Developing the DESCARTE Model: The Design of Case Study Research in Health Care

Pelvic floor muscle training for female urinary incontinence: development of a programme theory from a longitudinal qualitative case study

BACKGROUND

Urinary incontinence (UI) negatively affects the well-being of women globally. Pelvic Floor Muscle Training (PFMT) is a complex intervention that aims to decrease UI symptoms. Information about how the multiple complex components involved in PFMT achieve and maintain the desired effect are rarely studied as a whole. The evidence base lacks data about how women experience PFMT over time and in the longer-term. This study explored women's experiences of biofeedback-assisted PFMT and PFMT alone, to identify and understand what influenced self-reported adherence to PFMT, and UI outcomes over time.

METHODS

This rigorous longitudinal qualitative case study, nested within a randomised controlled trial, recruited forty cases (women with stress or mixed UI; 20 in biofeedback-assisted and 20 in PFMT alone group). A case included up to four semi-structured interviews with each woman (prior to starting PFMT, end of treatment [6 months], 12 months, 24 months). Analysis followed case study analytic traditions, resulting in a Programme Theory about PFMT from the perspectives of women with UI.

FINDINGS

The theory demonstrates factors that motivated women to seek UI treatment, and how these influenced long-term adherence. Therapists who delivered PFMT played a crucial role in supporting women to know how to undertake PFMT (to have capability). Some, but not all, women developed self-efficacy for PFMT. Where women did not have PFMT self-efficacy, adherence tended to be poor. When women had PFMT self-efficacy, the conditions to support adherence were present, but contextual factors could still intercede to inhibit adherence. The intercession of contextual factors was individual to a woman and her life, meaning any particular contextual factor had inconsistent influences on PFMT adherence over time for individual women and exerted varying influences across different women.

CONCLUSION

Long term adherence to PFMT is a complex interaction between many different factors. Enquiring about an individual woman's motivation to seek treatment and understanding the contextual factors that affect an individual woman will enable a practitioner to support longer-term adherence.

Integrating interventions supported by development assistance for health into local health system: evidence from a China-World Bank-UK rural health system strengthening project (1998-2007)

INTRODUCTION

To empirically investigate sustainability of development assistance for health (DAH), we conducted a retrospective case study on the Basic Health Services Project (BHSP) for rural health system strengthening, supported by the World Bank and the UK in China between 1998 and 2007. Specifically, this study examines the integration of the BHSP interventions into China's health system.

METHODS

From December 2021 to December 2022, we reviewed 64 published papers and project or policy documents, and conducted semistructured interviews with 22 key informants, ranging from managers of donor agencies and the government to township-level hospital directors. From February to March 2023, the data were analysed under an analytical framework for integration of targeted health interventions into health systems.

RESULTS

Evidence of the BHSP shows that the integration outcomes can vary by the levels of integration (national or subnational), geographical coverage (project areas or both project and non-project areas) and approach to integration (policy or routinisation). The country's health system reform facilitated the integration of the interventions relevant to the reform policies, as the BHSP was one of the pilot schemes. However, interventions incompatible with this broad context were integrated to a limited extent. This integration occurred through embedding the project within the existing system, with a higher degree of embeddedness leading to smoother integration. Cross-sectoral leading groups and a technical support system heightened the project visibility and enabled contextualised local adaptation, contributing to the smooth integration of the project interventions.

CONCLUSION

The DAH-supported interventions can achieve sustainability by being integrated into the local health system. This integration can take various forms to improve health outcomes, including being accepted and internalised, modified as well as innovated and expanded. The host country and development partners can promote DAH sustainability by contextually integrating these interventions within the project scope.

How a National Organization Works in Partnership With People Who Have Lived Experience in Mental Health Improvement Programs: Protocol for an Exploratory Case Study

BACKGROUND

This is a research proposal for a case study to explore how a national organization works in partnership with people with lived experience in national mental health improvement programs. Quality improvement is considered a key solution to addressing challenges within health care, and in Scotland, there are significant efforts to use quality improvement as a means of improving health and social care delivery. In 2016, Healthcare Improvement Scotland (HIS) established the improvement hub, whose purpose is to lead national improvement programs that use a range of approaches to support teams and services. Working in partnership with people with lived experience is recognized as a key component of such improvement work. There is, however, little understanding of how this is manifested in practice in national organizations. To address gaps in evidence and strengthen a consistent approach, a greater understanding is required to improve partnership working.

OBJECTIVE

The aim of this study is to better understand how a national organization works in partnership with people who have lived experience with improvement programs in mental health services, exploring people's experiences of partnership working in a national organization. An exploratory case study approach will be used to address the research questions in relation to the Personality Disorder (PD) Improvement Programme: (1) How is partnership working described in the PD Improvement Programme? (2) How is partnership working manifested in practice in the PD Improvement Programme? and (3) What factors influence partnership working in the PD Improvement Programme?

METHODS

An exploratory case study approach will be used in relation to the PD Improvement Programme, led by HIS. This research will explore how partnership working with people with lived experience is described and manifested in practice, outlining factors influencing partnership working. Data will be gathered from various qualitative sources, and analysis will deepen an understanding of partnership working.

RESULTS

This study is part of a clinical doctorate program at the University of Stirling and is unfunded. Data collection was completed in October 2023; analysis is expected to be completed and results will be published in January 2025.

