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  • What Is a Case Study? | Definition, Examples & Methods

What Is a Case Study? | Definition, Examples & Methods

Published on May 8, 2019 by Shona McCombes . Revised on November 20, 2023.

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

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

Table of contents

When to do a case study, step 1: select a case, step 2: build a theoretical framework, step 3: collect your data, step 4: describe and analyze the case, other interesting articles.

A case study is an appropriate research design when you want to gain concrete, contextual, in-depth knowledge about a specific real-world subject. It allows you to explore the key characteristics, meanings, and implications of the case.

Case studies are often a good choice in a thesis or dissertation . They keep your project focused and manageable when you don’t have the time or resources to do large-scale research.

You might use just one complex case study where you explore a single subject in depth, or conduct multiple case studies to compare and illuminate different aspects of your research problem.

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case studies are useful for

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

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

TipIf your research is more practical in nature and aims to simultaneously investigate an issue as you solve it, consider conducting action research instead.

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

Example of an outlying case studyIn the 1960s the town of Roseto, Pennsylvania was discovered to have extremely low rates of heart disease compared to the US average. It became an important case study for understanding previously neglected causes of heart disease.

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

Example of a representative case studyIn the 1920s, two sociologists used Muncie, Indiana as a case study of a typical American city that supposedly exemplified the changing culture of the US at the time.

While case studies focus more on concrete details than general theories, they should usually have some connection with theory in the field. This way the case study is not just an isolated description, but is integrated into existing knowledge about the topic. It might aim to:

  • Exemplify a theory by showing how it explains the case under investigation
  • Expand on a theory by uncovering new concepts and ideas that need to be incorporated
  • Challenge a theory by exploring an outlier case that doesn’t fit with established assumptions

To ensure that your analysis of the case has a solid academic grounding, you should conduct a literature review of sources related to the topic and develop a theoretical framework . This means identifying key concepts and theories to guide your analysis and interpretation.

There are many different research methods you can use to collect data on your subject. Case studies tend to focus on qualitative data using methods such as interviews , observations , and analysis of primary and secondary sources (e.g., newspaper articles, photographs, official records). Sometimes a case study will also collect quantitative data.

Example of a mixed methods case studyFor a case study of a wind farm development in a rural area, you could collect quantitative data on employment rates and business revenue, collect qualitative data on local people’s perceptions and experiences, and analyze local and national media coverage of the development.

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

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

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

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

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

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

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

Research bias

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

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Home » Case Study – Methods, Examples and Guide

Case Study – Methods, Examples and Guide

Table of Contents

Case Study Research

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.

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What the Case Study Method Really Teaches

  • Nitin Nohria

case studies are useful for

Seven meta-skills that stick even if the cases fade from memory.

It’s been 100 years since Harvard Business School began using the case study method. Beyond teaching specific subject matter, the case study method excels in instilling meta-skills in students. This article explains the importance of seven such skills: preparation, discernment, bias recognition, judgement, collaboration, curiosity, and self-confidence.

During my decade as dean of Harvard Business School, I spent hundreds of hours talking with our alumni. To enliven these conversations, I relied on a favorite question: “What was the most important thing you learned from your time in our MBA program?”

  • Nitin Nohria is the George F. Baker Jr. Professor at Harvard Business School and the former dean of HBS.

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What Is a Case Study?

Weighing the pros and cons of this method of research

Kendra Cherry, MS, is a psychosocial rehabilitation specialist, psychology educator, and author of the "Everything Psychology Book."

case studies are useful for

Cara Lustik is a fact-checker and copywriter.

case studies are useful for

Verywell / Colleen Tighe

  • Pros and Cons

What Types of Case Studies Are Out There?

Where do you find data for a case study, how do i write a psychology case study.

A case study is an in-depth study of one person, group, or event. In a case study, nearly every aspect of the subject's life and history is analyzed to seek patterns and causes of behavior. Case studies can be used in many different fields, including psychology, medicine, education, anthropology, political science, and social work.

The point of a case study is to learn as much as possible about an individual or group so that the information can be generalized to many others. Unfortunately, case studies tend to be highly subjective, and it is sometimes difficult to generalize results to a larger population.

While case studies focus on a single individual or group, they follow a format similar to other types of psychology writing. If you are writing a case study, we got you—here are some rules of APA format to reference.  

At a Glance

A case study, or an in-depth study of a person, group, or event, can be a useful research tool when used wisely. In many cases, case studies are best used in situations where it would be difficult or impossible for you to conduct an experiment. They are helpful for looking at unique situations and allow researchers to gather a lot of˜ information about a specific individual or group of people. However, it's important to be cautious of any bias we draw from them as they are highly subjective.

What Are the Benefits and Limitations of Case Studies?

A case study can have its strengths and weaknesses. Researchers must consider these pros and cons before deciding if this type of study is appropriate for their needs.

One of the greatest advantages of a case study is that it allows researchers to investigate things that are often difficult or impossible to replicate in a lab. Some other benefits of a case study:

  • Allows researchers to capture information on the 'how,' 'what,' and 'why,' of something that's implemented
  • Gives researchers the chance to collect information on why one strategy might be chosen over another
  • Permits researchers to develop hypotheses that can be explored in experimental research

On the other hand, a case study can have some drawbacks:

  • It cannot necessarily be generalized to the larger population
  • Cannot demonstrate cause and effect
  • It may not be scientifically rigorous
  • It can lead to bias

Researchers may choose to perform a case study if they want to explore a unique or recently discovered phenomenon. Through their insights, researchers develop additional ideas and study questions that might be explored in future studies.

It's important to remember that the insights from case studies cannot be used to determine cause-and-effect relationships between variables. However, case studies may be used to develop hypotheses that can then be addressed in experimental research.

Case Study Examples

There have been a number of notable case studies in the history of psychology. Much of  Freud's work and theories were developed through individual case studies. Some great examples of case studies in psychology include:

  • Anna O : Anna O. was a pseudonym of a woman named Bertha Pappenheim, a patient of a physician named Josef Breuer. While she was never a patient of Freud's, Freud and Breuer discussed her case extensively. The woman was experiencing symptoms of a condition that was then known as hysteria and found that talking about her problems helped relieve her symptoms. Her case played an important part in the development of talk therapy as an approach to mental health treatment.
  • Phineas Gage : Phineas Gage was a railroad employee who experienced a terrible accident in which an explosion sent a metal rod through his skull, damaging important portions of his brain. Gage recovered from his accident but was left with serious changes in both personality and behavior.
  • Genie : Genie was a young girl subjected to horrific abuse and isolation. The case study of Genie allowed researchers to study whether language learning was possible, even after missing critical periods for language development. Her case also served as an example of how scientific research may interfere with treatment and lead to further abuse of vulnerable individuals.

Such cases demonstrate how case research can be used to study things that researchers could not replicate in experimental settings. In Genie's case, her horrific abuse denied her the opportunity to learn a language at critical points in her development.

This is clearly not something researchers could ethically replicate, but conducting a case study on Genie allowed researchers to study phenomena that are otherwise impossible to reproduce.

There are a few different types of case studies that psychologists and other researchers might use:

  • Collective case studies : These involve studying a group of individuals. Researchers might study a group of people in a certain setting or look at an entire community. For example, psychologists might explore how access to resources in a community has affected the collective mental well-being of those who live there.
  • Descriptive case studies : These involve starting with a descriptive theory. The subjects are then observed, and the information gathered is compared to the pre-existing theory.
  • Explanatory case studies : These   are often used to do causal investigations. In other words, researchers are interested in looking at factors that may have caused certain things to occur.
  • Exploratory case studies : These are sometimes used as a prelude to further, more in-depth research. This allows researchers to gather more information before developing their research questions and hypotheses .
  • Instrumental case studies : These occur when the individual or group allows researchers to understand more than what is initially obvious to observers.
  • Intrinsic case studies : This type of case study is when the researcher has a personal interest in the case. Jean Piaget's observations of his own children are good examples of how an intrinsic case study can contribute to the development of a psychological theory.

The three main case study types often used are intrinsic, instrumental, and collective. Intrinsic case studies are useful for learning about unique cases. Instrumental case studies help look at an individual to learn more about a broader issue. A collective case study can be useful for looking at several cases simultaneously.

The type of case study that psychology researchers use depends on the unique characteristics of the situation and the case itself.

There are a number of different sources and methods that researchers can use to gather information about an individual or group. Six major sources that have been identified by researchers are:

  • Archival records : Census records, survey records, and name lists are examples of archival records.
  • Direct observation : This strategy involves observing the subject, often in a natural setting . While an individual observer is sometimes used, it is more common to utilize a group of observers.
  • Documents : Letters, newspaper articles, administrative records, etc., are the types of documents often used as sources.
  • Interviews : Interviews are one of the most important methods for gathering information in case studies. An interview can involve structured survey questions or more open-ended questions.
  • Participant observation : When the researcher serves as a participant in events and observes the actions and outcomes, it is called participant observation.
  • Physical artifacts : Tools, objects, instruments, and other artifacts are often observed during a direct observation of the subject.

If you have been directed to write a case study for a psychology course, be sure to check with your instructor for any specific guidelines you need to follow. If you are writing your case study for a professional publication, check with the publisher for their specific guidelines for submitting a case study.

Here is a general outline of what should be included in a case study.

Section 1: A Case History

This section will have the following structure and content:

Background information : The first section of your paper will present your client's background. Include factors such as age, gender, work, health status, family mental health history, family and social relationships, drug and alcohol history, life difficulties, goals, and coping skills and weaknesses.

Description of the presenting problem : In the next section of your case study, you will describe the problem or symptoms that the client presented with.

Describe any physical, emotional, or sensory symptoms reported by the client. Thoughts, feelings, and perceptions related to the symptoms should also be noted. Any screening or diagnostic assessments that are used should also be described in detail and all scores reported.

Your diagnosis : Provide your diagnosis and give the appropriate Diagnostic and Statistical Manual code. Explain how you reached your diagnosis, how the client's symptoms fit the diagnostic criteria for the disorder(s), or any possible difficulties in reaching a diagnosis.

Section 2: Treatment Plan

This portion of the paper will address the chosen treatment for the condition. This might also include the theoretical basis for the chosen treatment or any other evidence that might exist to support why this approach was chosen.

  • Cognitive behavioral approach : Explain how a cognitive behavioral therapist would approach treatment. Offer background information on cognitive behavioral therapy and describe the treatment sessions, client response, and outcome of this type of treatment. Make note of any difficulties or successes encountered by your client during treatment.
  • Humanistic approach : Describe a humanistic approach that could be used to treat your client, such as client-centered therapy . Provide information on the type of treatment you chose, the client's reaction to the treatment, and the end result of this approach. Explain why the treatment was successful or unsuccessful.
  • Psychoanalytic approach : Describe how a psychoanalytic therapist would view the client's problem. Provide some background on the psychoanalytic approach and cite relevant references. Explain how psychoanalytic therapy would be used to treat the client, how the client would respond to therapy, and the effectiveness of this treatment approach.
  • Pharmacological approach : If treatment primarily involves the use of medications, explain which medications were used and why. Provide background on the effectiveness of these medications and how monotherapy may compare with an approach that combines medications with therapy or other treatments.

This section of a case study should also include information about the treatment goals, process, and outcomes.

When you are writing a case study, you should also include a section where you discuss the case study itself, including the strengths and limitiations of the study. You should note how the findings of your case study might support previous research. 

In your discussion section, you should also describe some of the implications of your case study. What ideas or findings might require further exploration? How might researchers go about exploring some of these questions in additional studies?

Need More Tips?

Here are a few additional pointers to keep in mind when formatting your case study:

  • Never refer to the subject of your case study as "the client." Instead, use their name or a pseudonym.
  • Read examples of case studies to gain an idea about the style and format.
  • Remember to use APA format when citing references .

Crowe S, Cresswell K, Robertson A, Huby G, Avery A, Sheikh A. The case study approach .  BMC Med Res Methodol . 2011;11:100.

Crowe S, Cresswell K, Robertson A, Huby G, Avery A, Sheikh A. The case study approach . BMC Med Res Methodol . 2011 Jun 27;11:100. doi:10.1186/1471-2288-11-100

Gagnon, Yves-Chantal.  The Case Study as Research Method: A Practical Handbook . Canada, Chicago Review Press Incorporated DBA Independent Pub Group, 2010.

Yin, Robert K. Case Study Research and Applications: Design and Methods . United States, SAGE Publications, 2017.

By Kendra Cherry, MSEd Kendra Cherry, MS, is a psychosocial rehabilitation specialist, psychology educator, and author of the "Everything Psychology Book."

case studies are useful for

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

case studies are useful for

  • 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.

case studies are useful for

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.

case studies are useful for

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.

case studies are useful for

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 are useful for

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.

case studies are useful for

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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.

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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.

case studies are useful for

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.

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What is case study research?

Last updated

8 February 2023

Reviewed by

Cathy Heath

Suppose a company receives a spike in the number of customer complaints, or medical experts discover an outbreak of illness affecting children but are not quite sure of the reason. In both cases, carrying out a case study could be the best way to get answers.

Organization

Case studies can be carried out across different disciplines, including education, medicine, sociology, and business.

Most case studies employ qualitative methods, but quantitative methods can also be used. Researchers can then describe, compare, evaluate, and identify patterns or cause-and-effect relationships between the various variables under study. They can then use this knowledge to decide what action to take. 

Another thing to note is that case studies are generally singular in their focus. This means they narrow focus to a particular area, making them highly subjective. You cannot always generalize the results of a case study and apply them to a larger population. However, they are valuable tools to illustrate a principle or develop a thesis.

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Dovetail streamlines case study research to help you uncover and share actionable insights

  • What are the different types of case study designs?

Researchers can choose from a variety of case study designs. The design they choose is dependent on what questions they need to answer, the context of the research environment, how much data they already have, and what resources are available.

Here are the common types of case study design:

Explanatory

An explanatory case study is an initial explanation of the how or why that is behind something. This design is commonly used when studying a real-life phenomenon or event. Once the organization understands the reasons behind a phenomenon, it can then make changes to enhance or eliminate the variables causing it. 

Here is an example: How is co-teaching implemented in elementary schools? The title for a case study of this subject could be “Case Study of the Implementation of Co-Teaching in Elementary Schools.”

Descriptive

An illustrative or descriptive case study helps researchers shed light on an unfamiliar object or subject after a period of time. The case study provides an in-depth review of the issue at hand and adds real-world examples in the area the researcher wants the audience to understand. 

The researcher makes no inferences or causal statements about the object or subject under review. This type of design is often used to understand cultural shifts.

Here is an example: How did people cope with the 2004 Indian Ocean Tsunami? This case study could be titled "A Case Study of the 2004 Indian Ocean Tsunami and its Effect on the Indonesian Population."

Exploratory

Exploratory research is also called a pilot case study. It is usually the first step within a larger research project, often relying on questionnaires and surveys . Researchers use exploratory research to help narrow down their focus, define parameters, draft a specific research question , and/or identify variables in a larger study. This research design usually covers a wider area than others, and focuses on the ‘what’ and ‘who’ of a topic.

Here is an example: How do nutrition and socialization in early childhood affect learning in children? The title of the exploratory study may be “Case Study of the Effects of Nutrition and Socialization on Learning in Early Childhood.”

An intrinsic case study is specifically designed to look at a unique and special phenomenon. At the start of the study, the researcher defines the phenomenon and the uniqueness that differentiates it from others. 

In this case, researchers do not attempt to generalize, compare, or challenge the existing assumptions. Instead, they explore the unique variables to enhance understanding. Here is an example: “Case Study of Volcanic Lightning.”

This design can also be identified as a cumulative case study. It uses information from past studies or observations of groups of people in certain settings as the foundation of the new study. Given that it takes multiple areas into account, it allows for greater generalization than a single case study. 

The researchers also get an in-depth look at a particular subject from different viewpoints.  Here is an example: “Case Study of how PTSD affected Vietnam and Gulf War Veterans Differently Due to Advances in Military Technology.”

Critical instance

A critical case study incorporates both explanatory and intrinsic study designs. It does not have predetermined purposes beyond an investigation of the said subject. It can be used for a deeper explanation of the cause-and-effect relationship. It can also be used to question a common assumption or myth. 

The findings can then be used further to generalize whether they would also apply in a different environment.  Here is an example: “What Effect Does Prolonged Use of Social Media Have on the Mind of American Youth?”

Instrumental

Instrumental research attempts to achieve goals beyond understanding the object at hand. Researchers explore a larger subject through different, separate studies and use the findings to understand its relationship to another subject. This type of design also provides insight into an issue or helps refine a theory. 

For example, you may want to determine if violent behavior in children predisposes them to crime later in life. The focus is on the relationship between children and violent behavior, and why certain children do become violent. Here is an example: “Violence Breeds Violence: Childhood Exposure and Participation in Adult Crime.”

Evaluation case study design is employed to research the effects of a program, policy, or intervention, and assess its effectiveness and impact on future decision-making. 

For example, you might want to see whether children learn times tables quicker through an educational game on their iPad versus a more teacher-led intervention. Here is an example: “An Investigation of the Impact of an iPad Multiplication Game for Primary School Children.” 

  • When do you use case studies?

