA, Wells KB, Jones L, Collins LM, Duan N, Mittman BS, Wallace A et al. An overview of research and evaluation designs for dissemination and implementation. Annu Rev Public Health. 2017;38:1-22.

Download references

Acknowledgements

Thanks to Professor Fei Yin of Xiangya Hospital Central South University for his help in recruiting experts for the interviews.

This research was funded by the Chevidence Lab Child & Adolescent Health of Chongqing Medical University’s Children’s Hospital’s Key Project in 2022 (LY03007).

Author information

Min Meng and Jiale Hu contribute equally.

Authors and Affiliations

Chevidence Lab of Child & Adolescent Health, Children’s Hospital of Chongqing Medical University, Chongqing, China

Min Meng & Yaolong Chen

National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, International Science and Technology Cooperation Base of Child Development and Critical Disorders, Children’s Hospital of Chongqing Medical University, Chongqing, China

Min Meng, Enmei Liu, Qiu Li & Yaolong Chen

Chongqing Key Laboratory of Pediatrics, Chongqing, China

Department of Pharmacy, Gansu Provincial Hospital, Lanzhou, China

Min Meng, Min Tian & Wenjuan Lei

Department of Nurse Anesthesia, Virginia Commonwealth University, Richmond, USA

School of Public Health, Lanzhou University, Lanzhou, China

College of Pharmacy, Gansu University of Chinese Medicine, Lanzhou, China

Department of Nephrology, Children’s Hospital of Chongqing Medical University, Chongqing, China

Research Unit of Evidence-Based Evaluation and Guidelines, Chinese Academy of Medical Sciences(2021RU017), School of Basic Medical Sciences, Lanzhou University, Lanzhou, China

Yaolong Chen

 WHO Collaborating Centre for Guideline Implementation and Knowledge Translation, Lanzhou, China

Lanzhou University GRADE Center, Lanzhou, China

You can also search for this author in PubMed   Google Scholar

Contributions

MM and JH are joint first authors. YC and QL designed the study. MM organized all expert interviews with the help of JH and requested experts to examine the interview recordings. XL and MM extracted information and coded in Chinese.WL and XL analyzed the data. MT and ZH translated interview. MM and JH drafted the manuscript. YC and QL revised the article. All authors have read and approved the final manuscript.

Corresponding authors

Correspondence to Qiu Li or Yaolong Chen .

Ethics declarations

Ethics approval and consent to participate.

This study was approved by the Research Ethics Committees at Gansu Provincial People’s Hospital (approval number: 2022 − 152). All participants signed the informed consent form. All interviews were conducted anonymously, and all transcripts and other records were kept private. Participants were informed that they could start, refuse, or withdraw from the study without negative consequences.The study was performed in accordance with the Declaration of Helsinki.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.

Additional information

Publisher’s note.

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

Electronic supplementary material

Below is the link to the electronic supplementary material.

Supplementary Material 1

Supplementary material 2, rights and permissions.

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/ . The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/ ) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Cite this article.

Meng, M., Hu, J., Liu, X. et al. Barriers and facilitators to guideline for the management of pediatric off-label use of drugs in China: a qualitative descriptive study. BMC Health Serv Res 24 , 435 (2024). https://doi.org/10.1186/s12913-024-10860-0

Download citation

Received : 06 May 2023

Accepted : 12 March 2024

Published : 05 April 2024

DOI : https://doi.org/10.1186/s12913-024-10860-0

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Off-label use
• Qualitative research
• Implementation science

BMC Health Services Research

ISSN: 1472-6963

• General enquiries: [email protected]

ORIGINAL RESEARCH article

Public perception of media social responsibility in developing countries: a case study of albania provisionally accepted.

• 1 Aleksandër Moisiu University, Albania

The final, formatted version of the article will be published soon.

This study delves into public perceptions of media social responsibility within the contemporary Albanian media landscape. Through a comprehensive analysis of various factors, the study identifies the prevailing principles that the public deems crucial for the media's social responsibility and how these principles can enhance the media's contribution to society. A structured questionnaire was used to capture a wide range of public perceptions, with 1,321 questionnaires filled out. These questionnaires were distributed using a face-to-face method across five major urban centers in Albania, ensuring a comprehensive and representative sample of public viewpoints. The distribution method employed a stratified sampling approach to ensure diverse representation across different demographic groups. Additionally, employing a mixed-methods approach, the research includes qualitative interviews with 20 influential stakeholders, including media directors, professors, analysts, and media researchers. Purposive sampling was utilized to select stakeholders representing various sectors of the media landscape. Rigorous measures were taken to mitigate data pollution, including thorough interviewer training and constant monitoring of data quality. An overarching thematic analysis was conducted to identify common themes and patterns across the qualitative interviews, complementing the quantitative findings. To gain further insights, we purposefully selected and conducted a focus group with 28 journalists from various media platforms. The sampling method for the focus group involved purposive sampling to ensure representation from diverse media backgrounds and experiences. Data collected from the focus group underwent thematic analysis to identify common themes and patterns, contributing to an overarching qualitative analysis. The empirical findings reveal that the media's social responsibility in Albania does not fully adhere to the expected standards encompassing all relevant principles. Internal dynamics within media organizations and external forces from politics, economics, and society collectively influence this shortfall. The study highlights the importance of considering public perceptions and expectations in shaping media's social responsibility, emphasizing the need for substantial improvements. In conclusion, this research not only provides practical insights for media practitioners but also offers valuable perspectives for policymakers.

Keywords: media social responsibility, public perception, contemporary media landscape, transparency and accountability, Media ethics

Received: 14 Nov 2023; Accepted: 03 Apr 2024.

Copyright: © 2024 Skana and Gjerazi. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) or licensor are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

* Correspondence: Dr. Blerina Gjerazi, Aleksandër Moisiu University, Durrës, 3001-3006, Albania

People also looked at