Fundamentals of case study research in family medicine and community health

Building Case Investigation and Contact Tracing Programs in US State and Local Health Departments: A Conceptual Framework

OBJECTIVE

At the onset of the COVID-19 pandemic, and to this day, US state, tribal, local, and territorial health departments lacked comprehensive case investigation and contact tracing (CI/CT) guidelines that clearly define the capabilities and capacities of CI/CT programs and how to scale up these programs to respond to outbreaks. This research aims to identify the capabilities and capacities of CI/CT programs and to develop a conceptual framework that represents the relationships between these program components.

METHODS

This study conducted a narrative literature review and qualitative interviews with 10 US state and local health departments and 4 public health experts to identify and characterize the capacities and capabilities of CI/CT programs.

RESULTS

This research resulted in the first comprehensive analysis of the capabilities and capacities of CI/CT programs and a conceptual framework that illustrates the interrelationships between the capacities, capabilities, outcomes, and impacts of CI/CT programs.

CONCLUSIONS

Our findings highlight the need for further guidance to assist jurisdictional health departments in shifting CI/CT program goals as outbreaks evolve. Training the public health workforce on making decisions around CI/CT program implementation during outbreaks is critical to ensure readiness for a variety of outbreak scenarios.

A multiple case study of pre-diabetes care undertaken by general practice in Aotearoa/New Zealand: de-incentivised and de-prioritised work

BACKGROUND

In Aotearoa/New Zealand (NZ) general practices diagnose and manage pre-diabetes. This work is important as it has the potential to delay or prevent the onset of Type 2 Diabetes (T2DM), reduce NZ's health inequities, and the burden that T2DM places on health care services. However, no study has previously examined how this work routinely occurs in NZ.

METHODS

Two case studies of practices serving ethnically and socio-economically diverse populations, followed by cross-case analysis.

RESULTS

The NZ health care context including funding mechanisms, reporting targets, and the disease centred focus of care, acted together to dis-incentivise and de-prioritise pre-diabetes care in general practices. The social determinants of health differentially influenced patients' ability to engage with and respond to pre-diabetes care, significantly impacting this work. Differing perspectives about the significance of pre-diabetes and gaps in systematic screening practices were identified. Interventions used were inconsistent and lacked comprehensive ongoing support.

CONCLUSIONS

Complex multi-layered factors impact on pre-diabetes care, and many of the barriers cannot be addressed at the general practice level. The practice serving the most disadvantaged population who concurrently have higher rates of pre-diabetes/T2DM were more adversely affected by the barriers identified.

COVID-19's impact on care practice for alpha-1-antitrypsin deficiency patients

BACKGROUND

Patients with alpha-1 antitrypsin deficiency (AATD), commonly categorized as a rare disease, have been affected by the changes in healthcare management brought about by COVID-19. This study's aim was to identify the changes that have taken place in AATD patient care as a result of the COVID-19 pandemic in Spain and to propose experts' recommendations aimed at ensuring humanized and quality care for people with AATD in the post-pandemic situation.

METHODS

A qualitative descriptive case study with a holistic single-case design was conducted, using focus groups with experts in AATD clinical management, including 15 health professionals with ties to the Spanish health system (12 pneumologists and 2 hospital pharmacists from 11 different hospitals in Spain) and 1 patient representative.

RESULTS

COVID-19 has had a major impact on numerous aspects of AATD clinical patient management in Spain, including diagnostic, treatment, and follow-up phases. The experts concluded that there is a need to strengthen coordination between Primary Care and Hospital Care and improve the coordination processes across all the organizations and actors involved in the healthcare system. Regarding telemedicine and telecare, experts have concluded that it is necessary to promote this methodology and to develop protocols and training programs. Experts have recommended developing personalized and precision medicine, and patient participation in decision-making, promoting self-care and patient autonomy to optimize their healthcare and improve their quality of life. The possibility of monitoring and treating AATD patients from home has also been proposed by experts. Another result of the study was the recommendation of the need to ensure that plasma donations are made on a regular basis by a sufficient number of healthy individuals.

CONCLUSION

The study advances knowledge by highlighting the challenges faced by health professionals and changes in AATD patient management in the context of the COVID-19 pandemic. It also proposes experts' recommendations aimed at ensuring humanized and quality care for people with AATD in the post-pandemic situation. This work could serve as a reference study for physicians on their daily clinical practice with AATD patients and may also provide guidance on the changes to be put in place for the post-pandemic situation.