Case studies are ideal when you want to gain a contextual, concrete, or in-depth understanding of a particular subject. It helps you understand the characteristics, implications, and meanings of the subject.

They are also an excellent choice for those writing a thesis or dissertation, as they help keep the project focused on a particular area when resources or time may be too limited to cover a wider one. You may have to conduct several case studies to explore different aspects of the subject in question and understand the problem.

  • What are the steps to follow when conducting a case study?

1. Select a case

Once you identify the problem at hand and come up with questions, identify the case you will focus on. The study can provide insights into the subject at hand, challenge existing assumptions, propose a course of action, and/or open up new areas for further research.

2. Create a theoretical framework

While you will be focusing on a specific detail, the case study design you choose should be linked to existing knowledge on the topic. This prevents it from becoming an isolated description and allows for enhancing the existing information. 

It may expand the current theory by bringing up new ideas or concepts, challenge established assumptions, or exemplify a theory by exploring how it answers the problem at hand. A theoretical framework starts with a literature review of the sources relevant to the topic in focus. This helps in identifying key concepts to guide analysis and interpretation.

3. Collect the data

Case studies are frequently supplemented with qualitative data such as observations, interviews, and a review of both primary and secondary sources such as official records, news articles, and photographs. There may also be quantitative data —this data assists in understanding the case thoroughly.

4. Analyze your case

The results of the research depend on the research design. Most case studies are structured with chapters or topic headings for easy explanation and presentation. Others may be written as narratives to allow researchers to explore various angles of the topic and analyze its meanings and implications.

In all areas, always give a detailed contextual understanding of the case and connect it to the existing theory and literature before discussing how it fits into your problem area.

  • What are some case study examples?

What are the best approaches for introducing our product into the Kenyan market?

How does the change in marketing strategy aid in increasing the sales volumes of product Y?

How can teachers enhance student participation in classrooms?

How does poverty affect literacy levels in children?

Case study topics

Case study of product marketing strategies in the Kenyan market

Case study of the effects of a marketing strategy change on product Y sales volumes

Case study of X school teachers that encourage active student participation in the classroom

Case study of the effects of poverty on literacy levels in children

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5 Benefits of Learning Through the Case Study Method

Harvard Business School MBA students learning through the case study method

  • 28 Nov 2023

While several factors make HBS Online unique —including a global Community and real-world outcomes —active learning through the case study method rises to the top.

In a 2023 City Square Associates survey, 74 percent of HBS Online learners who also took a course from another provider said HBS Online’s case method and real-world examples were better by comparison.

Here’s a primer on the case method, five benefits you could gain, and how to experience it for yourself.

Access your free e-book today.

What Is the Harvard Business School Case Study Method?

The case study method , or case method , is a learning technique in which you’re presented with a real-world business challenge and asked how you’d solve it. After working through it yourself and with peers, you’re told how the scenario played out.

HBS pioneered the case method in 1922. Shortly before, in 1921, the first case was written.

“How do you go into an ambiguous situation and get to the bottom of it?” says HBS Professor Jan Rivkin, former senior associate dean and chair of HBS's master of business administration (MBA) program, in a video about the case method . “That skill—the skill of figuring out a course of inquiry to choose a course of action—that skill is as relevant today as it was in 1921.”

Originally developed for the in-person MBA classroom, HBS Online adapted the case method into an engaging, interactive online learning experience in 2014.

In HBS Online courses , you learn about each case from the business professional who experienced it. After reviewing their videos, you’re prompted to take their perspective and explain how you’d handle their situation.

You then get to read peers’ responses, “star” them, and comment to further the discussion. Afterward, you learn how the professional handled it and their key takeaways.

HBS Online’s adaptation of the case method incorporates the famed HBS “cold call,” in which you’re called on at random to make a decision without time to prepare.

“Learning came to life!” said Sheneka Balogun , chief administration officer and chief of staff at LeMoyne-Owen College, of her experience taking the Credential of Readiness (CORe) program . “The videos from the professors, the interactive cold calls where you were randomly selected to participate, and the case studies that enhanced and often captured the essence of objectives and learning goals were all embedded in each module. This made learning fun, engaging, and student-friendly.”

If you’re considering taking a course that leverages the case study method, here are five benefits you could experience.

5 Benefits of Learning Through Case Studies

1. take new perspectives.

The case method prompts you to consider a scenario from another person’s perspective. To work through the situation and come up with a solution, you must consider their circumstances, limitations, risk tolerance, stakeholders, resources, and potential consequences to assess how to respond.

Taking on new perspectives not only can help you navigate your own challenges but also others’. Putting yourself in someone else’s situation to understand their motivations and needs can go a long way when collaborating with stakeholders.

2. Hone Your Decision-Making Skills

Another skill you can build is the ability to make decisions effectively . The case study method forces you to use limited information to decide how to handle a problem—just like in the real world.

Throughout your career, you’ll need to make difficult decisions with incomplete or imperfect information—and sometimes, you won’t feel qualified to do so. Learning through the case method allows you to practice this skill in a low-stakes environment. When facing a real challenge, you’ll be better prepared to think quickly, collaborate with others, and present and defend your solution.

3. Become More Open-Minded

As you collaborate with peers on responses, it becomes clear that not everyone solves problems the same way. Exposing yourself to various approaches and perspectives can help you become a more open-minded professional.

When you’re part of a diverse group of learners from around the world, your experiences, cultures, and backgrounds contribute to a range of opinions on each case.

On the HBS Online course platform, you’re prompted to view and comment on others’ responses, and discussion is encouraged. This practice of considering others’ perspectives can make you more receptive in your career.

“You’d be surprised at how much you can learn from your peers,” said Ratnaditya Jonnalagadda , a software engineer who took CORe.

In addition to interacting with peers in the course platform, Jonnalagadda was part of the HBS Online Community , where he networked with other professionals and continued discussions sparked by course content.

“You get to understand your peers better, and students share examples of businesses implementing a concept from a module you just learned,” Jonnalagadda said. “It’s a very good way to cement the concepts in one's mind.”

4. Enhance Your Curiosity

One byproduct of taking on different perspectives is that it enables you to picture yourself in various roles, industries, and business functions.

“Each case offers an opportunity for students to see what resonates with them, what excites them, what bores them, which role they could imagine inhabiting in their careers,” says former HBS Dean Nitin Nohria in the Harvard Business Review . “Cases stimulate curiosity about the range of opportunities in the world and the many ways that students can make a difference as leaders.”

Through the case method, you can “try on” roles you may not have considered and feel more prepared to change or advance your career .

5. Build Your Self-Confidence

Finally, learning through the case study method can build your confidence. Each time you assume a business leader’s perspective, aim to solve a new challenge, and express and defend your opinions and decisions to peers, you prepare to do the same in your career.

According to a 2022 City Square Associates survey , 84 percent of HBS Online learners report feeling more confident making business decisions after taking a course.

“Self-confidence is difficult to teach or coach, but the case study method seems to instill it in people,” Nohria says in the Harvard Business Review . “There may well be other ways of learning these meta-skills, such as the repeated experience gained through practice or guidance from a gifted coach. However, under the direction of a masterful teacher, the case method can engage students and help them develop powerful meta-skills like no other form of teaching.”

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If the case method seems like a good fit for your learning style, experience it for yourself by taking an HBS Online course. Offerings span seven subject areas, including:

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  • Roberta Heale 1 ,
  • Alison Twycross 2
  • 1 School of Nursing , Laurentian University , Sudbury , Ontario , Canada
  • 2 School of Health and Social Care , London South Bank University , London , UK
  • Correspondence to Dr Roberta Heale, School of Nursing, Laurentian University, Sudbury, ON P3E2C6, Canada; rheale{at}laurentian.ca

https://doi.org/10.1136/eb-2017-102845

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What is it?

Case study is a research methodology, typically seen in social and life sciences. There is no one definition of case study research. 1 However, very simply… ‘a case study can be defined as an intensive study about a person, a group of people or a unit, which is aimed to generalize over several units’. 1 A case study has also been described as an intensive, systematic investigation of a single individual, group, community or some other unit in which the researcher examines in-depth data relating to several variables. 2

Often there are several similar cases to consider such as educational or social service programmes that are delivered from a number of locations. Although similar, they are complex and have unique features. In these circumstances, the evaluation of several, similar cases will provide a better answer to a research question than if only one case is examined, hence the multiple-case study. Stake asserts that the cases are grouped and viewed as one entity, called the quintain . 6  ‘We study what is similar and different about the cases to understand the quintain better’. 6

The steps when using case study methodology are the same as for other types of research. 6 The first step is defining the single case or identifying a group of similar cases that can then be incorporated into a multiple-case study. A search to determine what is known about the case(s) is typically conducted. This may include a review of the literature, grey literature, media, reports and more, which serves to establish a basic understanding of the cases and informs the development of research questions. Data in case studies are often, but not exclusively, qualitative in nature. In multiple-case studies, analysis within cases and across cases is conducted. Themes arise from the analyses and assertions about the cases as a whole, or the quintain, emerge. 6

Benefits and limitations of case studies

If a researcher wants to study a specific phenomenon arising from a particular entity, then a single-case study is warranted and will allow for a in-depth understanding of the single phenomenon and, as discussed above, would involve collecting several different types of data. This is illustrated in example 1 below.

Using a multiple-case research study allows for a more in-depth understanding of the cases as a unit, through comparison of similarities and differences of the individual cases embedded within the quintain. Evidence arising from multiple-case studies is often stronger and more reliable than from single-case research. Multiple-case studies allow for more comprehensive exploration of research questions and theory development. 6

Despite the advantages of case studies, there are limitations. The sheer volume of data is difficult to organise and data analysis and integration strategies need to be carefully thought through. There is also sometimes a temptation to veer away from the research focus. 2 Reporting of findings from multiple-case research studies is also challenging at times, 1 particularly in relation to the word limits for some journal papers.

Examples of case studies

Example 1: nurses’ paediatric pain management practices.

One of the authors of this paper (AT) has used a case study approach to explore nurses’ paediatric pain management practices. This involved collecting several datasets:

Observational data to gain a picture about actual pain management practices.

Questionnaire data about nurses’ knowledge about paediatric pain management practices and how well they felt they managed pain in children.

Questionnaire data about how critical nurses perceived pain management tasks to be.

These datasets were analysed separately and then compared 7–9 and demonstrated that nurses’ level of theoretical did not impact on the quality of their pain management practices. 7 Nor did individual nurse’s perceptions of how critical a task was effect the likelihood of them carrying out this task in practice. 8 There was also a difference in self-reported and observed practices 9 ; actual (observed) practices did not confirm to best practice guidelines, whereas self-reported practices tended to.

Example 2: quality of care for complex patients at Nurse Practitioner-Led Clinics (NPLCs)

The other author of this paper (RH) has conducted a multiple-case study to determine the quality of care for patients with complex clinical presentations in NPLCs in Ontario, Canada. 10 Five NPLCs served as individual cases that, together, represented the quatrain. Three types of data were collected including:

Review of documentation related to the NPLC model (media, annual reports, research articles, grey literature and regulatory legislation).

Interviews with nurse practitioners (NPs) practising at the five NPLCs to determine their perceptions of the impact of the NPLC model on the quality of care provided to patients with multimorbidity.

Chart audits conducted at the five NPLCs to determine the extent to which evidence-based guidelines were followed for patients with diabetes and at least one other chronic condition.

The three sources of data collected from the five NPLCs were analysed and themes arose related to the quality of care for complex patients at NPLCs. The multiple-case study confirmed that nurse practitioners are the primary care providers at the NPLCs, and this positively impacts the quality of care for patients with multimorbidity. Healthcare policy, such as lack of an increase in salary for NPs for 10 years, has resulted in issues in recruitment and retention of NPs at NPLCs. This, along with insufficient resources in the communities where NPLCs are located and high patient vulnerability at NPLCs, have a negative impact on the quality of care. 10

These examples illustrate how collecting data about a single case or multiple cases helps us to better understand the phenomenon in question. Case study methodology serves to provide a framework for evaluation and analysis of complex issues. It shines a light on the holistic nature of nursing practice and offers a perspective that informs improved patient care.

  • Gustafsson J
  • Calanzaro M
  • Sandelowski M

Competing interests None declared.

Provenance and peer review Commissioned; internally peer reviewed.

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10 Case Study Advantages and Disadvantages

case study advantages and disadvantages, explained below

A case study in academic research is a detailed and in-depth examination of a specific instance or event, generally conducted through a qualitative approach to data.

The most common case study definition that I come across is is Robert K. Yin’s (2003, p. 13) quote provided below:

“An empirical inquiry that investigates a contemporary phenomenon within its real-life context, especially when the boundaries between phenomenon and context are not clearly evident.”

Researchers conduct case studies for a number of reasons, such as to explore complex phenomena within their real-life context, to look at a particularly interesting instance of a situation, or to dig deeper into something of interest identified in a wider-scale project.

While case studies render extremely interesting data, they have many limitations and are not suitable for all studies. One key limitation is that a case study’s findings are not usually generalizable to broader populations because one instance cannot be used to infer trends across populations.

Case Study Advantages and Disadvantages

1. in-depth analysis of complex phenomena.

Case study design allows researchers to delve deeply into intricate issues and situations.

By focusing on a specific instance or event, researchers can uncover nuanced details and layers of understanding that might be missed with other research methods, especially large-scale survey studies.

As Lee and Saunders (2017) argue,

“It allows that particular event to be studies in detail so that its unique qualities may be identified.”

This depth of analysis can provide rich insights into the underlying factors and dynamics of the studied phenomenon.

2. Holistic Understanding

Building on the above point, case studies can help us to understand a topic holistically and from multiple angles.

This means the researcher isn’t restricted to just examining a topic by using a pre-determined set of questions, as with questionnaires. Instead, researchers can use qualitative methods to delve into the many different angles, perspectives, and contextual factors related to the case study.

We can turn to Lee and Saunders (2017) again, who notes that case study researchers “develop a deep, holistic understanding of a particular phenomenon” with the intent of deeply understanding the phenomenon.

3. Examination of rare and Unusual Phenomena

We need to use case study methods when we stumble upon “rare and unusual” (Lee & Saunders, 2017) phenomena that would tend to be seen as mere outliers in population studies.

Take, for example, a child genius. A population study of all children of that child’s age would merely see this child as an outlier in the dataset, and this child may even be removed in order to predict overall trends.

So, to truly come to an understanding of this child and get insights into the environmental conditions that led to this child’s remarkable cognitive development, we need to do an in-depth study of this child specifically – so, we’d use a case study.

4. Helps Reveal the Experiences of Marginalzied Groups

Just as rare and unsual cases can be overlooked in population studies, so too can the experiences, beliefs, and perspectives of marginalized groups.

As Lee and Saunders (2017) argue, “case studies are also extremely useful in helping the expression of the voices of people whose interests are often ignored.”

Take, for example, the experiences of minority populations as they navigate healthcare systems. This was for many years a “hidden” phenomenon, not examined by researchers. It took case study designs to truly reveal this phenomenon, which helped to raise practitioners’ awareness of the importance of cultural sensitivity in medicine.

5. Ideal in Situations where Researchers cannot Control the Variables

Experimental designs – where a study takes place in a lab or controlled environment – are excellent for determining cause and effect . But not all studies can take place in controlled environments (Tetnowski, 2015).

When we’re out in the field doing observational studies or similar fieldwork, we don’t have the freedom to isolate dependent and independent variables. We need to use alternate methods.

Case studies are ideal in such situations.

A case study design will allow researchers to deeply immerse themselves in a setting (potentially combining it with methods such as ethnography or researcher observation) in order to see how phenomena take place in real-life settings.

6. Supports the generation of new theories or hypotheses

While large-scale quantitative studies such as cross-sectional designs and population surveys are excellent at testing theories and hypotheses on a large scale, they need a hypothesis to start off with!

This is where case studies – in the form of grounded research – come in. Often, a case study doesn’t start with a hypothesis. Instead, it ends with a hypothesis based upon the findings within a singular setting.

The deep analysis allows for hypotheses to emerge, which can then be taken to larger-scale studies in order to conduct further, more generalizable, testing of the hypothesis or theory.

7. Reveals the Unexpected

When a largescale quantitative research project has a clear hypothesis that it will test, it often becomes very rigid and has tunnel-vision on just exploring the hypothesis.

Of course, a structured scientific examination of the effects of specific interventions targeted at specific variables is extermely valuable.

But narrowly-focused studies often fail to shine a spotlight on unexpected and emergent data. Here, case studies come in very useful. Oftentimes, researchers set their eyes on a phenomenon and, when examining it closely with case studies, identify data and come to conclusions that are unprecedented, unforeseen, and outright surprising.

As Lars Meier (2009, p. 975) marvels, “where else can we become a part of foreign social worlds and have the chance to become aware of the unexpected?”

Disadvantages

1. not usually generalizable.

Case studies are not generalizable because they tend not to look at a broad enough corpus of data to be able to infer that there is a trend across a population.

As Yang (2022) argues, “by definition, case studies can make no claims to be typical.”

Case studies focus on one specific instance of a phenomenon. They explore the context, nuances, and situational factors that have come to bear on the case study. This is really useful for bringing to light important, new, and surprising information, as I’ve already covered.