CONCLUSIONS

This study will produce new knowledge on ways of working with people with lived experience and will have practical implications for all improvement-focused interventions. Although the main focus of the study is on national improvement programs, it is anticipated that this study will contribute to the understanding of how all national public service organizations work in partnership with people with lived experience of mental health care.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/51779.

Happiness in Hospice Care in The Netherlands: A Case Study Design

Happiness is central in spirituality but has hardly been explored in palliative care. The objective of this study is to explore happiness in hospice care in the Netherlands. A case study design consisting of participatory observations and semi-structured interviews was used. Happiness was associated with all dimensions of health. Patients spoke about a growing receptivity and a deepening of connections with themselves and others. Hospice staff related their happiness to feeling a true connection and their work supported them in appreciating their own lives in new ways. This study suggests that happiness can be found in settings that are frequently associated with suffering.

Development assistance, donor-recipient dynamic, and domestic policy: a case study of two health interventions supported by World Bank-UK and Global Fund in China

BACKGROUND

This study views sustainability after the exit of development assistance for health (DAH) as a shared responsibility between donors and recipients and sees transitioning DAH-supported interventions into domestic health policy as a pathway to this sustainability. It aims to uncover and understand the reemergent aspects of the donor-recipient dynamic in DAH and how they contribute to formulating domestic health policy and post-DAH sustainability.

METHODS

We conducted a case study on two DAH-supported interventions: medical financial assistance in the Basic Health Services Project supported by the World Bank and UK (1998-2007) and civil society engagement in the HIV/AIDS Rolling Continuation Channel supported by the Global Fund (2010-2013) in China. From December 2021 to December 2022, we analyzed 129 documents and interviewed 46 key informants. Our data collection and coding were guided by a conceptual framework based on Walt and Gilson's health policy analysis model and the World Health Organization's health system building blocks. We used process tracing for analysis.

RESULTS

According to the collected data, our case study identified three reemergent, interrelated aspects of donor-recipient dynamics: different preferences and compromise, partnership dialogues, and responsiveness to the changing context. In the case of medical financial assistance, the dynamic was characterized by long-term commitment to addressing local needs, on-site mutual learning and understanding, and local expertise cultivation and knowledge generation, enabling proactive responses to the changing context. In contrast, the dynamic in the case of HIV/AIDS civil society engagement marginalized genuine civil society engagement, lacked sufficient dialogue, and exhibited a passive response to the context. These differences led to varying outcomes in transnational policy diffusion and sustainability of DAH-supported interventions between the cases.

CONCLUSIONS

Given the similarities in potential alternative factors observed in the two cases, we emphasize the significance of the donor-recipient dynamic in transnational policy diffusion through DAH. The study implies that achieving post-DAH sustainability requires a balance between donor priorities and recipient ownership to address local needs, partnership dialogues for mutual understanding and learning, and collaborative international-domestic expert partnerships to identify and respond to contextual enablers and barriers.

Coping with the hospital environment during the COVID-19 pandemic: A qualitative study of the survivors' perspective during their stay at the ICU and inpatient ward

The COVID-19 pandemic has significantly affected the clinical practice of healthcare professionals. This study aimed to explore the perspectives of COVID-19 survivors regarding the healthcare they received during their stay in the Intensive Care Unit (ICU) and the inpatient COVID-19 ward. A qualitative case-study approach was implemented. Participants were recruited using non-probabilistic purposeful sampling strategy. Inclusion criteria included patients aged ≥18 years who received follow-up from the Pulmonology service at a Hospital in de North of Spain, were diagnosed with COVID-19 and bilateral pneumonia, and were admitted to the ICU before being transferred to a COVID-19 inpatient ward. Data was collected through in-depth interviews and researchers' field notes, and thematic analysis was performed. Techniques such as credibility, transferability, dependability, and confirmability were employed to ensure the trustworthiness of the data. A total of 25 individuals (six women) were included in the study. Three main themes emerged from the analysis: common challenges faced in both units, coping with the hospital stay, and developing strategies. Findings highlighted the need to improve information dissemination, individualize care, and enhance direct patient interaction. Moreover, the study shed light on the psychological impact of hospitalization and ICU experience, including feelings of loneliness, confinement, and the lack of memories from the ICU stay, as well as the influence of care and healthcare language. Finally, strategies such as keeping the mind occupied and maintaining self-discipline were identified as crucial during hospitalization. These findings provide valuable insights for healthcare professionals in delivering care to individuals with COVID-19 in the ICU and hospital ward settings.

Supported: Supporting, enabling, and sustaining homecare workers to deliver end-of-life care: A qualitative study protocol

BACKGROUND

Homecare workers provide essential care at home for people at end-of-life but are often poorly trained and supported.

AIM

To explore the experiences and needs of homecare workers and the views of homecare clients and carers, and other community-based health and social care staff about the homecare worker role, including identification of good practice.