How health systems facilitate patient-centered care and care coordination: a case series analysis to identify best practices

Large- and small-scale transformation of healthcare delivery toward improved patient experience through promotion of patient-centered and coordinated care continues to be at the forefront of health system efforts in the United States. As part of a Quality Improvement (QI) project at a large, midwestern health system, a case series of high-performing organizations was explored with the goal of identifying best practices in patient-centered care and/or care coordination (PCC/CC). Identification of best practices was done through rapid realist review of peer-reviewed literature supporting three PCC/CC interventions per case. Mechanisms responsible for successful intervention outcomes and associated institutional-level facilitators were evaluated, and cross-case analysis produced high-level focus items for health system leadership, including (1) institutional values surrounding PCC/CC, (2) optimization of IT infrastructure to enhance performance and communication, (3) pay structures and employment models that enhance accountability, and (4) organizing bodies to support implementation efforts. Health systems may use this review to gain insight into how institutional-level factors may facilitate small-scale PCC/CC behaviors, or to conduct similar assessments in their own QI projects. Based on our analysis, we recommend health systems seeking to improve PCC/CC at any level or scale to evaluate how IT infrastructure affects provider-provider and provider-patient communication, and the extent to which institutional prioritization of PCC/CC is manifest and held accountable in performance feedback, incentivization, and values shared among departments and settings. Ideally, this evaluation work should be performed and/or supported by cross-department organizing bodies specifically devoted to PCC/CC implementation work.

Intergenerational Theater Workshops as Unique Recreational Activities among Older Adults in Japanese Care Facilities: A Qualitatively Driven Mixed-Methods Multiple-Case Study Design

Intergenerational theater activities have been recently employed in recreation for older adults. We held a series of four intergenerational theater workshops in two older adults' care facilities in Japan and sought the experiences of older participants, younger participants, and the facility managers. With a qualitatively driven mixed-methods multiple-case study design, we obtained data from field observation, interviews with participants, and preworkshop and postworkshop changes on a well-being scale (Ikigai-9) among older participants, and the results of the two sites were compared. "Immediate effects" were seen in older adults because they responded actively and demonstrated surprising faculties during the workshop. Facility staff members and younger participants received "extended effects" because they gained new ideas regarding the remaining skills of older participants and a sense of reuniting with old neighbors through the exercise. In the Ikigai-9 scale, the items measuring "present happiness" significantly improved at Site 1 but not at Site 2. Better results at Site 1 might have been caused by the lower care needs of participants and the inclusion of children. Less support from facility staff members during the activities also might have promoted the voluntary participation of older adults. Involving children and engaging the facility staff in preparation could enhance the quality of activities.

Community Health Workers Connecting Communities During COVID-19: A Case Study From Chicago

Coronavirus disease-2019 (COVID-19) has adversely impacted vulnerable communities. Community health workers (CHWs) are an evidence-based solution for helping communities navigate challenges and barriers. This case study describes the work of CHWs in a large Hispanic Chicago neighborhood who experienced a disproportionate number of COVID-19 cases. Methods included semistructured interviews and conventional qualitative content analysis. Results describe the problem; the situation; CHWs' roles, motivations and actions; outcomes; lessons learned; and recommendations. The case study concludes with a discussion of effective CHW engagement-particularly for underresourced communities-and presents recommendations for CHW workforce development and policies to strengthen the health care and public health systems.

Pain management and coping strategies for primary dysmenorrhea: A qualitative study among female nursing students

AIM

Primary dysmenorrhea is a problem that affects both young and adult women, with a significant impact on their daily lives. This pain is primarily managed through the consumption of non-steroidal anti-inflammatories and non-pharmacological approaches such as exercise, acupressure and heat. The present study aimed to describe how Spanish university students manage dysmenorrhea.

DESIGN

Qualitative case study.

METHODS

Nursing students (N = 33) from the region of Andalusia (Spain) participated in focus groups. A purposive sampling method was used, and the data were collected through videoconferencing and subsequently analysed thematically. The guidelines for conducting qualitative studies established by the consolidated criteria for reporting qualitative research (COREQ) and the standards for reporting qualitative research (SRQR) were followed.