But , it’s not often useful for generating data that has validity beyond the specific case study being examined.

2. Subjectivity in interpretation

Case studies usually (but not always) use qualitative data which helps to get deep into a topic and explain it in human terms, finding insights unattainable by quantitative data.

But qualitative data in case studies relies heavily on researcher interpretation. While researchers can be trained and work hard to focus on minimizing subjectivity (through methods like triangulation), it often emerges – some might argue it’s innevitable in qualitative studies.

So, a criticism of case studies could be that they’re more prone to subjectivity – and researchers need to take strides to address this in their studies.

3. Difficulty in replicating results

Case study research is often non-replicable because the study takes place in complex real-world settings where variables are not controlled.

So, when returning to a setting to re-do or attempt to replicate a study, we often find that the variables have changed to such an extent that replication is difficult. Furthermore, new researchers (with new subjective eyes) may catch things that the other readers overlooked.

Replication is even harder when researchers attempt to replicate a case study design in a new setting or with different participants.

Comprehension Quiz for Students

Question 1: What benefit do case studies offer when exploring the experiences of marginalized groups?

a) They provide generalizable data. b) They help express the voices of often-ignored individuals. c) They control all variables for the study. d) They always start with a clear hypothesis.

Question 2: Why might case studies be considered ideal for situations where researchers cannot control all variables?

a) They provide a structured scientific examination. b) They allow for generalizability across populations. c) They focus on one specific instance of a phenomenon. d) They allow for deep immersion in real-life settings.

Question 3: What is a primary disadvantage of case studies in terms of data applicability?

a) They always focus on the unexpected. b) They are not usually generalizable. c) They support the generation of new theories. d) They provide a holistic understanding.

Question 4: Why might case studies be considered more prone to subjectivity?

a) They always use quantitative data. b) They heavily rely on researcher interpretation, especially with qualitative data. c) They are always replicable. d) They look at a broad corpus of data.

Question 5: In what situations are experimental designs, such as those conducted in labs, most valuable?

a) When there’s a need to study rare and unusual phenomena. b) When a holistic understanding is required. c) When determining cause-and-effect relationships. d) When the study focuses on marginalized groups.

Question 6: Why is replication challenging in case study research?

a) Because they always use qualitative data. b) Because they tend to focus on a broad corpus of data. c) Due to the changing variables in complex real-world settings. d) Because they always start with a hypothesis.

Lee, B., & Saunders, M. N. K. (2017). Conducting Case Study Research for Business and Management Students. SAGE Publications.

Meir, L. (2009). Feasting on the Benefits of Case Study Research. In Mills, A. J., Wiebe, E., & Durepos, G. (Eds.). Encyclopedia of Case Study Research (Vol. 2). London: SAGE Publications.

Tetnowski, J. (2015). Qualitative case study research design.  Perspectives on fluency and fluency disorders ,  25 (1), 39-45. ( Source )

Yang, S. L. (2022). The War on Corruption in China: Local Reform and Innovation . Taylor & Francis.

Yin, R. (2003). Case Study research. Thousand Oaks, CA: Sage.

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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.

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

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

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.

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What is a Case Study? [+6 Types of Case Studies]

By Ronita Mohan , Sep 20, 2021

What is a Case Study Blog Header

Case studies have become powerful business tools. But what is a case study? What are the benefits of creating one? Are there limitations to the format?

If you’ve asked yourself these questions, our helpful guide will clear things up. Learn how to use a case study for business. Find out how cases analysis works in psychology and research.

We’ve also got examples of case studies to inspire you.

Haven’t made a case study before? You can easily  create a case study  with Venngage’s customizable templates.

CREATE A CASE STUDY

Click to jump ahead:

What is a case study, what is the case study method, benefits of case studies, limitations of case studies, types of case studies, faqs about case studies.

Case studies are research methodologies. They examine subjects, projects, or organizations to tell a story.

Case Study Definition LinkedIn Post

USE THIS TEMPLATE

Numerous sectors use case analyses. The social sciences, social work, and psychology create studies regularly.

Healthcare industries write reports on patients and diagnoses. Marketing case study examples , like the one below, highlight the benefits of a business product.

Bold Social Media Business Case Study Template

CREATE THIS REPORT TEMPLATE

Now that you know what a case study is, we explain how case reports are used in three different industries.

What is a business case study?

A business or marketing case study aims at showcasing a successful partnership. This can be between a brand and a client. Or the case study can examine a brand’s project.

There is a perception that case studies are used to advertise a brand. But effective reports, like the one below, can show clients how a brand can support them.

Light Simple Business Case Study Template

Hubspot created a case study on a customer that successfully scaled its business. The report outlines the various Hubspot tools used to achieve these results.

Hubspot case study

Hubspot also added a video with testimonials from the client company’s employees.

So, what is the purpose of a case study for businesses? There is a lot of competition in the corporate world. Companies are run by people. They can be on the fence about which brand to work with.

Business reports  stand out aesthetically, as well. They use  brand colors  and brand fonts . Usually, a combination of the client’s and the brand’s.

With the Venngage  My Brand Kit  feature, businesses can automatically apply their brand to designs.

A business case study, like the one below, acts as social proof. This helps customers decide between your brand and your competitors.

Modern lead Generation Business Case Study Template

Don’t know how to design a report? You can learn  how to write a case study  with Venngage’s guide. We also share design tips and examples that will help you convert.

Related: 55+ Annual Report Design Templates, Inspirational Examples & Tips [Updated]

What is a case study in psychology?

In the field of psychology, case studies focus on a particular subject. Psychology case histories also examine human behaviors.

Case reports search for commonalities between humans. They are also used to prescribe further research. Or these studies can elaborate on a solution for a behavioral ailment.

The American Psychology Association  has a number of case studies on real-life clients. Note how the reports are more text-heavy than a business case study.

What is a case study in psychology? Behavior therapy example

Famous psychologists such as Sigmund Freud and Anna O popularised the use of case studies in the field. They did so by regularly interviewing subjects. Their detailed observations build the field of psychology.

It is important to note that psychological studies must be conducted by professionals. Psychologists, psychiatrists and therapists should be the researchers in these cases.

Related: What Netflix’s Top 50 Shows Can Teach Us About Font Psychology [Infographic]

What is a case study in research?

Research is a necessary part of every case study. But specific research fields are required to create studies. These fields include user research, healthcare, education, or social work.

For example, this UX Design  report examined the public perception of a client. The brand researched and implemented new visuals to improve it. The study breaks down this research through lessons learned.

What is a case study in research? UX Design case study example

Clinical reports are a necessity in the medical field. These documents are used to share knowledge with other professionals. They also help examine new or unusual diseases or symptoms.

The pandemic has led to a significant increase in research. For example,  Spectrum Health  studied the value of health systems in the pandemic. They created the study by examining community outreach.

What is a case study in research? Spectrum healthcare example

The pandemic has significantly impacted the field of education. This has led to numerous examinations on remote studying. There have also been studies on how students react to decreased peer communication.

Social work case reports often have a community focus. They can also examine public health responses. In certain regions, social workers study disaster responses.

You now know what case studies in various fields are. In the next step of our guide, we explain the case study method.

Return to Table of Contents

A case analysis is a deep dive into a subject. To facilitate this case studies are built on interviews and observations. The below example would have been created after numerous interviews.

Case studies are largely qualitative. They analyze and describe phenomena. While some data is included, a case analysis is not quantitative.

There are a few steps in the case method. You have to start by identifying the subject of your study. Then determine what kind of research is required.

In natural sciences, case studies can take years to complete. Business reports, like this one, don’t take that long. A few weeks of interviews should be enough.

Blue Simple Business Case Study Template

The case method will vary depending on the industry. Reports will also look different once produced.

As you will have seen, business reports are more colorful. The design is also more accessible . Healthcare and psychology reports are more text-heavy.

Designing case reports takes time and energy. So, is it worth taking the time to write them? Here are the benefits of creating case studies.

  • Collects large amounts of information
  • Helps formulate hypotheses
  • Builds the case for further research
  • Discovers new insights into a subject
  • Builds brand trust and loyalty
  • Engages customers through stories

For example, the business study below creates a story around a brand partnership. It makes for engaging reading. The study also shows evidence backing up the information.

Blue Content Marketing Case Study Template

We’ve shared the benefits of why studies are needed. We will also look at the limitations of creating them.

Related: How to Present a Case Study like a Pro (With Examples)

There are a few disadvantages to conducting a case analysis. The limitations will vary according to the industry.

  • Responses from interviews are subjective
  • Subjects may tailor responses to the researcher
  • Studies can’t always be replicated
  • In certain industries, analyses can take time and be expensive
  • Risk of generalizing the results among a larger population

These are some of the common weaknesses of creating case reports. If you’re on the fence, look at the competition in your industry.

Other brands or professionals are building reports, like this example. In that case, you may want to do the same.

Coral content marketing case study template

There are six common types of case reports. Depending on your industry, you might use one of these types.

Descriptive case studies

Explanatory case studies, exploratory case reports, intrinsic case studies, instrumental case studies, collective case reports.

6 Types Of Case Studies List

USE THIS TEMPLATE

We go into more detail about each type of study in the guide below.

Related:  15+ Professional Case Study Examples [Design Tips + Templates]

When you have an existing hypothesis, you can design a descriptive study. This type of report starts with a description. The aim is to find connections between the subject being studied and a theory.

Once these connections are found, the study can conclude. The results of this type of study will usually suggest how to develop a theory further.

A study like the one below has concrete results. A descriptive report would use the quantitative data as a suggestion for researching the subject deeply.

Lead generation business case study template

When an incident occurs in a field, an explanation is required. An explanatory report investigates the cause of the event. It will include explanations for that cause.

The study will also share details about the impact of the event. In most cases, this report will use evidence to predict future occurrences. The results of explanatory reports are definitive.

Note that there is no room for interpretation here. The results are absolute.

The study below is a good example. It explains how one brand used the services of another. It concludes by showing definitive proof that the collaboration was successful.

Bold Content Marketing Case Study Template

Another example of this study would be in the automotive industry. If a vehicle fails a test, an explanatory study will examine why. The results could show that the failure was because of a particular part.

Related: How to Write a Case Study [+ Design Tips]

An explanatory report is a self-contained document. An exploratory one is only the beginning of an investigation.

Exploratory cases act as the starting point of studies. This is usually conducted as a precursor to large-scale investigations. The research is used to suggest why further investigations are needed.

An exploratory study can also be used to suggest methods for further examination.

For example, the below analysis could have found inconclusive results. In that situation, it would be the basis for an in-depth study.

Teal Social Media Business Case Study Template

Intrinsic studies are more common in the field of psychology. These reports can also be conducted in healthcare or social work.

These types of studies focus on a unique subject, such as a patient. They can sometimes study groups close to the researcher.

The aim of such studies is to understand the subject better. This requires learning their history. The researcher will also examine how they interact with their environment.

For instance, if the case study below was about a unique brand, it could be an intrinsic study.

Vibrant Content Marketing Case Study Template

Once the study is complete, the researcher will have developed a better understanding of a phenomenon. This phenomenon will likely not have been studied or theorized about before.

Examples of intrinsic case analysis can be found across psychology. For example, Jean Piaget’s theories on cognitive development. He established the theory from intrinsic studies into his own children.

Related: What Disney Villains Can Tell Us About Color Psychology [Infographic]

This is another type of study seen in medical and psychology fields. Instrumental reports are created to examine more than just the primary subject.

When research is conducted for an instrumental study, it is to provide the basis for a larger phenomenon. The subject matter is usually the best example of the phenomenon. This is why it is being studied.

Purple SAAS Business Case Study Template

Assume it’s examining lead generation strategies. It may want to show that visual marketing is the definitive lead generation tool. The brand can conduct an instrumental case study to examine this phenomenon.

Collective studies are based on instrumental case reports. These types of studies examine multiple reports.

There are a number of reasons why collective reports are created:

  • To provide evidence for starting a new study
  • To find pattens between multiple instrumental reports
  • To find differences in similar types of cases
  • Gain a deeper understanding of a complex phenomenon
  • Understand a phenomenon from diverse contexts

A researcher could use multiple reports, like the one below, to build a collective case report.

Social Media Business Case Study template

Related: 10+ Case Study Infographic Templates That Convert

What makes a case study a case study?

A case study has a very particular research methodology. They are an in-depth study of a person or a group of individuals. They can also study a community or an organization. Case reports examine real-world phenomena within a set context.

How long should a case study be?

The length of studies depends on the industry. It also depends on the story you’re telling. Most case studies should be at least 500-1500 words long. But you can increase the length if you have more details to share.

What should you ask in a case study?

The one thing you shouldn’t ask is ‘yes’ or ‘no’ questions. Case studies are qualitative. These questions won’t give you the information you need.

Ask your client about the problems they faced. Ask them about solutions they found. Or what they think is the ideal solution. Leave room to ask them follow-up questions. This will help build out the study.

How to present a case study?

When you’re ready to present a case study, begin by providing a summary of the problem or challenge you were addressing. Follow this with an outline of the solution you implemented, and support this with the results you achieved, backed by relevant data. Incorporate visual aids like slides, graphs, and images to make your case study presentation more engaging and impactful.

Now you know what a case study means, you can begin creating one. These reports are a great tool for analyzing brands. They are also useful in a variety of other fields.

Use a visual communication platform like Venngage to design case studies. With Venngage’s templates, you can design easily. Create branded, engaging reports, all without design experience.

How to write a case study — examples, templates, and tools

How to write a case study — examples, templates, and tools marquee

It’s a marketer’s job to communicate the effectiveness of a product or service to potential and current customers to convince them to buy and keep business moving. One of the best methods for doing this is to share success stories that are relatable to prospects and customers based on their pain points, experiences, and overall needs.

That’s where case studies come in. Case studies are an essential part of a content marketing plan. These in-depth stories of customer experiences are some of the most effective at demonstrating the value of a product or service. Yet many marketers don’t use them, whether because of their regimented formats or the process of customer involvement and approval.

A case study is a powerful tool for showcasing your hard work and the success your customer achieved. But writing a great case study can be difficult if you’ve never done it before or if it’s been a while. This guide will show you how to write an effective case study and provide real-world examples and templates that will keep readers engaged and support your business.

In this article, you’ll learn:

What is a case study?

How to write a case study, case study templates, case study examples, case study tools.

A case study is the detailed story of a customer’s experience with a product or service that demonstrates their success and often includes measurable outcomes. Case studies are used in a range of fields and for various reasons, from business to academic research. They’re especially impactful in marketing as brands work to convince and convert consumers with relatable, real-world stories of actual customer experiences.

The best case studies tell the story of a customer’s success, including the steps they took, the results they achieved, and the support they received from a brand along the way. To write a great case study, you need to:

  • Celebrate the customer and make them — not a product or service — the star of the story.
  • Craft the story with specific audiences or target segments in mind so that the story of one customer will be viewed as relatable and actionable for another customer.
  • Write copy that is easy to read and engaging so that readers will gain the insights and messages intended.
  • Follow a standardized format that includes all of the essentials a potential customer would find interesting and useful.
  • Support all of the claims for success made in the story with data in the forms of hard numbers and customer statements.

Case studies are a type of review but more in depth, aiming to show — rather than just tell — the positive experiences that customers have with a brand. Notably, 89% of consumers read reviews before deciding to buy, and 79% view case study content as part of their purchasing process. When it comes to B2B sales, 52% of buyers rank case studies as an important part of their evaluation process.

Telling a brand story through the experience of a tried-and-true customer matters. The story is relatable to potential new customers as they imagine themselves in the shoes of the company or individual featured in the case study. Showcasing previous customers can help new ones see themselves engaging with your brand in the ways that are most meaningful to them.

Besides sharing the perspective of another customer, case studies stand out from other content marketing forms because they are based on evidence. Whether pulling from client testimonials or data-driven results, case studies tend to have more impact on new business because the story contains information that is both objective (data) and subjective (customer experience) — and the brand doesn’t sound too self-promotional.

89% of consumers read reviews before buying, 79% view case studies, and 52% of B2B buyers prioritize case studies in the evaluation process.

Case studies are unique in that there’s a fairly standardized format for telling a customer’s story. But that doesn’t mean there isn’t room for creativity. It’s all about making sure that teams are clear on the goals for the case study — along with strategies for supporting content and channels — and understanding how the story fits within the framework of the company’s overall marketing goals.

Here are the basic steps to writing a good case study.

1. Identify your goal

Start by defining exactly who your case study will be designed to help. Case studies are about specific instances where a company works with a customer to achieve a goal. Identify which customers are likely to have these goals, as well as other needs the story should cover to appeal to them.

The answer is often found in one of the buyer personas that have been constructed as part of your larger marketing strategy. This can include anything from new leads generated by the marketing team to long-term customers that are being pressed for cross-sell opportunities. In all of these cases, demonstrating value through a relatable customer success story can be part of the solution to conversion.

2. Choose your client or subject

Who you highlight matters. Case studies tie brands together that might otherwise not cross paths. A writer will want to ensure that the highlighted customer aligns with their own company’s brand identity and offerings. Look for a customer with positive name recognition who has had great success with a product or service and is willing to be an advocate.