METHODS

In this qualitative exploratory study, we will conduct 150 semi-structured interviews with homecare workers within three geographic English localities chosen for maximum socio-demographic variation. Eligible participants will be consenting adults providing care services (workers [n = 45], managers [n = 15] community practitioners [n = 30]), receiving care (clients thought to be in the last 6 months of life [n = 30], family carers [n = 15], or commissioners of homecare services supporting end-of-life care [n = 15]. Interviews may adopt a Pictor-guided or standard semi-structured approach according to their preference. Managers and commissioners can contribute to an online focus group if preferred. A range of recruitment strategies will be used, including through homecare agencies, local authorities, local NHS services, charities, voluntary sector groups and social media. Interviews and focus groups will be recorded, transcribed, anonymised, and analysed adopting a case-based approach for each geographic area within-case and then comparison across cases using reflexive thematic analysis. The design and analysis will be informed by Bronfenbrenner's Adapted Ecological Systems theory. This study is registered on the Research Registry (No.8613).

CONTRIBUTION

We will provide evidence on ways to improve the experiences and address the needs of homecare workers in relation to caring for people nearing end-of-life. It will offer insight into good practice around supporting homecare workers including responding to their training and development needs. Findings will inform subsequent stages of an evaluation-phase study of a training resource for homecare workers.

The bereavement experiences of families of potential organ donors: a qualitative longitudinal case study illuminating opportunities for family care

OBJECTIVES

To illuminate opportunities for care in the context of deceased organ donation by exploring pre-existing family and healthcare professional characteristics, in-hospital experiences, and ongoing adjustment through the lenses of grief theory, systems theory, meaning-making, narrative, and organ donation literature.

METHOD

Qualitative longitudinal case studies explored individual and family change in five Australian families who had consented to Donation after Circulatory Determination of Death at a single centre. Participants attended semi-structured interviews at four, eight, and twelve months after the death.

FINDINGS

Family values, pre-existing relationships, and in-hospital experiences influenced first responses to their changed lives, understanding of the patient's death, and ongoing family adjustment. Novel behaviour that was conguent with family values was required at the hospital, especially if the patient had previously played a key role in family decision-making. This behaviour and emerging interactional patterns were drawn into family life over the first year of their bereavement.

RECOMMENDATIONS

Training that includes lenses introduced in this study will enable healthcare professionals to confidently respond to individual and family psychosocial needs.

CONCLUSION

The lenses of grief theory and systems thinking highlight opportunities for care tailored to the unique in-hospital context and needs that emerge in the months that follow.

Health care professional recruitment of patients and family carers to palliative care randomised controlled trials: A qualitative multiple case study

BACKGROUND

Trial participant recruitment is an interactional process between health care professionals, patients and carers. Little is known about how clinicians carry out this role in palliative care trials and the reasons why they do or do not recruit participants.

AIMS

To explore how clinicians recruit to palliative care trials, why they choose to implement particular recruitment strategies, and the factors that influence their choices.

DESIGN

A qualitative multiple case study of three UK palliative care trials. Data collection included interviews and study documentation. Analysis involved developing and refining theoretical propositions, guided by the '6Ps' of the 'Social Marketing Mix Framework' as an a priori framework (identifying participants, product, price, place, promotion and working with partners). Framework Analysis guided within and then cross-case analysis.

SETTINGS/PARTICIPANTS

Study investigators and research staff (n = 3, 9, 7) from trial coordinating centres and recruitment sites (hospice and hospital).

RESULTS

Cross-case analysis suggests the 'Social Marketing Mix Framework' is useful for understanding recruitment processes but wider contextual issues need to be incorporated. These include the 'emotional labour' of diagnosing dying and communicating palliative and end-of-life care to potential participants and how the recruitment process is influenced by the power relationships and hierarchies that exist among professional groups. These factors can lead to and support paternalistic practices.

CONCLUSIONS

Those planning trials need to ensure that trial recruiters, depending on their experience and trial characteristics, have access to training and support to address the 'emotional labour' of recruitment. The type of training required requires further research.

TRIPLE C reporting principles for case study evaluations of the role of context in complex interventions

BACKGROUND

Guidance and reporting principles such as CONSORT (for randomised trials) and PRISMA (for systematic reviews) have greatly improved the reporting, discoverability, transparency and consistency of published research. We sought to develop similar guidance for case study evaluations undertaken to explore the influence of context on the processes and outcomes of complex interventions.

METHODS

A range of experts were recruited to an online Delphi panel, sampling for maximum diversity in disciplines (e.g. public health, health services research, organisational studies), settings (e.g. country), and sectors (e.g. academic, policy, third sector). To inform panel deliberations, we prepared background materials based on: [a] a systematic meta-narrative review of empirical and methodological literatures on case study, context and complex interventions; [b] the collective experience of a network of health systems and public health researchers; and [c] the established RAMESES II standards (which cover one kind of case study). We developed a list of topics and issues based on these sources and encouraged panel members to provide free text comments. Their feedback informed development of a set of items in the form of questions for potential inclusion in the reporting principles. We circulated these by email, asking panel members to rank each potential item twice (for relevance and validity) on a 7-point Likert scale. This sequence was repeated twice.

RESULTS

We recruited 51 panel members from 50 organisations across 12 countries, who brought experience of a range of case study research methods and applications. 26 completed all three Delphi rounds, reaching over 80% consensus on 16 items covering title, abstract, definitions of terms, philosophical assumptions, research question(s), rationale, how context and complexity relates to the intervention, ethical approval, empirical methods, findings, use of theory, generalisability and transferability, researcher perspective and influence, conclusions and recommendations, and funding and conflicts of interest.

CONCLUSION

The 'Triple C' (Case study, Context, Complex interventions) reporting principles recognise that case studies are undertaken in different ways for different purposes and based on different philosophical assumptions. They are designed to be enabling rather than prescriptive, and to make case study evaluation reporting on context and complex health interventions more comprehensive, accessible and useable.