RESULTS

Four principal themes were identified: (a) Strategies for pain management; (b) using painkillers; (c) choosing the ideal treatment; (d) non-pharmacological interventions.

CONCLUSIONS

The nursing students experienced difficulties in managing primary dysmenorrhea, they self-medicated, expressed reluctance to seek professional medical advice, used non-pharmacological strategies and seeked advice from other women within their family/social circle.

Evaluating Outcomes of a Social Media-Based Peer and Clinician-Supported Smoking Cessation Program in Preventing Smoking Relapse: Mixed Methods Case Study

BACKGROUND

Smoking relapse prevention after completion of a smoking cessation program is highly germane to reducing smoking rates.

OBJECTIVE

The purpose of this study was to evaluate the 1-year outcomes of a social media-based and peer and clinician-supported smoking cessation program on Facebook and examine communication patterns that could support smoking cessation and identify risk of relapse.

METHODS

We used a mixed methods case study evaluation approach featuring a single-case holistic design. We recruited volunteers who signed up after successful completion of a 12-week clinical smoking cessation program in a general medicine department in Japan. Participants contemporaneously accessed a closed Facebook page, and we analyzed their posts including text and emoticons. We used joint display analysis, which involved iterative structuring and restructuring construct-specific tables with both types of data to find the most effective approach for integrating the quantitative results with the qualitative results of content analysis.

RESULTS

One successful participant and 2 relapsed participants were analyzed to explore the specific patterns of postings prior to relapse. Decisive comments about quitting smoking were common among participants, but encouraging messages for peers were more common from the successful participant. Comments seeking social support and reassurance were warning signs of relapse. Conflicted comments also may be a warning sign of relapse risk.

CONCLUSIONS

These findings based on a mixed methods case study of a social media platform supporting smoking cessation could be used to guide messaging in other online social networking service communities after a smoking cessation program to help reduce smoking relapse.

TRIAL REGISTRATION

UMIN Clinical Trials Registry UMIN000031172; https://upload.umin.ac.jp/cgi-open-bin/ctr/ctr_view.cgi?recptno=R000035595.

Epidemic Prevention During Work Resumption: A Case Study of One Chinese Company's Experience

Background: The COVID-19 epidemic not only brings challenges to the health of people all over the world, but also impacts the global economy, and employment. Therefore, promoting industry and business to resume work safely has become an important step to be taken by all countries in overcoming the economic recession and restarting growth. Objective: This study aims to elaborate on epidemic prevention measures a Chinese company (Company C) took during work resumption. Methods: In this study, we used a case study design, with field research method applied to data collection and analysis. Results: It has been identified that Company C took a range of measures to prevent the outbreak of COVID-19 inside the company, which involve work resumption preparation (information survey, health training, work resumption plan, epidemic prevention plan), facilities management, materials management, employee activity management, and so on. Conclusion: When the COVID-19 epidemic was initially controlled in February, the Chinese government allowed enterprises to resume work voluntarily, which did not bring about a rebound in the epidemic. One important reason is that Chinese enterprises have taken multiple measures to prevent the spread of the COVID-19 virus. Company C's practices could shed some light on how companies in Western countries resume their work during the COVID-19 pandemic.

The Meaning of Physical Activity: A Qualitative Study on the Perspective of South American Immigrant Parents

Physical activity facilitates the acquisition of healthy habits from childhood to adulthood. There are differences in the practice of physical activity between immigrant children and native Spanish children. The aim was to describe physical activity in children, from the perspective of South American immigrant parents. A qualitative case study was conducted. Parents were recruited using purposeful sampling. Data were collected from 12 participants by means of unstructured interviews together with researcher notes. A thematic analysis was applied. The following topics were identified: (a) physical activity and health, (b) socialization, (c) the need for movement, (d) gender, (e) barriers, (f) educational burden, (g) community living, and (h) reason for immigrating. Parents described how physical activity is fundamental and has benefits for health, and for the relationship between children. They perceived that physical activity should not be limited by gender. The time dedicated to other school activities, the norms related to community living, and financial limitations were especially relevant as barriers for the performance of physical activity. These results can be used to revise the curriculum in schools, promote equal opportunities for physical activity and support family participation.