The client should also match up with the identified target audience. Whichever company or individual is selected should be a reflection of other potential customers who can see themselves in similar circumstances, having the same problems and possible solutions.

Some of the most compelling case studies feature customers who:

  • Switch from one product or service to another while naming competitors that missed the mark.
  • Experience measurable results that are relatable to others in a specific industry.
  • Represent well-known brands and recognizable names that are likely to compel action.
  • Advocate for a product or service as a champion and are well-versed in its advantages.

Whoever or whatever customer is selected, marketers must ensure they have the permission of the company involved before getting started. Some brands have strict review and approval procedures for any official marketing or promotional materials that include their name. Acquiring those approvals in advance will prevent any miscommunication or wasted effort if there is an issue with their legal or compliance teams.

3. Conduct research and compile data

Substantiating the claims made in a case study — either by the marketing team or customers themselves — adds validity to the story. To do this, include data and feedback from the client that defines what success looks like. This can be anything from demonstrating return on investment (ROI) to a specific metric the customer was striving to improve. Case studies should prove how an outcome was achieved and show tangible results that indicate to the customer that your solution is the right one.

This step could also include customer interviews. Make sure that the people being interviewed are key stakeholders in the purchase decision or deployment and use of the product or service that is being highlighted. Content writers should work off a set list of questions prepared in advance. It can be helpful to share these with the interviewees beforehand so they have time to consider and craft their responses. One of the best interview tactics to keep in mind is to ask questions where yes and no are not natural answers. This way, your subject will provide more open-ended responses that produce more meaningful content.

4. Choose the right format

There are a number of different ways to format a case study. Depending on what you hope to achieve, one style will be better than another. However, there are some common elements to include, such as:

  • An engaging headline
  • A subject and customer introduction
  • The unique challenge or challenges the customer faced
  • The solution the customer used to solve the problem
  • The results achieved
  • Data and statistics to back up claims of success
  • A strong call to action (CTA) to engage with the vendor

It’s also important to note that while case studies are traditionally written as stories, they don’t have to be in a written format. Some companies choose to get more creative with their case studies and produce multimedia content, depending on their audience and objectives. Case study formats can include traditional print stories, interactive web or social content, data-heavy infographics, professionally shot videos, podcasts, and more.

5. Write your case study

We’ll go into more detail later about how exactly to write a case study, including templates and examples. Generally speaking, though, there are a few things to keep in mind when writing your case study.

  • Be clear and concise. Readers want to get to the point of the story quickly and easily, and they’ll be looking to see themselves reflected in the story right from the start.
  • Provide a big picture. Always make sure to explain who the client is, their goals, and how they achieved success in a short introduction to engage the reader.
  • Construct a clear narrative. Stick to the story from the perspective of the customer and what they needed to solve instead of just listing product features or benefits.
  • Leverage graphics. Incorporating infographics, charts, and sidebars can be a more engaging and eye-catching way to share key statistics and data in readable ways.
  • Offer the right amount of detail. Most case studies are one or two pages with clear sections that a reader can skim to find the information most important to them.
  • Include data to support claims. Show real results — both facts and figures and customer quotes — to demonstrate credibility and prove the solution works.

6. Promote your story

Marketers have a number of options for distribution of a freshly minted case study. Many brands choose to publish case studies on their website and post them on social media. This can help support SEO and organic content strategies while also boosting company credibility and trust as visitors see that other businesses have used the product or service.

Marketers are always looking for quality content they can use for lead generation. Consider offering a case study as gated content behind a form on a landing page or as an offer in an email message. One great way to do this is to summarize the content and tease the full story available for download after the user takes an action.

Sales teams can also leverage case studies, so be sure they are aware that the assets exist once they’re published. Especially when it comes to larger B2B sales, companies often ask for examples of similar customer challenges that have been solved.

Now that you’ve learned a bit about case studies and what they should include, you may be wondering how to start creating great customer story content. Here are a couple of templates you can use to structure your case study.

Template 1 — Challenge-solution-result format

  • Start with an engaging title. This should be fewer than 70 characters long for SEO best practices. One of the best ways to approach the title is to include the customer’s name and a hint at the challenge they overcame in the end.
  • Create an introduction. Lead with an explanation as to who the customer is, the need they had, and the opportunity they found with a specific product or solution. Writers can also suggest the success the customer experienced with the solution they chose.
  • Present the challenge. This should be several paragraphs long and explain the problem the customer faced and the issues they were trying to solve. Details should tie into the company’s products and services naturally. This section needs to be the most relatable to the reader so they can picture themselves in a similar situation.
  • Share the solution. Explain which product or service offered was the ideal fit for the customer and why. Feel free to delve into their experience setting up, purchasing, and onboarding the solution.
  • Explain the results. Demonstrate the impact of the solution they chose by backing up their positive experience with data. Fill in with customer quotes and tangible, measurable results that show the effect of their choice.
  • Ask for action. Include a CTA at the end of the case study that invites readers to reach out for more information, try a demo, or learn more — to nurture them further in the marketing pipeline. What you ask of the reader should tie directly into the goals that were established for the case study in the first place.

Template 2 — Data-driven format

  • Start with an engaging title. Be sure to include a statistic or data point in the first 70 characters. Again, it’s best to include the customer’s name as part of the title.
  • Create an overview. Share the customer’s background and a short version of the challenge they faced. Present the reason a particular product or service was chosen, and feel free to include quotes from the customer about their selection process.
  • Present data point 1. Isolate the first metric that the customer used to define success and explain how the product or solution helped to achieve this goal. Provide data points and quotes to substantiate the claim that success was achieved.
  • Present data point 2. Isolate the second metric that the customer used to define success and explain what the product or solution did to achieve this goal. Provide data points and quotes to substantiate the claim that success was achieved.
  • Present data point 3. Isolate the final metric that the customer used to define success and explain what the product or solution did to achieve this goal. Provide data points and quotes to substantiate the claim that success was achieved.
  • Summarize the results. Reiterate the fact that the customer was able to achieve success thanks to a specific product or service. Include quotes and statements that reflect customer satisfaction and suggest they plan to continue using the solution.
  • Ask for action. Include a CTA at the end of the case study that asks readers to reach out for more information, try a demo, or learn more — to further nurture them in the marketing pipeline. Again, remember that this is where marketers can look to convert their content into action with the customer.

While templates are helpful, seeing a case study in action can also be a great way to learn. Here are some examples of how Adobe customers have experienced success.

Juniper Networks

One example is the Adobe and Juniper Networks case study , which puts the reader in the customer’s shoes. The beginning of the story quickly orients the reader so that they know exactly who the article is about and what they were trying to achieve. Solutions are outlined in a way that shows Adobe Experience Manager is the best choice and a natural fit for the customer. Along the way, quotes from the client are incorporated to help add validity to the statements. The results in the case study are conveyed with clear evidence of scale and volume using tangible data.

A Lenovo case study showing statistics, a pull quote and featured headshot, the headline "The customer is king.," and Adobe product links.

The story of Lenovo’s journey with Adobe is one that spans years of planning, implementation, and rollout. The Lenovo case study does a great job of consolidating all of this into a relatable journey that other enterprise organizations can see themselves taking, despite the project size. This case study also features descriptive headers and compelling visual elements that engage the reader and strengthen the content.

Tata Consulting

When it comes to using data to show customer results, this case study does an excellent job of conveying details and numbers in an easy-to-digest manner. Bullet points at the start break up the content while also helping the reader understand exactly what the case study will be about. Tata Consulting used Adobe to deliver elevated, engaging content experiences for a large telecommunications client of its own — an objective that’s relatable for a lot of companies.

Case studies are a vital tool for any marketing team as they enable you to demonstrate the value of your company’s products and services to others. They help marketers do their job and add credibility to a brand trying to promote its solutions by using the experiences and stories of real customers.

When you’re ready to get started with a case study:

  • Think about a few goals you’d like to accomplish with your content.
  • Make a list of successful clients that would be strong candidates for a case study.
  • Reach out to the client to get their approval and conduct an interview.
  • Gather the data to present an engaging and effective customer story.

Adobe can help

There are several Adobe products that can help you craft compelling case studies. Adobe Experience Platform helps you collect data and deliver great customer experiences across every channel. Once you’ve created your case studies, Experience Platform will help you deliver the right information to the right customer at the right time for maximum impact.

To learn more, watch the Adobe Experience Platform story .

Keep in mind that the best case studies are backed by data. That’s where Adobe Real-Time Customer Data Platform and Adobe Analytics come into play. With Real-Time CDP, you can gather the data you need to build a great case study and target specific customers to deliver the content to the right audience at the perfect moment.

Watch the Real-Time CDP overview video to learn more.

Finally, Adobe Analytics turns real-time data into real-time insights. It helps your business collect and synthesize data from multiple platforms to make more informed decisions and create the best case study possible.

Request a demo to learn more about Adobe Analytics.

https://business.adobe.com/blog/perspectives/b2b-ecommerce-10-case-studies-inspire-you

https://business.adobe.com/blog/basics/business-case

https://business.adobe.com/blog/basics/what-is-real-time-analytics

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When and How to Use a Case Study for Research

May 17, 2021 (Updated: May 4, 2023)

case studies are useful for

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What Is Case Study Research?

Types of case studies, when should you use a case study, case study benefits, case study limitations, how to write a case study.

Imagine your company receives a string of negative reviews online. You notice a few common themes among the complaints, but you still aren’t quite sure what went wrong. Or suppose an old blog post suddenly went viral, and you’d like to know why and how to do it again. In both of these situations, a case study could be the best way to find answers.

A case study is a process whereby researchers examine a specific subject in a thorough, detailed way. The subject of a case study could be an individual, a group, a community, a business, an organization, an event, or a phenomenon. Regardless of the type of subject, case studies are in-depth investigations designed to identify patterns and cause-and-effect relationships. Case studies are often used by researchers in the field of psychology , medicine, business, social work, anthropology, education, or political science.

Because they are singular in their focus and often rely on qualitative data, case studies tend to be highly subjective. The results of a single case study cannot always be generalized and applied to the larger population. However, case studies can be valuable tools for developing a thesis or illustrating a principle. They can help researchers understand, describe, compare, and evaluate different aspects of an issue or question.

case studies are useful for

Image via Flickr by plings

Case studies can be classified according to their purpose or their subject. For instance, a case study can focus on any of the following:

  • A person:  Some case studies focus on one particular person. Often, the subject will be an individual with some rare characteristic or experience.
  • A group:  Group case studies could look at a family, a group of coworkers, or a friend group. It could be people thrown together by circumstance or who share some bond or relationship. A group case study could even focus on an entire community of people.
  • An organization:  An organizational case study could focus on a business, a nonprofit, an institution, or any other formal entity. The study could look at the people in the organization, the processes they use, or an incident at the organization.
  • A location:  An event case study focuses on a specific area. It could be used to study environmental and population changes or to examine how people use the location.
  • An event:  Event case studies can be used to cover anything from a natural disaster to a political scandal. Often, these case studies are conducted retrospectively, as an investigation into a past event.

In addition to different types of subjects, case studies often have different designs or purposes. Here are a few of the most common types of case studies:

  • Explanatory:  An explanatory case study tries to explain the why or how behind something. This type of case study works well when studying an event or phenomenon, like an airplane crash or unexpected power outage.
  • Descriptive:  A descriptive, or illustrative, case study is designed to shed light on an unfamiliar subject. Case studies like this provide in-depth, real-world examples of whatever the researcher wants to help the audience understand. For instance, a descriptive case study could focus on the experience of a mother with postpartum depression or on a young adult who has aged out of the foster care system.
  • Exploratory:  An exploratory case study, or pilot case study, often serves as the first step in a larger research project. Researchers may use a case study to help them narrow their focus, draft a specific research question, and guide the parameters of a formal, large-scale study.
  • Intrinsic:  An intrinsic case study has no goal beyond a deeper understanding of its subject. In this type of study, researchers are not trying to make generalized conclusions, challenge existing assumptions, or make any compare-and-contrast connections. The most interesting thing about the study is the subject itself.
  • Critical Instance:  A critical instance case study is similar to an explanatory or intrinsic study. Like an intrinsic study, it may have no predetermined purpose beyond investigating the subject. Like an explanatory study, it may be used to explain a cause-and-effect relationship. A critical instance case study may also be used to call into question a commonly held assumption or popular theory.
  • Instrumental:  An instrumental case study is the opposite of an intrinsic study because it serves a purpose beyond understanding the immediate subject. In this type of study, researchers explore a larger question through an individual case or cases. For instance, researchers could use a handful of case studies to investigate the relationship between social media use and happiness.
  • Cumulative:  A cumulative, or collective, case study uses information from several past studies as the basis for a new study. Because it takes into account multiple case studies, a cumulative study allows for greater generalization than a single case study. It can also be a more time- and cost-effective option since it makes use of existing research.

Case studies are often used in the exploratory phase of research to gather qualitative data. They can also be used to create, support, or refute a hypothesis and guide future research. For instance, a marketing professional might conduct a case study to discover why a viral ad campaign was so successful . They can then take any lessons they glean from the case study and apply them to future marketing efforts. A psychologist could use a case study to form a theory about the best way to treat a specific disorder. That theory could then be tested later through a large-scale controlled study.

Case studies are a good way to explore a real-world topic in-depth, illustrate a point, discuss the implications or meaning of an event, or compare the experiences of different individuals. A trainer may use a case study to bring to life what would otherwise be an abstract series of recommended action steps or to spark a conversation about how to respond in a specific scenario. Similarly, professors can use case studies to highlight key concepts from a lecture and pose questions to test students’ understanding of the material.

In some situations, case studies are the only way to compile quantitative data in an ethical manner. For instance, many of the recommendations that doctors make regarding what is or is not safe during pregnancy are based on case studies. It wouldn’t be ethical to conduct a controlled study that exposes pregnant women to potentially harmful substances, so doctors rely on the anecdotal evidence provided by case studies to find correlations and draw their conclusions.

Case studies can also be used to gather data that would be otherwise impossible or impractical to obtain. Students often use case studies for their thesis or dissertation when they lack the time or resources to conduct large-scale research. Zoologists might use existing case studies to determine the success rate of reintroducing rehabilitated animals into the wild. A historian could use case studies to explore the strategies used by dictators to gain and maintain power.

case studies are useful for

Image via Flickr by calebmmartin

Case studies can be used on their own or as a complement to other research methods, depending on the situation. The examples above are just a few instances where case studies can be useful. Case studies also work well for the following:

Providing Insight Through Qualitative Data

Case studies generally provide more qualitative data as opposed to quantitative data , and that makes them an invaluable tool for gathering insight into complex topics. Psychologists, for instance, use case studies to better understand human behavior. Crafting theories on the motives behind human actions would be difficult with quantitative data alone. The information gleaned through case studies may be subjective, but so is much of what makes us human. As individuals, we each have a unique blend of emotions, attitudes, opinions, motivations, and behaviors. Objective quantitative data is rarely the best way to identify and explain these nuances.

By their very nature, case studies allow more more intensive, in-depth study than other research methods. Rather than aiming for a large sample size, case studies follow a single subject. Often case studies are conducted over a longer period of time, and the narrow focus allows researchers to gather more detail than would be possible in a study of thousands of people. The information gleaned may not be representative of the broader population, but it does provide richer insight into the subject than other research methods.

Identifying Avenues for Future Research

Case studies are often used as the first step in a larger research project. The results of a case study cannot necessarily be generalized, but they can help researchers narrow their focus. For instance, researchers in the medical field might conduct a case study on a patient who survived an injury that typically proves fatal.

Over the course of the study, researchers may identify two or three ways in which this patient’s situation differed from others they have seen. Perhaps they identify something unique in the patient’s DNA or lifestyle choices or in the steps doctors took to treat the injury. Letting that information guide them, researchers could use other methods to deepen their understanding of those factors and perhaps develop new treatments or preventative recommendations.

Case studies can also be used in the fields of social work, politics, and anthropology to draw attention to a widespread problem and spur more research. A detailed narrative about one person’s experience will inspire more compassion than an academic paper filled with quantitative data. Stories often have a greater impact than statistics.

Challenging, Testing, or Developing Theories

Case studies can be particularly useful in the process of forming and testing theories. A case study may lead researchers to form a new theory or call into a question an existing one. They are an invaluable tool for identifying exceptions to a rule or disproving conventional wisdom.

For instance, a medical professional may write a case study about a patient who exhibited atypical symptoms to assert that the list of symptoms for a condition should be expanded. A psychologist could use a case study to determine whether the new treatment they devised for depression is effective, or to demonstrate that existing treatment methods are flawed. As the result of a case study, a marketing professional could suggest that consumers values have changed and that marketing best practices should be updated accordingly.

Enabling the Study of Unique Subjects

Some subjects would be impossible, impractical, or unethical to study through other research methods. This is true in the case of extremely rare phenomenon, many aspects of human behavior, and even some medical conditions.

Suppose a medical professional would like to gather more information about multiple-birth pregnancies with four or more fetuses. More information would be helpful because we have less information about them, but the reason we have less information is because they are so rare. Conducting case studies of a few women who are currently pregnant with multiples or have given birth to multiples in the past may be the only practical way to research them.