A Case Study of Community-Academic Partnership in Improving the Quality of Life for Asthmatic Urban Minority Children in Low-Income Households

Community–academic partnerships (CAPs) are being increasingly used to study and address health disparity issues. CAPs help to create new bodies of knowledge and innovative solutions to community problems, which benefits the community and academia. Supported by a grant, a partnership was formed between an academic research team and a community health organization to analyze and interpret data collected from the caregivers of asthmatic African American children living in urban low-income households. Using a case study approach, we discuss how we built a healthy CAP and the lessons learned from the process. Our analysis was guided by the six main factors that facilitate success in developing collaborative relationships, including (1) environment; (2) membership; (3) process and structure; (4) communication; (5) purpose; and (6) resources. Based on these six factors, we describe our collaboration process, challenges, and areas for improvement. We aimed to provide a “points-to-consider” roadmap for academic and community partners to establish and maintain a mutually beneficial and satisfactory relationship. Collaborating with community members and organizations provides unique opportunities for researchers and students to apply their skills and knowledge from textbooks and the classroom, engage with community members, and improve real-life community needs. Building a constructive CAP involves efforts, energy, and resources from both parties. The six major themes derived from our project offer suggestions for building a healthy, collaborative, and productive relationship that best serves communities in the future.

Intervening factors in health care professionals' attitudes and behaviours towards comprehensive abortion care in the workplace: a comparative case study of Tanzania and Ethiopia

PURPOSE

Health care professionals' attitudes and behaviours play a fundamental role in the provision of timely comprehensive abortion care as a maternal health intervention and save hundreds of thousands of women's lives, annually. This study explores underlying factors influencing Tanzanian and Ethiopian health care professionals' attitudes and behaviours towards comprehensive abortion care between 2015 and 2020.

MATERIALS AND METHODS

The study inductively explored Ethiopian and Tanzanian health care professionals' behaviours using a comparative case study design and a textual analytical approach. Published and unpublished literature, documents and newspapers were used as data sources. The two cases were selected because of their different approaches towards the governance of abortion care, one gradually legalising while the other persistently restricting.

RESULTS

Results demonstrated that there are both subjective (beliefs, attitudes, images, pre-dispositions) and objective (institutional incapacity) factors that impact the actions of health care professionals in the work environment.

CONCLUSIONS

The study concluded that the intervention of subjective factors results from the institutional failure to effectively bridge the divide between governance and accessibility of safe abortion care.

The intellectual capital supporting nurse practice in a post-emergency state: A case study

AIM

To explore the resources supporting current nurse practice in the post-emergency country of Liberia, using the nursing intellectual capital framework, as nurses work to meet the targets set by Government of Liberia's Essential Package of Health Services.

DESIGN

Case study.

METHODS

Data were collected in Liberia February-June 2019. Direct observation, semi-structured interviews and photographs were used to investigate how nurse practice is supported. Field notes, transcripts and photographs were coded using both directed and conventional content analysis. Reports were then generated by code to triangulate the data.

RESULTS

Thirty-seven nurses at 12 health facilities participated. The intellectual capital supporting inpatient and outpatient nurse practice differs in important ways. Inpatient nurse practice is more likely to be supported by facility-based protocols and trainings, whereas outpatient nurse practice is more likely to be supported by external protocols and trainings, often developed by the Liberian government or non-governmental organizations. This can lead to uneven provision of inpatient protocols and trainings, often favouring private facilities. Similarly, inpatient nurses rely primarily on other nurses at their facilities for clinical support while outpatient nurses often have external professional relationships that provided them with clinical guidance.

CONCLUSION

Much has been accomplished to enable outpatient nurses to provide the primary- and secondary-care target services in the Essential Package of Health Services. However, as the Liberian government and its partners continue to work towards providing certain tertiary care services, developing analogous protocols, trainings and clinical mentorship networks for inpatient nurses will likely be fruitful, and will decrease the burden on individual facilities.

IMPACT

Nurses are often expected to meet new service provision targets in post-emergency states. Further research into how best to support nurses as they work to meet those targets has the potential to strengthen health systems.

Case study research: Building the occupational therapy evidence base one case at a time

BACKGROUND

There is growing recognition in healthcare that evidence from randomised controlled trials may not be appropriate to answer the full spectrum of practice-based questions and a more pluralistic approach is needed.

AIM

To consider the use of case study research in contributing to the occupational therapy evidence base.

MATERIAL AND METHODS

A critical discussion of the current state of evidence-based practice in occupational therapy and exploration of a viable approach to case study research is used.

RESULTS

Case study research can capture the context and complexity of occupational therapy practice. Cases can then be pooled to make a substantial contribution to the evidence base.

CONCLUSIONS

Occupational therapists should consider the use of case study research to produce practice related, meaningful research. Journal editorial boards need to be mindful of the value of high-quality case study research when considering publication priorities in occupational therapy literature.

SIGNIFICANCE

Highlights a changing landscape in the literature about how best to conduct research in health and social care, particularly for complex interventions and describes a pragmatic approach to case study research for occupational therapy.

A qualitative study on a novel peer collaboration care programme during the first COVID-19 outbreak: A SWOT analysis

The pandemic has forced nursing teams to incorporate new programmes that modify the organization of care and the use of material resources.