Living with Pain and Looking for a Safe Environment: A Qualitative Study among Nursing Students with Dysmenorrhea

Dysmenorrhea refers to chronic pain associated with menstruation that is often accompanied by other symptoms. Primary dysmenorrhea (PD) occurs without any associated pelvic disease. Nonetheless, it may negatively affect women's quality of life. Among university students, dysmenorrhea decreases academic performance and is a cause of absenteeism. The purposes of our study were to describe how nursing students experienced PD and the changes affecting their body and mood. A qualitative case study was performed among 33 nursing students with PD. Data were collected through five focus groups (with two sessions each) and 10 researchers' field notes. We used a video meeting platform to conduct the focus groups. A thematic analysis was performed, and the Standards for Reporting Qualitative Research and the Consolidated Criteria for Reporting Qualitative Research guidelines were followed. Three main themes emerged from the data: (a) living with dysmenorrhea, with two subthemes: menstruation and pain; (b) body changes and mood swings; and (c) seeking a safe environment, with three subthemes: safe environment, unsafe environment, and key safety aspects. Students considered menstruation to be negative and limiting, causing physical and mood changes, making them feel less attractive, and conditioning their way of dressing and relating.

Fundamentals of qualitative analysis in family medicine

The primary purpose of this article is to provide family physician researchers interested in conducting a qualitative research study a concise guide to the analysis. Drawing from approaches outlined in popular research methodology textbooks and employing an exemplar from a minority health disparities research study, this article outlines specific steps useful for researchers and practitioners in the field of family medicine. This process of qualitative data analysis is situated within the larger framework of qualitative research to better position those new to qualitative designs to more effectively conduct their studies. A 10-step process useful for guiding qualitative data analysis is provided. The 10 steps include (1) assembling data for analysis, (2) refamiliarising oneself with the data, (3) open or initial coding procedures, (4) generating categories and assigning codes to them, (5) generating themes from categories, (6) strategies of validation, (7) interpreting and reporting findings from the participants, (8) interpreting and reporting findings from the literature, (9) visual representations of data and findings, and (10) strengths, limitations, delimitations and suggestions for future research. This work provides clear and accessible guidelines for conducting qualitative data analysis for emerging researchers that is applicable across a wide array of topics, disciplines and settings.

Getting started in primary care research: choosing among six practical research approaches

While many primary care practitioners want to conduct research, many also struggle with getting started. This article’s purpose is to assist emerging researchers in identifying a topic of interest, to try the ‘fit’ of feasible research approaches and commit to a research approach. The article addresses six objectives: (1) identify how important primary care research comes from clinical stories; (2) recognise how clinical stories become the source of research topics; (3) discern how the research process resembles the care of patients; (4) distinguish the essential features of six research approaches feasible for primary care researchers; (5) evaluate the fit of the six research approaches featured in this special issue; and (6) develop a list of steps that need to be taken to implement primary care research projects. Using ‘HPV (human papilloma) vaccination’ as a hypothetical topic, the article illustrates how an emerging researcher can complete the worksheets. Using the HPV topic, a worksheet illustration shows how to complete the worksheets, and examples from the literature illustrate how actual studies have used six feasible research approaches for primary care: (1) survey research, (2) semistructured qualitative interviews, (3) curriculum development, (4) continuous quality improvement, (5) clinical policy analysis and (6) case study research. The worksheet exercises support choosing a feasible research approach for emerging researchers. Emerging researchers using these exercises can identify a topic, choose a research strategy aligned with the researcher’s interest, create a study title, develop a list of the next steps, and be well positioned to implement an original research project

Curriculum development: a how to primer

Curriculum development is a topic everyone in the field of medical education will encounter. Due to the breadth of ages and types of care provided in Family Medicine, family medicine faculty in particular need to be facile in developing effective curricula for medical students, residents, fellows and for faculty development. In the area of medical education, changing and evolving learning environments, as well as changing requirements necessitate new and innovative curricula to address these evolving needs. The process of developing a medical education curriculum can seem daunting but when broken down into smaller components can become very straightforward and easy to accomplish. This paper focuses on the curriculum development process using a six-step approach: performing a needs assessment, determining content, writing goals and objectives, selecting the educational strategies, implementing the curriculum and, finally, evaluating the curriculum. This process may serve as a template for Family Medicine educators, and all medical educators looking to design (or redesign) their own medical education curriculum.