Case studies can also be used to gain insight into historical events and natural phenomenon — things we are not able to repeat at will. Case studies have also been used to study subjects such as a feral child , child prodigies, rare psychological conditions, crisis response, and more.

Helping People Better Understand Nuanced Concepts

Educators incorporate case studies into their lectures for a reason. Walking students through a detailed case study can make the abstract seem more real and draw out the nuances of a concept. Case studies can facilitate engaging discussions, spark thoughtful questions, and give students a chance to apply what they have learned to real-world situations.

Outside the classroom, case studies can be used to illustrate complex ideas. For instance, a well-constructed case study can highlight the unintended consequences of a new piece of legislation or demonstrate that depression does not always manifest in an obvious way. Case studies can help readers and listeners understand and care about an issue that does not directly affect them.

Despite their benefits, case studies do come with a few limitations. Compared to other research methods, case studies are often at a disadvantage in terms of the following:

Replicability

In most cases, scientists strive to create experiments that can be repeated by others. That way, other scientists can perform their own research and compare their results to those of the initial study. Assuming these other scientists achieve similar results, the replicability of the experiment lends credibility to the findings and theories of the original researchers.

One limitation of case studies is that they are often difficult, if not impossible, to replicate. Although this fact does not diminish the value of case studies, it does demonstrate that case studies are not a good fit for every research problem — at least, not on their own. Additional research would have to be performed to corroborate the results and prove or disprove any generalized theories generated by a case study.

Generalization

Generalization is another area in which case studies cannot match other research methods. A case study can help us challenge existing theories and form new ones, but its results cannot necessarily be generalized. The data we gather from a case study is only valid for that specific subject, and we cannot assume that our conclusions apply to the broader population.

Researchers or readers can attempt to apply the principles from a particular case to similar situations or incorporate the results into a more comprehensive theory. However, a case study by itself can only prove the existence of certain possibilities and exceptions, not a general rule.

Reliability

The reliability of case studies may be called into question for two reasons. The first objection centers on the fallibility of human memory and the question of whether subjects are being honest. Many case studies rely on subjects to self-report biographical details, their state of mind, their thoughts and feelings, or their behaviors.

The second issue is the Hawthorne effect, which refers to the tendency of individuals to modify their behavior when they know they are being observed. This effect makes it nearly impossible for researchers to ensure that the observations and conclusions of their case study are reliable.

Researcher Bias

Researcher bias is another potential issue with case studies. The results of a case study are by nature subjective and qualitative rather than objective and qualitative, and any findings rely heavily on the observations and narrative provided by the researcher. Even the best researchers are still human, and no matter how hard they try to remain objective, they will not be able to keep their findings completely free of bias.

Researchers may have biases they are not even aware of. A researcher may over-identify with the subject and lose the benefit of a dispassionate outside perspective. If the researcher already has an opinion on the subject, they may subconsciously overlook or discount facts that contradict their pre-existing assumptions. Researcher bias can affect what the researcher observes and records, as well as how they interpret and apply their observations.

Case studies can be time-consuming and expensive to conduct. Crafting a thorough case study can be a lengthy project due to the intensive, detailed nature of this type of research. Plus, once the information has been gathered, it must be interpreted. Between the observation and analysis, a case study could take months or even years to complete. Researchers will need to be heavily involved in every step of the process, putting in a lot of time, energy, focus, and effort to ensure that the case study is as informative as possible.

Now that you understand the benefits, limitations, and types of case studies, you can follow these steps to write your own:

  • Determine your objective.  Write out your research problem, question, or goal. If you aren’t sure, ask yourself questions like, “What am I trying to accomplish? What do I need to know? What will success look like?” Be clear and specific. Your answers will help you choose the right type of case study for your needs.
  • Review the research.  Before delving into your case study, take some time to review the research that is already available. The information you gather during this preliminary research can help guide your efforts.
  • Choose a subject.  Decide what or who the subject of your case study will be. For instance, if you are conducting a case study to find out how businesses have been affected by new CDC guidelines, you will need to choose a specific restaurant or retailer. In some cases, you may need to draft a release form for the subject to sign so that you will be able to publish your study.
  • Gather information.  Case studies about a person, organization, or group may rely on questionnaires or interviews to gather information. If you are studying an event, you might use a combination of academic research and witness interviews. In some cases, you will record your own observations as part of the study.
  • Write a report.  Most case studies culminate in a written report, similar to a research paper. Most case studies include five sections : an introduction, a literature review, an explanation of your methods, a discussion of your findings and the implications, followed by a conclusion.
  • Publish your findings.  Once you’ve written your case study, consider the most engaging way to present your findings. A well-written research article is a good place to start, but going a step further will maximize the impact of your research. For instance, you could design an infographic to highlight key findings or commission an animated video to turn your case study into a visual narrative.

Whether research is your primary occupation or only an incidental part of your job, you can benefit from a solid understanding of what case studies are, how they work, and when to use them. Use the information and steps above to design and write a case study that will provide the answers you’re looking for.

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The case study approach

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

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

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

Peer Review 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 1 , 2 , 3 and 4 ) and those of others to illustrate our discussion[ 3 – 7 ].

What is a case study?

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

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

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

What are case studies used for?

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

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

How are case studies conducted?

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

Defining the case

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

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

Selecting the case(s)

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

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

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

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

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

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

Collecting the data

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

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

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

Analysing, interpreting and reporting case studies

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

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

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

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

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

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

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

Conclusions

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

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Acknowledgements

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

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Sarah Crowe & Anthony Avery

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

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case studies are useful for

Hertz CEO Kathryn Marinello with CFO Jamere Jackson and other members of the executive team in 2017

Top 40 Most Popular Case Studies of 2021

Two cases about Hertz claimed top spots in 2021's Top 40 Most Popular Case Studies

Two cases on the uses of debt and equity at Hertz claimed top spots in the CRDT’s (Case Research and Development Team) 2021 top 40 review of cases.

Hertz (A) took the top spot. The case details the financial structure of the rental car company through the end of 2019. Hertz (B), which ranked third in CRDT’s list, describes the company’s struggles during the early part of the COVID pandemic and its eventual need to enter Chapter 11 bankruptcy. 

The success of the Hertz cases was unprecedented for the top 40 list. Usually, cases take a number of years to gain popularity, but the Hertz cases claimed top spots in their first year of release. Hertz (A) also became the first ‘cooked’ case to top the annual review, as all of the other winners had been web-based ‘raw’ cases.

Besides introducing students to the complicated financing required to maintain an enormous fleet of cars, the Hertz cases also expanded the diversity of case protagonists. Kathyrn Marinello was the CEO of Hertz during this period and the CFO, Jamere Jackson is black.

Sandwiched between the two Hertz cases, Coffee 2016, a perennial best seller, finished second. “Glory, Glory, Man United!” a case about an English football team’s IPO made a surprise move to number four.  Cases on search fund boards, the future of malls,  Norway’s Sovereign Wealth fund, Prodigy Finance, the Mayo Clinic, and Cadbury rounded out the top ten.

Other year-end data for 2021 showed:

  • Online “raw” case usage remained steady as compared to 2020 with over 35K users from 170 countries and all 50 U.S. states interacting with 196 cases.
  • Fifty four percent of raw case users came from outside the U.S..
  • The Yale School of Management (SOM) case study directory pages received over 160K page views from 177 countries with approximately a third originating in India followed by the U.S. and the Philippines.
  • Twenty-six of the cases in the list are raw cases.
  • A third of the cases feature a woman protagonist.
  • Orders for Yale SOM case studies increased by almost 50% compared to 2020.
  • The top 40 cases were supervised by 19 different Yale SOM faculty members, several supervising multiple cases.

CRDT compiled the Top 40 list by combining data from its case store, Google Analytics, and other measures of interest and adoption.

All of this year’s Top 40 cases are available for purchase from the Yale Management Media store .

And the Top 40 cases studies of 2021 are:

1.   Hertz Global Holdings (A): Uses of Debt and Equity

2.   Coffee 2016

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Lessons learnt: examining the use of case study methodology for nursing research in the context of palliative care

Paula brogan.

School of Communication and Media, University of Ulster, Northern Ireland, UK

Felicity Hasson

Institute of Nursing Research, University of Ulster, Northern Ireland, UK

An empirical social research approach, facilitating in-depth exploration of complex, contemporary contextualised phenomena, case study research has been used internationally in healthcare studies across clinical settings, to explore systems and processes of care delivery. In the United Kingdom, case study methods have been championed by nurse researchers, particularly in the context of community nursing and palliative care provision, where its applicability is well established. Yet, dogged by conceptual confusion, case study remains largely underutilised as a research approach.

Drawing on examples from nursing and palliative care studies, this paper clarifies case study research, identifies key concepts and considers lessons learned about its potential for nursing research within the unique and complex palliative and end of life context.

A case study approach offers nurse researchers the opportunity for in-depth, contextualised understanding of the systems and processes which influence their role in palliative care delivery across settings. However, philosophical and conceptual understandings are needed and further training in case study methodology is required to enable researchers to articulate and conduct case study.

Introduction

An empirical social research approach, facilitating in-depth exploration of a contemporary phenomenon ( Yin, 2009 ), case study research has been used internationally in healthcare studies ( Anthony and Jack, 2009 ) to explore systems of palliative care ( Lalor et al., 2013 ), diverse contexts for palliative care delivery ( Sussman et al., 2011 ), roles of professional groups such as pharmacy ( O’Connor et al., 2011 ), the impact of services such as complementary therapy ( Maddalena et al., 2010 ) and nursing (Kaasalainen et al., 2013). In the United Kingdom, case study methods have been championed by nurse researchers ( Payne et al., 2006 ), particularly in the context of community nursing and palliative care provision ( Kennedy, 2005 ; Walshe et al., 2004 , 2008 ) and its applicability to palliative and end-of-life care research is established ( Goodman et al., 2012 ). Suited to the study of complex processes ( Walshe, 2011 ), case study methodology is embedded in professional guidance on the development of complex interventions ( Medical Research Council, 2008 ). Yet, case study is dogged by conceptual confusion (Flyvberg, 2006), and, despite sporadic use, remains underutilised as a research approach in healthcare settings ( Froggatt et al., 2003 ).

Illustrated by examples from nursing and palliative care studies, this paper aims to clarify conceptual understanding and identify key lessons for its application within these unique and complex contexts and, more broadly, for nursing research.

Origins and definitions

French sociologist Frederic Le Play (1806–1882) is associated with the origin of the case study approach ( Hamel et al., 1993 ). Using a purposive sample of working class families and fieldwork methods of observation and individual interview, he sought a contextualised and in-depth understanding of their individual experiences. Each family case study uncovered the unique experience of that family, but each additional family studied was another ‘ case of the lived experience’ of working class families in mid-18th century France. Thereby, Le Play used the lens of individual experience ( Yin, 2013 ) to build comparisons across families and enrich overall understanding of that complex society.

This early glimpse of the case study approach showed it to be a straightforward ‘field investigation’ ( Hamel et al., 1993 ); epistemologically pragmatic as it generated knowledge through data drawn from diverse sources, such as family members, and used the best available data collection methods then, to inform a holistic and contextualised understanding of how people operated within a complex social system ( Stake, 1995 ).

However, defining case study has become increasingly challenging since its expansion into North America in the 1800s ( Platt, 1992 ), and its use across a range of disciplines such as politics ( Gerring, 2004 ), social science ( George and Bennett, 2005 ), education ( Merriam, 1998 ) and healthcare ( Yin, 2013 ). Variously characterised as a case report, data collection method and methodology ( Anthony and Jack, 2009 ), the development of case histories as illustrations in health and social care and in education ( Merriam, 1998 ) has contributed to further confusion for researchers and readers of case study research ( Gomm et al., 2000 ). Critiques of case study note that it lacks a single definition, such that a plethora of discipline dependant interpretations ( Simons, 2009 ) and loose use of the term case study ( Tight, 2010 ) have contributed to confusion and undermined case study credibility. However, Simons ( 2009 , p. 63) advises researchers that case study must be seen within the complex nexus of political, methodological and epistemological convictions that constitute the field of enquiry, and variations of these may be glimpsed in Table 1 as definitions from four eminent and frequently cited case study authors illustrate philosophical and discipline-influenced differences in emphasis. Consequently, the case study definition selected, with its underpinning ontology and epistemology has important implications for the coherent outworking of the overall research design. It is therefore notable that many of the palliative care case studies contained in Table 2 fail to identify any such definition and this may have implications for interpretation of the quality of studies.

Definitions of case study by four key authors, showing the variation in meaning and interpretation.

Examples of Case Studies (CS) conducted in palliative care contexts.

Case study as a philosophy for the epistemology of knowledge generation

Although frequently linked to naturalistic inquiry ( Lincoln and Guba, 1986 ), interpretative/constructivist philosophy and qualitative methodology ( Stake, 1995 ), case study is not in fact bound to any single research paradigm ( Creswell, 2013 ). It is philosophically pragmatic, such that the case study design should reflect the ontological positions and epistemological considerations of the researchers and their topic of interest ( Luck et al., 2006 ). In practice, this means that case study research may pragmatically employ both qualitative and quantitative methods independently or together in order to respond to the research objectives ( Cooper et al., 2012 ; Simons, 1987 ; Stake, 2006 ). So whilst Table 2 shows that qualitative case studies are common in palliative care, epistemological variation is evident and reflects the study topic, purpose and context of the research. For example, Maddalena et al. (2010) used in-depth interview and discourse analysis to understand individual patient meaning-making; Brogan et al. (2017) used focus groups and thematic analysis as part of an embedded element of a multiple case study, to contrast the diverse perspectives of multi-disciplinary healthcare practitioners on end-of-life decision-making; Sussman et al. (2011) incorporated survey data into a mixed methods multiple case study which explored health system characteristics and quality of care delivery for cancer patients across four regions of Canada. Consequently, it is useful to ‘conceptualise (case study) as an approach to research rather than a methodology in its own right’ ( Rosenberg and Yates, 2007 , p. 448), so that a non-standardised approach exists and the case study design, its boundaries, numbers of cases and methods are guided by the stated underpinning ontological perspectives of the researcher and their topic of interest. The study then flexibly adopts the best methods to gain an in-depth, holistic and contextualised understanding of the phenomenon of interest – the latter objectives being at the core of any definition of case study research.

Key case study concepts and lessons for practice

When considering the utility of a case study approach, research conducted in complex palliative care contexts offers several insights into how central concepts translate to practice.

Contextualised understanding

Drawing on the definitions in Table 1 , Stake emphasised the particularity and intrinsic value of each individual case ( Stake, 1995 ), to emphasise the usefulness of multiple cases to increase insight ( Stake, 2006 ), analyse patterns ( Gerring, 2004 ; George and Bennett, 2005 ) and develop causal hypotheses ( Yin, 2013 ). Yet, whatever the purpose, all case studies are concerned with the crucial relationship between a phenomenon and the environment in which it has occurred. In practice therefore, case study researchers must be concerned with understanding the background systems, structures and processes that influence and interact with the phenomenon under study. This capacity for contextualised and holistic understanding is underpinned by use of multiple data collection methods, such as observation, interview and document review, used simultaneously or sequentially ( Stake, 2006 ; Scholz and Tietje, 2002 ), to mine multiple sources of data, such as participant experience ( Brogan et al., 2017 ; Kaasalainen et al., 2012 ), documents (Lalor et al., 2003) service evaluations ( Walshe et al., 2008 ), and diaries ( Skilbeck and Seymour, 2002 ). This is exemplified in a study by Walshe et al. (2011) , who investigated referral decisions made by community palliative care nurses in the UK, by capturing interview data on the self-reported perspectives of healthcare professionals, in combination with observed team meetings in which decisions were influenced, and review of the written referral policies, protocols and palliative healthcare strategies specific to those decisions. This comprehensive and complex data enabled comparison of decisional processes and their influencing factors both within and across three Primary Care Trusts, thus providing a contemporaneous understanding of the complex relationship between individual nurse's referral decisions and the impact of the organisational and professional systems that underpinned them. Enhancing rigor, such methodological triangulation importantly contributed to the richness of data analysis and the development of assertions which might be drawn from the findings ( Cooper et al., 2012 ; Stake, 2006 ).

Process-focused

Flexible data collection methods, linked to the research purpose, enables case study researchers to gather both historical and real-time data in a variety of ways. For example, Kennedy’s longitudinal case study ( Kennedy, 2002 ) observed snapshots of the initial and follow-up assessment conducted by 11 district nurses over the subsequent 12 months, enabling an exploration of the outcome and impact of their decision-making, demonstrating the usefulness of case study to understand complex roles and processes which are fluid and elusive ( Yin, 2013 ), or otherwise difficult to capture, particularly in the intimate interpersonal contexts where nursing happens.