AIMS

The purpose of this study was to describe the perspectives of the nursing team about the strengths/opportunities and weaknesses/threats of a novel peer collaboration care programme during the first outbreak of the pandemic.

DESIGN

A qualitative case study with focus groups was conducted in June 2020.

METHODS

We included 23 participants (seven nurses, seven assistant nursing care technicians and nine charge nurses). Thematic and strengths/opportunities and weaknesses/threats analysis were performed.

RESULTS

The strengths of the peer collaboration care programme are the optimization of care and protective equipment. Its weaknesses are that veteran nurses carry the entire burden, and the lack of personal protective equipment makes it difficult to implement the peer collaboration care programme. Finally, misinformation, lack of facilities and time to teach the peer collaboration care programme are considered threats.

CONCLUSION

This strengths/opportunities and weaknesses/threats analysis has led to a comprehensive new project to improve the nursing care.

IMPACT

The incorporation of the peer collaboration care programme contributed to the development of new organizational and management programmes for the COVID-19 pandemic. This study has gave empirical evidence to nurses and care managers to optimize and organize care, work, human and material resources during the pandemic.

The Drivers of Environmentally Sustainable Hospital Foodservices

Background: Hospital foodservices have the potential to positively contribute to the local food system and planetary healthcare. Understanding the factors contributing to the success of “exemplar hospitals” with environmentally sustainable foodservices gives an opportunity to reimagine foodservices and guide strategic planning. The aim of this study was to identify the drivers of sustainable hospital foodservices.

Methods: For this qualitative multiple case study, purposive sampling was used to identify exemplar hospitals internationally. Semi-structured interviews were conducted with staff with extensive knowledge of their foodservices to explore the drivers of sustainable practices. Relevant documents provided background on the case. These documents and interview data were analyzed using the framework and thematic analysis.

Findings: There were 21 participants from 14 hospitals recruited across nine countries. Sustainable foodservice practices included local and organic food procurement, gardens onsite, vegetarian menus, re-serving unopened portion-controlled items, traditional foods, and food waste composting. Four themes were identified: initiating drivers, supporting enablers, challenges, and influence. Initiating drivers that “sparked” sustainable practices included the values of individuals or the hospital (e.g., community, environmental, or religious values), logical solutions to a problem, or government requirements. Enablers that facilitated success included motivated individuals, dedicated personnel, supportive leadership, internal protocols, and perceived benefits. External enablers included being part of member organizations, government requirements, and learning from other hospitals. Exemplar hospitals had broader influence, including educating the hospital community, supporting other hospitals, and influencing government policies/targets. Common challenges were staff resistance and inadequate policy directive.

Interpretation: These findings examine the successful international cases of sustainable hospital foodservices to provide a global overview to assist with strategic planning both within hospitals and within governing bodies.

Evaluating complex interventions in context: systematic, meta-narrative review of case study approaches

BACKGROUND

There is a growing need for methods that acknowledge and successfully capture the dynamic interaction between context and implementation of complex interventions. Case study research has the potential to provide such understanding, enabling in-depth investigation of the particularities of phenomena. However, there is limited guidance on how and when to best use different case study research approaches when evaluating complex interventions. This study aimed to review and synthesise the literature on case study research across relevant disciplines, and determine relevance to the study of contextual influences on complex interventions in health systems and public health research.

METHODS

Systematic meta-narrative review of the literature comprising (i) a scoping review of seminal texts (n = 60) on case study methodology and on context, complexity and interventions, (ii) detailed review of empirical literature on case study, context and complex interventions (n = 71), and (iii) identifying and reviewing 'hybrid papers' (n = 8) focused on the merits and challenges of case study in the evaluation of complex interventions.

RESULTS

We identified four broad (and to some extent overlapping) research traditions, all using case study in a slightly different way and with different goals: 1) developing and testing complex interventions in healthcare; 2) analysing change in organisations; 3) undertaking realist evaluations; 4) studying complex change naturalistically. Each tradition conceptualised context differently-respectively as the backdrop to, or factors impacting on, the intervention; sets of interacting conditions and relationships; circumstances triggering intervention mechanisms; and socially structured practices. Overall, these traditions drew on a small number of case study methodologists and disciplines. Few studies problematised the nature and boundaries of 'the case' and 'context' or considered the implications of such conceptualisations for methods and knowledge production.

CONCLUSIONS

Case study research on complex interventions in healthcare draws on a number of different research traditions, each with different epistemological and methodological preferences. The approach used and consequences for knowledge produced often remains implicit. This has implications for how researchers, practitioners and decision makers understand, implement and evaluate complex interventions in different settings. Deeper engagement with case study research as a methodology is strongly recommended.

Examining the Utility of the DESCARTE Model for Case Study Research

The DESCARTE model aims to guide health care researchers on the design, conduct, and reporting of case studies. The current article critically appraises the utility of the model and provides an example of its application to a multiple case study that examined the effect of MARIO, a social robot, on the resilience of people with dementia. The DESCARTE model is explained, and its strengths and the challenges encountered during its application are discussed. DESCARTE provides a structured framework that promotes quality in case study research by requiring the researcher to articulate philosophical cohesiveness, ethical considerations, reflexivity, and the strategies used during data integration and throughout data analysis. However, the model does not prompt the development of research questions or methods to promote rigor and reflexivity throughout the case study. A task list and additional guiding questions are provided to address these deficits and to improve the utility of the DESCARTE model. [Research in Gerontological Nursing, 14(2), 60-68.].

Evaluation of DeChoker, an Airway Clearance Device (ACD) Used in Adult Choking Emergencies Within the Adult Care Home Sector: A Mixed Methods Case Study

Foreign Body Airway Obstruction (FBAO) is a medical emergency that can result in death, particularly if swift, appropriate action is not taken. It can be a frightening experience for all involved. DeChoker, an Airway Clearance Device (ACD), might provide an additional alternative in the management of choking; however, limited evidence around its safety and effectiveness makes adoption controversial. Objectives: An independent evaluation to explore the experiences of health and care professionals who used DeChoker in real-life adult choking emergencies, focusing on the product's safety, efficacy and ease of application. Design: Retrospective mixed methods case study, with multiple embedded units of analysis. Setting: UK adult care homes. Participants: Twenty seven incidents of adult choking emergencies self-reported by care home staff where DeChoker was used. This data was augmented by an in-depth exploration of four individual choking incidences. Results: The choking victim's ages range: 45 to 101 years (mean 79.8 years). The device was reported to have successfully removed the obstruction in 26 of 27 cases, with very few complications or adverse events reported. In 21 of 27 incidents (78%) the victim was not required to visit Accident and Emergency. Qualitative data indicated nursing home staff found the DeChoker easy to use and valued its presence as an adjunct to current guideline procedures. Conclusion: There is a dearth of evidence surrounding the management of choking and little innovation in this area for five decades. This retrospective evaluation contributes to discussion regarding the role ACDs might play in the management of choking, particularly in cases where current choking management guidance are ineffective, insufficient, inappropriate or impractical (e.g., frail or movement restricted people). The interview data presents a view from care home staff that the DeChoker, as an ACD, contributed to saving the life of choking victims.

Designing process evaluations using case study to explore the context of complex interventions evaluated in trials

Background

Process evaluations are an important component of an effectiveness evaluation as they focus on understanding the relationship between interventions and context to explain how and why interventions work or fail, and whether they can be transferred to other settings and populations. However, historically, context has not been sufficiently explored and reported resulting in the poor uptake of trial results. Therefore, suitable methodologies are needed to guide the investigation of context. Case study is one appropriate methodology, but there is little guidance about what case study design can offer the study of context in trials. We address this gap in the literature by presenting a number of important considerations for process evaluation using a case study design.

Main text

In this paper, we define context, the relationship between complex interventions and context, and describe case study design methodology. A well-designed process evaluation using case study should consider the following core components: the purpose; definition of the intervention; the trial design, the case, the theories or logic models underpinning the intervention, the sampling approach and the conceptual or theoretical framework. We describe each of these in detail and highlight with examples from recently published process evaluations.

Conclusions

There are a number of approaches to process evaluation design in the literature; however, there is a paucity of research on what case study design can offer process evaluations. We argue that case study is one of the best research designs to underpin process evaluations, to capture the dynamic and complex relationship between intervention and context during implementation. We provide a comprehensive overview of the issues for process evaluation design to consider when using a case study design.

Trial registration

DQIP - ClinicalTrials.gov number, NCT01425502 - OPAL - ISRCTN57746448

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

BACKGROUND

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

MAIN BODY

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

CONCLUSION

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

Impressions of aquatic therapy treatment in children with prolonged mechanical ventilation - clinician and family perspectives: a qualitative case study

PURPOSE

To describe the experiences of applying aquatic therapy (AT) to children with ventilation needs after discharge from the paediatric intensive care unit (PICU).

MATERIAL AND METHODS

A qualitative and descriptive case study with integrated units. Purposive sampling was carried out, including the parents of the children participating in the AT programme and the healthcare professionals treating them. Fourteen participants were included: four parents, five physicians, three physiotherapists and two nurses. The study was carried out as part of a program on AT in critically ill children. Semi-structured interviews were conducted. A thematic analysis was performed.

RESULTS

Three themes were identified. Theme (1) Difficulties for implementation: AT was not perceived as a viable therapeutic modality; lack of knowledge and resources. Theme (2) Risks and challenges: Perceptions of anxiety at the beginning; planning and precautions. Theme (3) AT facilitates new possibilities and benefits: The necessity of the presence of parents during the AT session; a sense of "normalcy;" outcomes of AT in relation to post-intensive care syndrome.

CONCLUSIONS

Our results will help to better understand a safe and feasible way to work with children with PPMV, even though this approach is not yet widespread due to its special circumstances. These results can be used in future AT programmes in children undergoing special treatments.IMPLICATIONS FOR REHABILITATIONChildren with ventilation needs after discharge from the intensive care unit present physical, cognitive, and mental alterations that decrease functional capacity and quality of life.In a relatively small sample, positive outcomes were found for AT in relation to post-intensive care syndrome, enabling children to participate in aquatic therapy activities with the involvement of parents.This study highlighted the positive impact on the quality of life of both children and their parents.Aquatic therapy is a feasible intervention in children requiring prolonged mechanical ventilation, although certain difficulties should be addressed in terms of implementation, together with challenges regarding safety and planning.These difficulties may be overcome by promoting coordination between professionals, creating security protocols, and/or facilitating specialised education for therapists.