Analytic frame

Palliative care studies reviewed frequently report the use of thematic analysis. However, whilst this approach is certainly useful to process data generated in qualitative case studies, the approach to analysis must be congruent with the research design and reflect the purpose of the research and methods used. Moreover, beyond decisions about use of thematic analysis or descriptive statistics etc., in case study, important decisions must be made about the analytic frame of the research. Gerring’s definition (2004) set out the analytic frame in which the cases studied might be understood, explaining that each unit of analysis (or case), sheds light on other units (or cases). Thus defined, an individual case offers intrinsically valuable information about a phenomenon ( Stake, 1995 ) and the purposeful selection of cases is central to case study design. This is because, viewed from a certain angle, each case is also a case of something else, such that the findings have broader implications ( Gerring, 2004 ; Simons, 2009 , 1987 ; Yin, 2013 ). In practice, this means that the case and what it is a case of, must be clearly identified and well defined at the outset of a study, since this has implications for the relevance of findings. This can be seen in a study by O’Connor et al., (2011) , who considered the perceived role of community pharmacists in palliative care teams in Australia. Each unique case included multi-disciplinary healthcare team members, such as pharmacists, doctors and nurses working in localities, whose perspectives were sought. Each locality group was a case of community pharmacy provision in palliative care settings in Australia, and findings had implications for the planning of community services overall. So, insight development was possible at an individual, group and organisational level, and inferences were made directly in relation to the parameters of that case study.

The addition of several carefully selected cases, as in multiple case studies, offers the opportunity to analyse data gained within and across cases ( Stake, 2006 ). Case selection may be made in order to explore similarities and contrasting perspectives ( Brogan et al., 2017 ), understand the various impacts of geographical differences ( Sussman et al., 2011 ), and different organisational influences ( Walshe et al., 2008 ). However, whilst repetition of data across cases may reinforce propositions made at the outset of a study, the purpose of increasing the number of cases in case study research is primarily about increasing insight development into the complexity of a phenomenon ( Stake, 2006 ). Since case study is the study of a boundaried phenomenon ( Yin, 2013 ), establishing the analytic frame then underpins the selection criteria for potentially useful cases. Such clarification is essential since it provides the lens through which to focus research ( Gerring, 2004 ; Scholz and Tietje, 2002 ; Stake, 2006 ) and permits key decisions to be made about data which may be included and that which is not applicable.

However, significantly, this information is rarely articulated within published case studies in palliative care. This is an important issue for the quality of case study research, since description of the process of refining case study parameters, establishing clear boundaries of the case, articulating propositions based on existing literature, identifying the sources of data (people, records, policies, etc.) and the ways in which data would be captured, establishes clarity and underpins a rigorous, systematic and comprehensive process ( Gibbert et al., 2008 ), which can usefully contribute to practice and policy development ( George and Bennett, 2005 ).

Shaped by organisational systems, intimate settings and significant life stage contexts, the interconnection between context and participant experience of palliative care is one example of a process of healthcare provision that is often complex, subtle and elusive ( Walshe et al., 2011 ). Case studies conducted in these swiftly changing contexts illustrate several characteristics of case study research, which make it an appropriate methodological option for nurse researchers, providing the opportunity for in-depth, contextualised understanding of the systems and processes which influence their role in palliative care delivery across settings ( Walshe et al., 2004 ) and many others who seek a contextualised, contemporaneous understanding of any complex role or process ( Yin, 2013 ; Simons, 2009 ). This fieldwork-based approach has the potential to achieve depth and breadth of insight through the pragmatic, but carefully planned and articulated, use of multiple methods of data collection in order to answer the research question ( Stake, 2006 ) when analysed systematically within a frame determined at the outset by the definition of the case and its boundaries ( Gerring, 2004 ). Yet, the methodological flexibility that is advantageous in complex contexts, may be misunderstood ( Hammersley, 2012 ), particularly where terminology is unclear ( Lather, 1996 ) or where description of the systematic and rigorous application of the approach is missing from the report ( Morrow, 2005 ). Taken as an example of one area of healthcare research, evidence suggests that palliative care studies that deal meaningfully with underpinning philosophical perspectives for their selected case study approach, or which articulate coherent links between the defined case, its boundaries and the analytical frame are rare. The impact of such omissions may be the perpetuation of confusion and out-dated perceptions about the personality and quality of case study research ( King et al., 1994 ), with implications for its wider adoption by nurses in healthcare research. Further training in case study methodology is required to promote philosophical and conceptual understanding, and to enable researchers to fully articulate, conduct and report case study, to underpin its credibility, relevance and future use ( Hammersley et al., 2000 ; Stake and Turnbull, 1982).

Key points for policy, practice and/or research

  • Case study is well suited to nursing research in palliative care contexts, where in-depth understanding of participant experience, complex systems and processes of care within changing contexts is needed.
  • Not bound to any single paradigm, nor defined by any methodology, case study’s pragmatism and flexibility makes it useful for studies in palliative care.
  • Training is needed in the underpinning philosophical and conceptual basis of case study methodology, in order to articulate, conduct and report credible case study research, and take advantage of the opportunities it offers for the conduct of palliative and end-of-life care research.

Paula Brogan is a Lecturer in counselling and communication in the School of Communication and Media, and was recently appointed as Faculty Partnership Manager, University of Ulster. Dual qualified as a Registered Nurse with specialism in District Nursing and as a Counsellor/couple psychotherapist (Reg MBACPaccred), she has over 30 years’ clinical practice experience in community palliative care nursing and the provision of psychological care to patients and families dealing with palliative and chronic illness. Having worked across statutory, voluntary and private sectors, her PhD focused on multi-disciplinary decision-making at the end of life with patients and families in the community setting. Currently secretary of the Palliative Care Research Forum for Northern Ireland (PCRFNI), Paula’s ongoing research interests include communication and co-constructed decision-making in palliative and chronic illness, and the psychological support of individuals, couples, patient-family groups and multi-disciplinary staff responding to challenges of advanced progressive illness.

Felicity Hasson is a Senior Lecturer in the Institute of Nursing Research at the University of Ulster with 20 years’ experience in research. A social researcher by background, she has extensive experience and knowledge of qualitative, quantitative and mixed method research and has been involved in numerous research studies in palliative and end-of-life care. She completed her MSc in 1996 and her PhD from University of Ulster in 2012. Felicity sits on the Council of Partners for the All Ireland Institute of Hospice and the Palliative Care Palliative Care Research Network (PCRN) and is an executive board member for the UK Palliative Care Research Society. She holds an editorial board position on Futures and Foresight Science. Felicity has an established publication track recorded and successful history of grant applications. Her research interests include nurse and assistant workforce, workforce training, palliative care and chronic illness (malignant and non-malignant with patients, families and multi-disciplinary health care professionals) and public awareness of palliative care and end of life issues.

Sonja McIlfatrick is a Professor in Nursing and Palliative Care and has recently been appointed as the Head of School of Nursing at University of Ulster. She is an experienced clinical academic with experience in nursing and palliative care practice, education and research. She previously worked as the Head of Research for the All Ireland Institute of Hospice and Palliative Care (2011-2014) and led the establishment of the All Ireland Palliative Care Research Network (PCRN) and is the current Chair of the Strategic Scientific Committee for the PCRN (AIIHPC). Sonja is an Executive Board member for the UK, Palliative Care Research Society and is member of the Research Scientific Advisory Committee for Marie Curie, UK. Sonja holds an Editorial Board position on the International Journal of Palliative Nursing and Journal of Research in Nursing. Professor McIlfatrick has published widely in academic and professional journals focused on palliative care research and has a successful history of grant acquisition. Sonja has a keen interest in doctoral education and is the current President of the International Network of Doctoral Education in Nursing (INDEN). Her research interests include, palliative care in chronic illness, decision making at end of life; public awareness of palliative care and psychosocial support for family caregivers affected by advanced disease.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Ethics statement

Ethical permission was not required for this paper.

The author(s) received no financial support for the research, authorship, and/or publication of this article.

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Why Are Case Studies Important? Top 4 Reasons

Updated February 2023: Has a boss or colleague ever asked you, “Why are case studies so important?” This is a question all SaaS marketers must be able to answer, especially when it comes time to create your marketing budget for the year.

SaaS case studies are the #1 marketing tactic to increase sales

The importance of a case study can’t be underestimated. For the second year in a row, SaaS marketers ranked case studies the #1 most effective marketing tactic to increase sales —ahead of general website content, SEO, blog posts, social media and other marketing tactics. 

Marketers rank case studies at #1 most important marketing tactic to increase sales

These metrics come from the 123 SaaS marketers we surveyed for our 2023 SaaS Case Studies Trends & Insights Report . (We’d encourage you to check out the report.)

Importance of a case study is undeniable

Why are case studies so important? What is the need and significance of a case study? Case studies are top-tier marketing tools for SaaS companies to showcase the value of their products to potential customers, helping to drive sales and revenue.

Customers are our best marketers. I love getting to know our customers through these stories, especially because documenting their successes helps advance their careers and gives more senior leaders the chance to celebrate their teams.

Megan Donaldson

Why are case studies important in marketing?

Case studies are essentially a play-by-play of how your customer recognized that they had a challenge they needed to overcome, why they chose you, what products or services you provided, and how those products or services helped them solve their challenge.

And what makes case studies even more valuable? They’re a great investment because case studies can be repurposed so heavily —everything from PDFs and videos to infographics to social.

In this post, we’ll demonstrate the importance of a case study in business and discuss the top 4 advantages of using case studies in your marketing mix.

Need a hand with writing case studies? We are a SaaS content marketing agency that specializes in writing case studies for companies like ClickUp, WalkMe and LeanData. Check out our case study writing services .

What are 4 advantages of case studies?

1. case studies demonstrate your expertise in your niche.

case studies are useful for

As a SaaS marketer, your job is to know how to produce a business case study in a way that makes your product or service stand out among your competitors.

Creating case studies is an effective way to capture the attention of buyers in your industry because the content—including the products, services and use cases covered in the piece—will be highly relevant to your target audience and will therefore have a strong chance of resonating with them.

If you’re still wondering, “Why are case studies important?”, then put yourself in your buyer’s shoes. Say you’re evaluating several different customer relationship management (CRM) platforms. All three vendors have an eye-catching website with informative and clever product copy, but only one has a repository of case studies that illustrate how its clients have landed 50% more sales since they’ve implemented this particular CRM. Sounds like a winner to us (and it demonstrates case study importance)!

Case studies are important because our prospects want to see that we’ve helped customers who are in the same industry and have similar pain points. Reference calls are helpful, but it’s important to have stories that sales folks can share easily.  

Michelle Cloutier

2. Case studies provide social proof in an original way

case studies are useful for

What is the importance of a case study? Well, nearly 90% of consumers read product reviews before they make a purchase, which means gathering and publishing social proof is a crucial activity for your SaaS company.

Changing consumer behavior is another reason why case studies are important. Case studies give your readers what they’re looking for, which is confirmation from other B2B buyers just like them that your products and services are the real deal.

Another advantage of case studies is that by nature, they’re original stories about individuals with specific challenges and goals. Knowing how to write a case study that goes beyond generic product reviews is critical.

When writing a case study, dig deep into everything from how your team helps customers implement your software to what your customer’s future use cases could include. This type of content gives your prospect thorough insight into what it’s like to use your products and work with your company.

Case studies offer social proof for how we provide value to our customers. Our sales team uses our case studies to build credibility and offer “proof points” for why (and how) Crossbeam can solve their problems.

Jasmine Jenkins

3. Case studies help your SaaS company close sales

case studies are useful for

Let’s quickly recap the last 2 points:

1) Case studies capture your buyers’ attention with highly relevant content that positions your SaaS company as an expert in the products or services you deliver.

2) Case studies also build trust by sharing social proof in an interesting format that uses storytelling to weave a narrative. For those two reasons, case studies are fantastic content marketing tools to help you close sales. 

In addition, especially if your offerings are complex, it’s essential to help potential customers understand how your software will meet their needs. Case studies give you an opportunity to explain— with real-world examples and visual aids —the more complicated aspects of your products and services.

Case studies are important because they provide real-life examples of positive customer outcomes and sentiment—a critical part of gaining buy-in from prospects during a sales cycle.

Jake Sotir

4. Strengthen customer relationships

case studies are useful for

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When it comes to the question, “Why are case studies important?”, one of the best answers is that they can help you strengthen customer relationships by letting your customers know you believe they have a valuable story. This gesture of goodwill can increase customer retention, which can in turn grow your SaaS company’s revenue by as much as 95% .

Case studies are important because they give you the opportunity to celebrate an existing customer, which in and of itself is of immense value. Secondarily, for both customers and prospects alike, they always prefer to “see someone like them” rather than just hear you spew what-ifs at them.

Patrick Clore

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Toward a framework for selecting indicators of measuring sustainability and circular economy in the agri-food sector: a systematic literature review

  • LIFE CYCLE SUSTAINABILITY ASSESSMENT
  • Published: 02 March 2022

Cite this article

  • Cecilia Silvestri   ORCID: orcid.org/0000-0003-2528-601X 1 ,
  • Luca Silvestri   ORCID: orcid.org/0000-0002-6754-899X 2 ,
  • Michela Piccarozzi   ORCID: orcid.org/0000-0001-9717-9462 1 &
  • Alessandro Ruggieri 1  

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A Correction to this article was published on 24 March 2022

This article has been updated

The implementation of sustainability and circular economy (CE) models in agri-food production can promote resource efficiency, reduce environmental burdens, and ensure improved and socially responsible systems. In this context, indicators for the measurement of sustainability play a crucial role. Indicators can measure CE strategies aimed to preserve functions, products, components, materials, or embodied energy. Although there is broad literature describing sustainability and CE indicators, no study offers such a comprehensive framework of indicators for measuring sustainability and CE in the agri-food sector.

Starting from this central research gap, a systematic literature review has been developed to measure the sustainability in the agri-food sector and, based on these findings, to understand how indicators are used and for which specific purposes.

The analysis of the results allowed us to classify the sample of articles in three main clusters (“Assessment-LCA,” “Best practice,” and “Decision-making”) and has shown increasing attention to the three pillars of sustainability (triple bottom line). In this context, an integrated approach of indicators (environmental, social, and economic) offers the best solution to ensure an easier transition to sustainability.

Conclusions

The sample analysis facilitated the identification of new categories of impact that deserve attention, such as the cooperation among stakeholders in the supply chain and eco-innovation.

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case studies are useful for

Source: Authors’ elaboration. Notes: The graph shows the temporal distribution of the articles under analysis

case studies are useful for

Source: Authors’ elaborations. Notes: The graph shows the time distribution of articles from the three major journals

case studies are useful for

Source: Authors’ elaboration. Notes: The graph shows the composition of the sample according to the three clusters identified by the analysis

case studies are useful for

Source: Authors’ elaboration. Notes: The graph shows the distribution of articles over time by cluster

case studies are useful for

Source: Authors’ elaboration. Notes: The graph shows the network visualization

case studies are useful for

Source: Authors’ elaboration. Notes: The graph shows the overlay visualization

case studies are useful for

Source: Authors’ elaboration. Notes: The graph shows the classification of articles by scientific field

case studies are useful for

Source: Authors’ elaboration. Notes: Article classification based on their cluster to which they belong and scientific field

case studies are useful for

Source: Authors’ elaboration

case studies are useful for

Source: Authors’ elaboration. Notes: The graph shows the distribution of items over time based on TBL

case studies are useful for

Source: Authors’ elaboration. Notes: The graph shows the Pareto diagram highlighting the most used indicators in literature for measuring sustainability in the agri-food sector

case studies are useful for

Source: Authors’ elaboration. Notes: The graph shows the distribution over time of articles divided into conceptual and empirical

case studies are useful for

Source: Authors’ elaboration. Notes: The graph shows the classification of articles, divided into conceptual and empirical, in-depth analysis

case studies are useful for

Source: Authors’ elaboration. Notes: The graph shows the geographical distribution of the authors

case studies are useful for

Source: Authors’ elaboration. Notes: The graph shows the distribution of authors according to the continent from which they originate

case studies are useful for

Source: Authors’ elaboration. Notes: The graph shows the time distribution of publication of authors according to the continent from which they originate

case studies are useful for

Source: Authors’ elaboration. Notes: Sustainability measurement indicators and impact categories of LCA, S-LCA, and LCC tools should be integrated in order to provide stakeholders with best practices as guidelines and tools to support both decision-making and measurement, according to the circular economy approach

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A Correction to this paper has been published: https://doi.org/10.1007/s11367-022-02038-9

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Association between dietary selenium and zinc intake and risk of dilated cardiomyopathy in children: a case-control study

  • Maryam Aryafar 1 ,
  • Mohammad Mahdavi 1 ,
  • Hossein Shahzadi 1 ,
  • Yeganeh Rajabpour Ranjbar 2 ,
  • Mohammad Hassan Sohouli 3 ,
  • Sina Afzal 4 ,
  • Asal Neshatbini Tehrani 5 , 6 ,
  • Danial Fotros 2 &
  • Ghazal Daftari 7 , 8  

BMC Pediatrics volume  24 , Article number:  251 ( 2024 ) Cite this article

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Dilated cardiomyopathy (DCMP) is characterized by the enlargement and weakening of the heart and is a major cause of heart failure in children. Infection and nutritional deficiencies are culprits for DCMP. Zinc is an important nutrient for human health due to its anti-oxidant effect that protects cell against oxidative damage. This case-control study aimed to investigate the relationship between dietary intake of zinc and selenium and the risk of DCMP in pediatric patients.

A total of 36 DCMP patients and 72 matched controls were recruited, and their dietary intakes were assessed via a validated food frequency questionnaire. We used chi-square and sample T-test for qualitative and quantitative variables, respectively. Logistic regression analysis was applied to assess the relationship between selenium and zinc intake with the risk of DCMP.

After fully adjusting for confounding factors, analyses showed that selenium (OR = 0.19, CI = 0.057–0.069, P trend < 0.011) and zinc (OR = 0.12, CI = 0.035–0.046, P trend < 0.002) intake were strongly associated with 81% and 88% lower risk of pediatric DCMP, respectively.

Conclusions

This study highlights the protective role of adequate dietary intake of selenium and zinc in decreasing the risk of DCMP in children. Malnutrition may exacerbate the condition and addressing these micronutrient deficiencies may improve the cardiac function. Further studies are recommended to detect the underlying mechanisms and dietary recommendations for DCMP prevention.

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Introduction

Dilated cardiomyopathy (DCMP) is a condition characterized by systolic dysfunction and biventricular or left ventricle dilation in the lack of predisposing factors such as coronary artery disease, hypertension or valvular disorders which cause systolic dysfunction [ 1 ]. DCMP usually begins in the left ventricle by thinning and stretching of the heart muscles resulting in enlargement of heart chambers that impairs the normal contraction and blood pumping [ 2 ]. DCMP presents with orthopnea, heart failure, breathlessness, impaired exercise tolerance, poor feeding, fatigue and sweating [ 3 ]. The prevalence of DCMP is estimated from 1:500 to 1:2500 in general population [ 4 , 5 ]. In children, the incidence rate is about 0.57 per 100,000 population annually and is higher in boys than girls [ 6 ]. In children, the common causes of DCMP is idiopathic, neuromuscular disorders such as Becker and Duchen dystrophies, nutritional deficiencies and inflammation [ 7 ]. Paediatric DCMP is observed to occur after influenza, parvo virus B19, coxsackie, herpes, Ebstein Barr, adeno and human immunodeficiency viruses [ 7 ]. Furthermore, taurine, calcium, zinc and selenium depletion decrease the heart contractility and are implicated in DCMP [ 8 ].

Selenium and zinc, micronutrients found in red meat, grains, nuts and sea foods is an indispensable elements in human health [ 9 ]. Selenium in the form of selenocysteine and as the 21st amino acid is incorporated in the selenoproteins, modulating immunologic, cardiovascular and metabolic functions via anti-inflammatory, anti-cancer and anti-oxidant effects [ 10 ]. Also, selenium is crucial for sperm motility and thyroid function [ 11 ]. Gluthatione peroxidases, iodothyronine deiodinases and thioredoxin reductases are anti-oxidant enzymes depending on selenium [ 12 , 13 ]. Zinc is an important element in apoptosis and cellular membrane stability [ 14 ]. In addition, it is a necessary component of enzymes such as angiotensinogen converting enzyme and carbonic anhydrases that are regulators of acid-base balance and fluid homeostasis [ 15 ]. Zinc is a co-factor of different enzymes that contribute to function of anti-oxidant systems. It stabilizes cellular membrane and protects the cells against oxidative conditions. In addition, zinc inhibits pro-oxidant enzymes and decreases reactive oxygen species production in stress conditions [ 16 , 17 , 18 ].

Several studies have demonstrated that selenium deficiency may contribute to cardiovascular disorders such as Keshan disease, which is an endemic DCMP in China [ 19 ]. It is also indicated that zinc deficiency is culprit of cardiac cellular damage and decreased cardiac function [ 20 , 21 ]. It is suggested that high selenium and zinc intake may reduce the risk of cardiovascular incidence and mortality [ 22 ]. Considering previous studies, little is known about the selenium and zinc intake in children with DCMP, thus we aimed to explore the association of dietary intake of selenium and zinc with DCMP risk in children.

Methods and materials

Study population.

In this case-control study, 45 patients within the age range of 2–17 years old who had been diagnosed with idiopathic DCMP for at least 6 months, were recruited from Rajaie cardiovascular, medical and research center during spring and summer of 2022 in Tehran, Iran. Physical exam, electrocardiogram (ECG), clinical history, echocardiography and chest X-ray had been used for diagnosis.

Inclusion criteria were individuals with signs and symptoms of heart failure such as low exercise tolerance, fatigue, edema and shortness of breath. Exclusion criteria were following: having renal failure, diabetes mellitus, malignancies, infectious disease, pregnancy, valvular, rheumatic, hypertensive and congenital heart diseases and also, life expectancy less than 6 months. Among 45 patients that were initially identified, 9 patients were excluded due to the high risk of mortality. Also, 72 controls were matched according to sex and age. The controls were randomly allocated patients admitted to other wards of the same hospital with no history of cardiovascular diseases, confirmed with echocardiography. It is important to mention that when the cases are selected from hospital, controls from hospital are preferred over community-based control selection. The protocol of this study was approved by Rajaie cardiovascular, medical and research center ethics committee (IR.RHC.REC.1401.016). All the parents / legal guardian of participants were informed about the study and signed the written informed consent form.

Dietary intake assessment

A reproducible and valid food frequency questionnaire (FFQ) [ 23 , 24 , 25 ] was used to collect dietary intake. A trained dietician collected the portion size and frequency of food items based on daily, weekly, monthly or yearly intake. The dietary intakes of participants were checked with their parents to reduce the recall bias. We used Nutritionist IV [ 26 ] to analyse the collected data and The United States Department of Agriculture (USDA) Food Composition Table (FCT) to calculate nutrients and energy contents.

Data collection

Socio-demographic and anthropometric information of the participants were collected by a trained interviewer. Body weight was measured to the nearest 100 g while standing on digital scales (Soehnle, Berlin, Germany). Height was calculated by a non-stretch portable meter to the nearest 0.5 cm. Body mass index (BMI) was measured by dividing of weight in kilograms to square of height in meter.

Statistical analysis

After assessing the normality of the variable’s distribution by Kolmogorov-Smirnov test, independent sample T-test was used to compare quantitative variables between the two groups, as Chi-square was also used for qualitative variables. The baseline characteristics were reported as mean ± standard deviation (SD) for quantitative variables, and number for qualitative variables. The association of selenium/zinc with the odds of cardiomyopathy was assessed by applying logistic regression. The analyses were adjusted for probable confounders, including age, sex, BMI, energy, fiber, Na and K. All analyses were performed using statistical package software for social science (SPSS) 22.0 statistical software, and P -value less than 0.05 was considered statistically significant.

Baseline characteristics

The mean ± SD for the age across case and control groups were 9.83 ± 4.55 and 8.7 ± 1.54 years, respectively. There was a significant difference in the distribution of sex between cases and controls ( p  < 0.001), with a higher proportion of males in the control group. However, no significant differences were observed in weight ( p  = 0.208) and BMI ( p  = 0.702) between the two groups (Table  1 ).

Dietary intakes

The dietary intakes of study participants across the case and control groups are presented in Table  2 . Significant differences were found in the intake of protein, carbohydrate, total fiber, fat, cholesterol, sodium, potassium, vitamin A.RE, vitamin C, iron, vitamin D, vitamin E, folate, B12, magnesium, zinc, and selenium between cases and controls ( p  < 0.05 for all). Cases generally exhibited lower intakes of these nutrients compared to controls.

Odds ratios for cardiomyopathy

The odds ratio (ORs) and 95% confidence interval (CIs) for the occurrence of cardiomyopathy based on the tertiles of selenium and zinc intake are reported in Table  3 . In the crude model, selenium and zinc were inversely associated with the lower odds of cardiomyopathy, with an OR of 0.144 and 0.179 for the highest tertile, respectively ( P  < 0.05 for trend). Furthermore, after adjusting for age, sex, BMI, energy, fiber, Na and K (in the fully adjusted model), in the highest versus lowest tertile of selenium and zinc, the lower odds of cardiomyopathy remained significant (OR = 0.198, 95% CI: 0.05–0.69; P value = 0.011 for trend and OR = 0.127, 95% CI: 0.03–0.46; P value = 0.002 for trend, respectively).

The present case-control study demonstrated that lower intake of macronutrients and micronutrients such as selenium and zinc is associated with higher risk of DCMP in children, after fully adjusting of confounding factors such as energy, BMI, age, sex, fiber, Na and K.

In our study, dietary intake of macronutrients was significantly lower in cases than controls. Align with our finding Ocal et al. reported that children with malnutrition exhibit cardiovascular disorder including arrythmia, sudden death, heart failure and dilated cardiomyopathy [ 27 ]. Also, gross examination of the myocardium in malnourished children showed a flabby, pale and thin-walled heart [ 28 ]. Nutritional interventions may improve the quality of life and myocardial function. Failure to thrive is one of the most important problems in children with cardiomyopathy. Adequate intake of macronutrients may improve cardiac function and also, specific micronutrients decrease the myocardial abnormalities that occur in cardiomyopathies and heart failure [ 29 ].

There is a vicious circle between malnutrition and DCMP. Poor nutritional status is a cause of DCMP and on the other hand, DCMP leads to malnutrition through metabolic disturbances, chronic inflammation and gastrointestinal malabsorption [ 30 , 31 , 32 ]. The inflammatory condition in most chronic diseases such as DCMP affects the metabolism and results in reduced cardiac muscle function and mass over time [ 33 ]. Different micronutrients deficiency may cause DCMP. Vema et al. reported a 15-month-old child with DCMP caused by hypocalcemia nutritional rickets that responded to vitamin D and calcium supplementation and systolic function normalized after 3 months [ 34 ].

Consistent with our study, Ripa et al. reported that primary or secondary zinc deficiency may result in DCMP and also, reduced plasma level of zinc is an important prognostic and diagnostic marker for DCMP [ 35 ]. In addition, Topuzoglu et al. demonstrated that patients with DCMP have lower plasma level of zinc compared with healthy controls [ 36 ]. Zinc is an important component of various enzymes such as superoxide dismutase. An impairment in superoxide dismutase function leads to reaction of superoxide anions with hydrogen peroxide and production of hydroxide radicals that induce cell damage. Zinc protects the cells against free radicals and thus decreases the cardiovascular disorders. In DCMP and consequently heart failure, activation of atrial natriuretic peptide (ANP) causes high urinary excretion of zinc, concluding to zinc deficiency and impaired cardiac performance [ 37 ]. On the other hand, Chou et al. did not find any association between patients with DCMP and control group [ 38 ]. The differences in reports may be due to sample size, dietary food intake and methodology.

Another micronutrient that is protective in cardiovascular diseases is selenium. Dasgupta et al. reported a 14 years old boy with severe malnutrition, selenium deficiency and heart failure that has been treated with selenium replacement and nutritional support and become completely asymptomatic after four weeks [ 33 ]. In line with our study, Khater et al. demonstrated that pediatric patients with DCMP have reduced plasma level of selenium and this element can prevent myocardial damage [ 39 ]. Frustaci et al. indicated that in patients with intestinal malabsorption, a reversible selenium and zinc DCMP may occur oxidative damages to cell membrane, increased cell autophagy and decreased anti-oxidant activity [ 40 ]. Furthermore, Basil et al. reported that selenium level is significantly lower in patients with DCMP in comparison with control group [ 41 ]. In contrast to our study, Cunha et al. investigated that there is no difference between selenium level in patients with DCMP and control group [ 42 ]. It may be due to different food pattern and sample size. Selenium is a crucial element in inflammation and immunity and improves antioxidant reserve and suppresses production of tumor necrosis factor alfa and interleukins. Selenium deficiency may also play a role in myocardial damage and recovery.

Current study has some strengths including the analysis of various macro and micronutrients and also adjusting the confounding factors to improve the reliability of the study. There are some limitations, due to case-control nature of the study we could not establish a causative relationship between selenium and zinc intake with DCMP and the possibility of recall bias is another issue to consider.

In conclusion, current study concluded that there is an inverse association between macronutrients, selenium and zinc intake with the risk of pediatric DCMP. Further studies are needed to evaluate the amount of selenium and zinc intake to prevent DCMP.

Data availability

The datasets examined in the current study are available from the corresponding author on.

reasonable request.

Abbreviations

dilated cardiomyopathy

electrocardiogram

food frequency questionnaire

the United States department of agriculture

food composition table

body mass index

standard deviation

statistical package software for social science

confidence interval

saturated fatty acid

retinol equivalent

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Rajaei Cardiovascular Medical and Research Center, Iran University of Medical Sciences Tehran, Tehran, Iran

Maryam Aryafar, Mohammad Mahdavi & Hossein Shahzadi

Department of Clinical Nutrition and Dietetics, Faculty of Nutrition Sciences and Food Technology, Research Institute, National Nutrition and Food Technology, Shahid Beheshti University of Medical Sciences, Tehran, Iran

Yeganeh Rajabpour Ranjbar & Danial Fotros

Student Research Committee, Shahid Beheshti University of Medical Sciences, Tehran, Iran

Mohammad Hassan Sohouli

Department of Orthopedic and Trauma Surgery, Shahid Beheshti University of Medical Sciences, Tehran, Iran

Student Research Committee, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran

Asal Neshatbini Tehrani

Department of Nutrition, School of Allied Medical Sciences, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran

School of Medicine, Tehran University of Medical Sciences, Tehran, Iran

Ghazal Daftari

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Contributions

Conceptualization, M.A; Formal analysis, M.S and D.F; Methodology, M.M, H.S and Y.R; Project administration, M.A and G.D; Writing – original draft, S.A and A.N.T; Writing – review & editing, G.D and S.A. All authors read and approved.

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Correspondence to Ghazal Daftari .

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The protocol of this study was approved by Rajaie cardiovascular, medical and research center ethics committee (IR.RHC.REC.1401.016). All the parents / legal guardian of participants were informed about the study and signed the written informed consent form. All procedures performed in studies involving human participants adhered to the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. A copy of the written consent is available for review by the Editor-in-Chief of this journal.

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Aryafar, M., Mahdavi, M., Shahzadi, H. et al. Association between dietary selenium and zinc intake and risk of dilated cardiomyopathy in children: a case-control study. BMC Pediatr 24 , 251 (2024). https://doi.org/10.1186/s12887-024-04706-1

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DOI : https://doi.org/10.1186/s12887-024-04706-1

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  • 1 Institute for Clinical and Experimental Medicine (IKEM), Czechia

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We present a case of a 32-year-old male with a history of palpitations and preexcitation on ECG who underwent altogether four failed catheter ablations using different approaches in the two other electrophysiology centers within two years. ECG showed overt preexcitation with a positive delta wave in lead I and negative in leads V1 to V3, suggesting a right free wall accessory pathway. During the electrophysiological study, the accessory pathway was localized on the free lateral wall. However, the electrograms and mapping during atrial and ventricular pacing suggested the presence of true epicardial accessory pathway. Repeated radiofrequency energy delivery with the support of the steerable sheath and excellent contact (as assessed by intracardiac echocardiography) at the earliest ventricular activation was not successful. Therefore, the Farawave catheter (Boston Scientific, Inc) was used, and a flower configuration with the intention to cover the entire atrial attachment of the pathway during ventricular pacing was selected. Application of pulsed field resulted in interruption of accessory pathway conduction. An electrophysiological study one year later confirmed the persistent effect of ablation. This case illustrates the potential utility of pulsed field energy for the ablation of atrial insertion of the accessory pathway with an epicardial course. Such an approach can avoid epicardial mapping and access and may improve the safety of the procedure.

Keywords: Accessory pathway, Radiofrequency ablation, pulsed field ablation, Intracardiac echocardiography, Electroanatomical mapping

Received: 27 Feb 2024; Accepted: 15 Apr 2024.

Copyright: © 2024 Haskova, Peichl, Borišincová and Kautzner. 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. Jana Haskova, Institute for Clinical and Experimental Medicine (IKEM), Prague, Czechia

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  • Published: 15 April 2024

Life expectancy, long-term care demand and dynamic financing mechanism simulation: an empirical study of Zhejiang Pilot, China

  • Xueying Xu 1 ,
  • Yichao Li 2 &
  • Hong Mi 2  

BMC Health Services Research volume  24 , Article number:  469 ( 2024 ) Cite this article

Metrics details

China has piloted Long-Term Care Insurance (LTCI) to address increasing care demand. However, many cities neglected adjusting LTCI premiums since the pilot, risking the long-term sustainability of LTCI. Therefore, using Zhejiang Province as a case, this study simulated mortality-adjusted long-term care demand and the balance of LTCI funds through dynamic financing mechanism under diverse life expectancy and disability scenarios.

Three-parameter log-quadratic model was used to estimate the mortality from 1990 to 2020. Mortality with predicted interval from 2020 to 2080 was projected by Lee-Carter method extended with rotation. Cohort-component projection model was used to simulate the number of older population with different degrees of disability. Disability data of the older people is sourced from China Health and Retirement Longitudinal Study 2018. The balance of LTCI fund was simulated by dynamic financing actuarial model.

Life expectancy of Zhejiang for male (female) is from 80.46 (84.66) years in 2020 to 89.39 [86.61, 91.74] (91.24 [88.90, 93.25]) years in 2080. The number of long-term care demand with severe disability in Zhejiang demonstrates an increasing trend from 285 [276, 295] thousand in 2023 to 1027 [634, 1657] thousand in 2080 under predicted mean of life expectancy. LTCI fund in Zhejiang will become accumulated surplus from 2024 to 2080 when annual premium growth rate is 5.25% [4.20%, 6.25%] under various disability scenarios, which is much higher than the annual growth of unit cost of long-term care services (2.25%). The accumulated balance of LTCI fund is sensitive with life expectancy.