Influence of Aquatic Therapy in Children and Youth with Cerebral Palsy: A Qualitative Case Study in a Special Education School

Cerebral palsy results in the progressive loss of motor functions, with a negative impact on daily activities and participation. Despite the well described benefits of aquatic therapy in children, little is known about the effects of the same in school settings. This study aimed to describe the experience of children and youth with cerebral palsy participating in an aquatic therapy program within a special education school considering their educational and therapeutic perspectives. A qualitative descriptive case study with embedded units was developed, comprising 27 participants. This study employed purposeful sampling to include children and youth with cerebral palsy from the Asociación Ayuda a la Paralisis Cerebral (APACE) special education school, together with their parents, the special education teachers, and health care professionals. Data were collected via non-participant observation, semi-structured and informal interviews, focus groups, and researcher field notes. A thematic analysis was conducted, revealing the following themes: (a) the connection with the environment; (b) postural improvements and mobility; (c) the opportunity to perform tasks; (d) learning and transfer. A motivating environment leads to physical, cognitive and social benefits, both at school and in the home. Aquatic therapy was viewed as a means for learning and participation. These findings may enhance understanding regarding the potential benefits of implementing multidisciplinary aquatic therapy programs in specialist school settings.

Understanding the Particularities of an Unconditional Prenatal Cash Benefit for Low-Income Women: A Case Study Approach

We explored the particularities of the Healthy Baby Prenatal Benefit (HBPB), an unconditional cash transfer program for low-income pregnant women in Manitoba, Canada, which aims to connect recipients with prenatal care and community support programs, and help them access healthy foods during pregnancy. While previous studies have shown associations between HBPB and improved birth outcomes, here we focus on how the intervention contributed to positive outcomes. Using a case study design, we collected data from government and program documents and interviews with policy makers, academics, program staff, and recipients of HBPB. Key informants identified using evidence and aligning with government priorities as key facilitators to the implementation of HBPB. Program recipients described how HBPB helped them improve their nutrition, prepare for baby, and engage in self-care to moderate the effect of stressful life events. This study provides important contextualized evidence to support government decision making on healthy child development policies.

Developing the evidence base for evaluating dementia training in NHS hospitals (DEMTRAIN): a mixed-methods study protocol

INTRODUCTION

Around 70% of acute hospital beds in the UK are occupied by older people, approximately 40% of whom have dementia. Improving the quality of care in hospitals is a key priority within national dementia strategies. Limited research has been conducted to evaluate dementia training packages for staff, and evaluation of training often focuses on immediate, on-the-day training feedback and effects.

OBJECTIVES

Our study aims to answer two research questions: (1) How do variations in content, implementation and intensity of staff dementia training in acute hospitals in England relate to health service outcome/process measures and staff outcomes? and (2) What components of staff dementia training are most strongly related to improved patient and staff outcomes?

METHODS AND ANALYSIS

Using the principles of programme theory, a mixed-method study will be used to identify mechanisms and the interactions between them, as well as facilitators and barriers to dementia training in hospitals. We will use existing data, such as Hospital Episode Statistics, alongside two surveys (at hospital and staff level).We will recruit up to 193 acute hospitals in England to participate in the hospital level survey. We aim to recruit up to 30 staff members per hospital, from a random sample of 24 hospitals. In addition, we will explore the cost-effectiveness of dementia training packages and carry out an in-depth case study of up to six hospitals.

ETHICS AND DISSEMINATION

The study has been reviewed and approved by the Faculty of Health and Medicine Research Ethics Committee (FHMREC 17056) and Health Research Authority (Integrated Research Approval System (IRAS) ID 242166: REC reference 18/HRA/1198). We plan to develop both standard (eg, academic publications, presentations at conferences) and innovative (eg, citizen scientist web portals, online fora, links with hospitals and third sector organisations) means of ensuring the study findings are accessible and disseminated regionally, nationally and internationally.

"Wounds Home Alone"-Why and How Venous Leg Ulcer Patients Self-Treat Their Ulcer: A Qualitative Content Study

BACKGROUND

Venous leg ulcers (VLUs), the most common type of leg ulcerations, have long healing times and high recurrence rates; reimbursement rules and a general shortage of nursing staff have put self-treatment into focus. The study aimed to investigate why and how patients with VLUs self-treat their ulcers.

METHODS

Patients with VLUs (N = 32) were selected by criterion sampling for a multicentric qualitative study using semi-structured interviews. The interviews were analyzed via inductive qualitative content analysis.

RESULTS

More than two-thirds of participants sometimes self-treated VLU and one quarter changed their prescribed treatment. Experiences were expressed through four themes as follows: (a) current local VLU therapy; (b) VLU self-treatment; (c) patient education; and (d) psychosocial issues. The main reasons for self-treatment were a lack of healthcare resources, reimbursement restrictions, and dissatisfaction with conventional treatment together with insufficient knowledge about the wound-healing process and possible side effects. No educational materials were provided for patients or caregivers. Many patients adopted homemade remedies.

CONCLUSION

Patients with VLUs practice self-care due to limited healthcare availability, a low awareness of the causes of their condition, and the effects of therapy on VLU healing. Future educational intervention is needed to enhance self-treatment.

Recognition of Barriers to Physical Activity Promotion in Immigrant Children in Spain: A Qualitative Case Study

Physical activity facilitates the acquisition of healthy habits from childhood to adulthood. Differences exist regarding the performance of physical activity among immigrant children compared to native Spanish children. The purpose of the study was to describe the barriers that exist for the promotion of physical activity. A qualitative case-study approach was implemented. Parents of immigrant children, teachers, a school principal, and priests were included, using purposeful sampling. Data were collected from 25 participants, via unstructured and semi-structured interviews, focus groups, and researchers’ field notes. A thematic analysis was performed and ecological levels were identified. Our findings revealed the following barriers to performing physical activity: (a) the meaning of physical activity, (b) gender inequalities, (c) academic burden, (d) lack of social contact, (e) expenses and family economy, (f) lack of infrastructure and natural surroundings, (g) time constraints, (h) fear and insecurity, and (i) the reason for immigrating. These results may be used to revise the school curriculum, promoting equal opportunities for physical activity and encouraging family participation. Additionally, urban design policies should be encouraged to facilitate access to open spaces for recreation within cities.

"Living an Obstacle Course": A Qualitative Study Examining the Experiences of Caregivers of Children with Rett Syndrome

Background: Rett syndrome has considerable effects on the quality of life of affected children, impairing everyday activities and potentially impacting the life of both the caregivers and the family. Our aim was to explore the experiences of a group of caregivers of children with Rett syndrome with regards to living and caring for their children. Methods: We conducted a qualitative case study to examine how 31 caregivers of children with Rett syndrome perceived living with their children. Data were collected through in-depth interviews, focus groups, researchers’ field notes and caregivers’ personal documents. A thematic analysis was performed following the Consolidated Criteria for Reporting Qualitative Research (COREQ) guideline. Results: The experience of being a caregiver of a child with Rett syndrome was expressed as being akin to an “obstacle course”, and was described via three main themes: (a) looking for answers, with two subthemes identified, namely ‘the first symptoms’, and ‘the need for a diagnosis’; (b) managing day to day life, with the subthemes ‘applying treatments’, and ‘learning to care’; and (c) money matters. Conclusions: Rett syndrome has a considerable impact on the lives of the caregivers involved. The health-care process and the management of economic resources are some of the aspects highlighted by caregivers. These findings have important implications for the planning of support services, health systems and health policies.

When the Hospital Is No Longer an Option: A Multiple Case Study of Defining Moments for Women Choosing Home Birth in High-Risk Pregnancies in The Netherlands

Some women in a high-risk pregnancy go against medical advice and choose to birth at home with a "holistic" midwife. In this exploratory multiple case study, grounded theory and triangulation were employed to examine 10 cases. The women, their partners, and (regular and holistic) health care professionals were interviewed in an attempt to determine whether there was a pattern to their experiences. Two propositions emerged. The dominant one was a trajectory of trauma, self-education, concern about paternalism, and conflict leading to a negative choice for holistic care. The rival proposition was a path of trust and positive choice for holistic care without conflict. We discuss these two propositions and make suggestions for professionals for building a trusting relationship using continuity of care, true shared decision making, and an alternative risk discourse to achieve the goal of making women perceive the hospital as safe again.

The impact of a short-term cohousing initiative among schizophrenia patients, high school students, and their social context: A qualitative case study

Background

A number of programs have been developed to promote the contact between adolescents and mentally-ill patients, in order to break the stigma, improve understanding, promote mental health and prevent substance abuse. The aim of this study was to describe the experience of patients with schizophrenia, high school students, and their social context, participating in a short-term cohousing initiative.

Methods

A qualitative case-study approach was implemented. Patients with schizophrenia from the San Juan de Dios Psychiatric Hospital, female students from Almen High School, and participants from their social context (parents, hospital staff, and teachers) were included, using purposeful sampling. Data were collected from 51 participants (15 patients, nine students, 11 hospital staff, six teachers, 10 parents) via non-participant observation, focus groups, informal interviews, researchers’ field notes and patients’ personal diaries and letters. A thematic analysis was performed.

Results

The themes identified included a) learning to live together: students and patients participate and learn together; b) the perception of the illness and the mentally-ill: the barrier between health and disease is very slim, and society tends to avoid contact with those who are ill; c) change: a transformation takes place in students, in their self-perception, based on the real and intense nature of the experience; d) a trial and an opportunity: patients test their ability to live outside the hospital; e) discharge and readmission: discharge is experienced as both a liberation and a difficulty, whereas relapse and readmission are experienced as failures.

Conclusions

Our findings can help us to better understand schizophrenia and encourage a more positive approach towards both the illness and those who suffer from it. These results may be used for the development of cohousing programs in controlled environments.

Case Study Observational Research: A Framework for Conducting Case Study Research Where Observation Data Are the Focus

Case study research is a comprehensive method that incorporates multiple sources of data to provide detailed accounts of complex research phenomena in real-life contexts. However, current models of case study research do not particularly distinguish the unique contribution observation data can make. Observation methods have the potential to reach beyond other methods that rely largely or solely on self-report. This article describes the distinctive characteristics of case study observational research, a modified form of Yin's 2014 model of case study research the authors used in a study exploring interprofessional collaboration in primary care. In this approach, observation data are positioned as the central component of the research design. Case study observational research offers a promising approach for researchers in a wide range of health care settings seeking more complete understandings of complex topics, where contextual influences are of primary concern. Future research is needed to refine and evaluate the approach.