Conclusions

Dynamic growth of LTCI premium is essential in dealing with current deficit around 2050 and realizing Zhejiang’s LTCI sustainability in the long-run. The importance of dynamic monitoring disability and mortality information is emphasized to respond immediately to the increase of premiums. LTCI should strike a balance between expanding coverage and controlling financing scale. This study provides implications for developing countries to establish or pilot LTCI schemes.

Peer Review reports

The lack of sufficient long-term care (LTC) for older individuals has become a pressing concern in both developed and developing countries with global population aging and increased longevity [ 1 ]. Although healthy life expectancy generally increased over last decades [ 2 ], the episode of disability in older people could have catastrophic impact on their household welfare [ 3 ]. Several developed countries, such as the Netherlands, Germany, and Japan, have established social long-term care insurance (LTCI) to address LTC demands of households with disabled older individuals. This approach proves more efficient in pooling disability risks than private LTCI [ 4 , 5 ]. Nonetheless, many developed countries had to reform their LTCI systems to deal with increasing aging population with LTC demands, often by raising premiums. Even though, these adjustments usually had time lags which affected the long-term sustainability of LTCI schemes. However, establishing social LTCI in developing countries proves more challenging than in developed countries because the lower income of residents restricts the financing capacity of LTCI. In addition, the lack of high-quality death registration and health survey data hinders optimizing LTCI systems design according to changing LTC demands, particularly in developing countries or small areas [ 6 ].

Massive evidence shows that there will be a steady and slow increase in life expectancy [ 7 , 8 , 9 ]. Evidence from developed countries shows that the long-term care needs increasing rapidly because of the increasing life expectancy [ 10 , 11 ]. The trend of the gap between life expectancy and healthy life expectancy is still inconclusive [ 12 ], which also affects the identification of LTC needs [ 13 ]. There is still mixed conclusion of disability and LTC demands trend in the future based on the three different assumptions of health transitions [ 14 , 15 , 16 ]. Whereas, there is less evidence regarding the assessment of LTC needs under different mortality scenarios. Zeng, et al. [ 17 ] calculated long-term care needs under different life expectancy scenarios, but the setting of life expectancy was relatively subjective. Besides, many studies in country-level controlled the impact of underreported mortality on the LTCI system by using modified mortality data [ 18 , 19 ], but few studies in the provincial level took that into consideration.

Most countries such as Germany and the Netherlands adopt a fixed percentage of income model to collect social LTCI premiums from individuals [ 20 ], and a few countries such as Singapore adopt a fixed amount premium model [ 21 ]. The premium of Germany LTCI has been 3.05% of gross income or 3.40% if individuals aged 23 and above without children since 2020 [ 22 ]. The Netherlands also has a tax-funded LTCI with the compulsory contribution of 9.65% of taxable income since 2017 [ 20 ]. In Singapore, fixed amount premium of LTCI is determined by the age of starting contribution and sex. The premium for a 30-year-old male (female) is around 200 (250) Singapore Dollars in 2020 [ 21 ], with an increase of 2% per year from 2020 to 2025 [ 23 ]. Financing parameters from both models should be adjusted regularly to ensure sustainability [ 24 , 25 ]. In China, both models are adopted in different LTCI pilot areas [ 26 ], but the areas that adopt the fixed amount of premium have not increased the premium level since the pilot, which affects long-term sustainability.

OECD countries will face high pressure of LTCI financing because of increasing average public LTC expenditures to 2.3% of GDP in 2040 for the future financing level of LTCI [ 27 ]. Therefore, an adjustment factor is suggested incorporated to simulate LTCI fund to reduce future financing pressure [ 22 ], but a higher short-term financing will bring greater resistance to reforms. Most simulation studies on China’s LTCI, based on fixed percentage of income model, demonstrated that LTCI financing will increase rapidly based on different disability scenarios [ 28 , 29 , 30 , 31 ]. Some studies also simulated LTCI financing based on fixed amount of premium model [ 32 , 33 ], but they did not consider its variation under different mortality scenarios. Only one study modified the mortality in a pilot city by using national mortality data when simulating the dynamic financing burden [ 34 ]. However, it only simulated to 2040 which did not cover plateau period of China’s aging.

China, as a developing country, pioneered social LTCI schemes in 2016. Local governments were granted significant autonomy, resulting in fragmented LTCI structures due to regional disparities in the pilot cities [ 35 ]. Thus it has become crucial to ensure the sustainability of China’s LTCI pilot areas. Zhejiang Province stands as a representative case among these pilot areas and its five cities (Tonglu, Ningbo, Jiaxing, Yiwu and Whenzhou) have piloted LTCI since 2017. Zhejiang has standardized disability assessments, coverage groups, benefit levels, and financing amounts of LTCI in province-level by 2022 [ 36 ]. It faces rapid aging ahead with high life expectancy in China. Notably, Zhejiang, one of the areas with fixed amount of premium of LTCI in China, has never increased its fixed premium since the pilot’s inception [ 36 ]. This lack of financing adjustment coupled with inflationary pressures strains Zhejiang’s LTCI fund. Zhejiang has capacities to facilitate LTCI operations through modified financing mechanism as the demonstration zone for the Initiative of Common Prosperity in China. Therefore, it can serve as a practical model for other developing countries establishing LTCI schemes to evaluate life expectancy and LTC demand parameters and guide its LTCI financing.

In summary, massive studies predict the LTC needs in developed countries and China. However, most of the studies on LTCI financing in China pilots overlook the potential death underreporting in census and uncertainty of mortality in projection period, which may misestimate the future LTC needs and financing pressure. In addition, current studies on the sustainability of China’s LTCI rarely involve the dynamic financing adjustment of fixed amount of premium model, and most studies do not cover the plateau period of China’s aging in the future, which may underestimate the financing level to achieve sustainable LTCI. Therefore, drawing from the Zhejiang Province case in China, this study proposes a dynamic financing mechanism to achieve a balance between sustainability and efficiency in social LTCI schemes, utilizing a simulation model with limited mortality and disability information. Our aim is to offer insights for developing countries to establish or pilot LTCI schemes. Three research questions will be addressed:

What is the long-term trend of life expectancy in Zhejiang from 1990 to 2080?

What extent of LTC demand will be reached among older people in Zhejiang from 2023 to 2080, with aging process?

What level of LTCI dynamic financing standards will achieve an actuarial equilibrium of the LTCI fund in Zhejiang, with rising life expectancy and LTC demand?

Data sources

For demographic data, the age-specific mortality and the population number by gender are from population census of Zhejiang Province in 1990, 2000, 2010 and 2020. The population census, which has been conducted once every 10 years since 1990, is a complete account of the entire population, mortality and fertility by age and sex in each census year and has the province-level representativeness of Zhejiang. Child mortality data is from Chinese Center for Disease Control and Prevention (CDC) in 1990–2013 [ 37 ], and official annual data of Zhejiang reported u p to 2020 [ 38 ]. Chinese CDC sorted and estimated under-5 mortality rates in China before 2013 with county-level and province-level representativeness, including data in Zhejiang. Data on the prevalence rate of disability of the older people is sourced from China Health and Retirement Longitudinal Study (CHARLS) in 2018. CHARLS is a national representative survey which covers a wide range of topics related to the adults aged 45 and above, including demographic information and health status. The national prevalence rate of disability by age and sex from CHARLS is used as a proxy for Zhejiang referring to existing research, due to lack of latest representative disability data in Zhejiang [ 39 ]. Older people are defined as those aged 60 and above based the statistical standards from World Health Organization [ 40 ], whose age groups are covered by CHARLS. The benefit criteria and financing criteria data is from the LTCI official regulations of pilot cities in Zhejiang [ 41 , 42 , 43 , 44 , 45 ]. Healthcare Consumer Price Index (CPI) from 2010 to 2020 in Zhejiang is from National Bureau of Statistics of China, covering the socio-economic indicators at province-level [ 46 ]. The change rate of total fertility of China from 2020 to 2080 is from World Population Prospects 2022 which forecasted fertility in country-level around the world [ 47 ].

Estimation of mortality pattern with three-parameter model life table approach

Model life tables methods are widely used in simulation of mortality for their effectiveness and accessibility to overcome the limited mortality information in developing countries [ 48 , 49 ]. Two-parameters log-quadratic model considering the child and adult mortality overcomes the shortage of Coale-Demeny and UN model life tables, among those model life tables methods [ 50 ]. Three-parameter log-quadratic model is designed on this to calculate the life table considering extra old-age mortality parameter with an adjustment of intercept with real census information [ 51 ]. It is so-called developing countries mortality database (DCMD) model which was adopted in the World Population Prospects 2019 since the three-parameter log-quadratic model life table was initially used in those developing countries without the high-quality mortality data [ 52 ]. The basic function of DCMD model is showed below:

This study used adjusted DCMD model to estimate the mortality in Zhejiang from 1990 to 2020 to make it usable for open population conditions. Child mortality ( \({\,}_{5}{q_0}\) ) is the first parameter of DCMD model, and adult mortality ( \({\,}_{{45}}{q_{15}}\) ) is the second parameter to be compared with estimated adult mortality ( \({\,}_{{45}}{\hat {q}_{15}}\) ) from two-parameter log-quadratic model with adjustment factor \(k\) . Specifically, child mortality by gender in consecutive years is estimated by sex ratio of child mortality in China [ 53 ]. Adult mortality in census years is calculated from census life table directly as the register completeness of adults’ death is higher in China [ 53 ]. Moreover, we averaged old-age mortality estimated from two-parameter log-quadratic model and from survival model for midpoint of old-age mortality between censuses (1995, 2005 and 2015) [ 51 ]. We averaged old-age mortality from two-parameter log-quadratic model and from census life table calculations for census years (1990, 2000, 2010 and 2020). The adjusted DCMD model was constructed on the incorporated old-age mortality. After that, the cubic hermite polynomial interpolation approach (pchip package in R) was adopted to estimate adult and old-age mortality from 1990 to 2020 [ 54 ]. The life table for consecutive years was estimated with DCMD model.

After that, Lee-Carter method extended with rotation (LC_ER) (mortcast package in R) was used to forecast the mortality up to 2080 [ 55 ], which provides critical death parameters to assess the LTCI demands in our case area. Since in low mortality countries, mortality decline is decelerating at younger ages and accelerating at older ages [ 56 ], the static assumption of mortality decline of traditional Lee-Carter model would be anomalous in long-term projection. LC_ER is a time-varying Lee-Carter model considering the changes of mortality decline between different age groups when modeling, which was widely recognized and adopted by World Population Prospects 2022 [ 57 , 58 ]. Therefore, potential LTCI demands change caused by changes in old-age mortality decline in long-term projections could be captured by LC_ER. The predicted mean of life expectancy would be set as the medium life expectancy scenario, and the lower and upper 95% predicted interval would be set as the low and high life expectancy scenarios.

Number of severe disabled older adults

LTCI beneficiaries refer to the severe disabled population according to the rules of LTCI in Zhejiang [ 36 ]. The study used the cohort-component projection (CCP) method to forecast the number of older population of Zhejiang from 2020 to 2080 [ 59 ]. The number of age-specific population by sex from Zhejiang population census 2020 was used as the base population of CCP model. Furthermore, the age-specific prevalence rate of disability from CHARLS 2018 was calculated. After that, the number of severe disabled older adults as the LTCI beneficiaries was calculated by multiplying age-specific older population and prevalence rate of disability. The basic project method is as follows:

\({\,}_{{x+1}}P_{x}^{{t+1}}\) represents the population of single age groups with the age of x to x  + 1 at the t  + 1 time. \(\left[ {{L^t}(x+1)/{L^t}(x)} \right]\) represents the survival ratio of age x to x  + 1 at t time. \(N{I^*}\) represents the net migration numbers in the corresponding age group from the t to t +  1 period, from other regions to Zhejiang.

Our estimated mortality will be used in CCP model. Since the total fertility of Zhejiang is lower than that of China, this study assumed that the total fertility of Zhejiang would start at 1.04 in 2020 based on Zhejiang population census [ 60 ]. Then, the future trend of Zhejiang’s total fertility would follow the United Nations’ estimated change rate of total fertility of China from 2020 to 2080 [ 47 ]. For net migration, The Census Survival Ratio Method was used to estimate the migration pattern based on the census data [ 61 ]. As one of the highest net in-migration provinces since 2010, Zhejiang will face the lower net in-migration intensity and be close to migration equilibrium in 2040 [ 62 ]. Based on this, it is assumed that the net migration rate in Zhejiang will experience a linear decrease and realize migration equilibrium by 2045.

Disability is defined as a difficulty in performing at least one of six Activities in Daily Living (ADL) [ 63 ], including bathing, dressing, eating, getting in/out of bed, using the toilet, and controlling urination and defecation in CHARLS. Then, mild disability is defined as having difficulty in 1–2 items of ADL, moderate disability as having difficulty in 3–4 items of ADL, and severe disability as having difficulty in at least 5 items of ADL [ 64 , 65 ]. Based on the discussion on the Disease Expansion, Disease Compression and Dynamic Equilibrium Theory [ 66 ], three different scenarios in changing disability were calculated [ 16 ]: a 0.8% annual decrease for age-specific prevalence rate of disability as the low disability scenario, the constant age-specific prevalence rate of disability as the middle disability scenario, and a 0.8% annual increase for age-specific prevalence rate of disability as the high disability scenario.

Dynamic financing actuarial model of social LTCI schemes

The study built a macro simulation model to further simulate the expenditure, financing and fund balance of LTCI based on the projection of severe disabled older population ( \(DisOP\) ) aged 60 and above and contribution population ( \(CP\) ) of LTCI aged 20 and above. The macro model is showed below:

In Formula (4), \(LTCE\) means LTC expenditures, \(HbdcCost\) , \(IcCost\) , \(HbdmcCost\) and \(NhcCost\) represent the unit cost of home-based daily living care (HBDC), institutional care, home-based daily living & medical care (HBDMC) and nursing hospital care per person per year, respectively. Among them, HBDC means that beneficiaries only receive formal daily living care services at home but without any medical care. HBDMC means that beneficiaries receive both formal daily living care services and professional medical care services at home. The difference of institutional care and nursing hospital care lies in that the former focuses more on daily living care, while the latter specializes in medical care. From 2023 to 2080, the unit cost of each type of LTC services is given an increase of 2.25% annually based on the average increase of healthcare CPI from 2010 to 2020. \(\alpha \) means the percentage of different types of LTC services utilization. Formula (5) describes the dynamic financing model and current balance of LTCI every year. \(premiu{m_{{t_0}}}\) is the fixed amount of premiums of LTCI in our base period. \(\lambda \) is annual growth of the amount of LTCI premiums. Formula (6) shows the accumulated balance of LTC fund which is determined by the current balance and the accumulated balance in previous period. \(\gamma \) is the interest rate of LTCI fund which represents the time value of the LTCI fund. Taking the inflation rate (2.25%) as a reference in the simulation process, we test the minimum value of \(\lambda \) that ensures a consistently positive accumulated balance in the LTCI fund up to 2080 across various disability scenarios.

Parameters of LTCI schemes in Zhejiang Province, China

The policies of LTCI schemes in five pilot cities in Zhejiang are sorted in Additional Table 1  (see Additional file 1 ) [ 41 ]. The LTCI schemes in Jiaxing City are representative among five pilot cities of LTCI in Zhejiang. Firstly, Jiaxing is the first city covering all employees and urban and rural residents equitably with the same benefits and premium since the adoption of LTCI (in 2017), which has navigated the reform of LTCI in Zhejiang. Secondly, LTCI benefits in Jiaxing are at the middle level among the five pilot cities, which is representative of average level in Zhejiang. The maximum benefits of HBDC in Jiaxing are lower than those in Yiwu and Wenzhou, and equal to those in Tonglu and Ningbo. Besides, the maximum benefits of institutional care are also lower than those in Yiwu, but higher than those in Tonglu and Ningbo. Overall, Jiaxing’s LTCI benefits stay average in Zhejiang. Thirdly, LTCI financing criteria in Jiaxing align with Ningbo and Tonglu (90 Chinese Yuan (CNY)/person/year), reflecting the standards across five cities. Therefore, this study adopted Jiaxing’s LTCI criteria as the parameters of LTCI simulations in Zhejiang. The unit costs of HBDC, institutional care, HBDMC and nursing hospital care are set at 1200 CNY/month, 2100 CNY/month, 1680 CNY/month and 1680 CNY/month in 2024 according to LTCI maximum benefits in Jiaxing (see Additional Table 1 , Additional file 1 ) [ 41 ]. The contributory group of LTCI is the group participating in social health insurance, whether retired or not. The LTCI financing parameter \(premiu{m_{{t_0}}}\) is based on a fixed amount of premiums in Jiaxing, of which the standard is 90 CNY/person/year [ 41 ].

Chinese government proposed a model of elderly care named “9073” model: 90% of older people receive home-based care, 7% receive community care and 3% receive institutional care [ 67 ]. “9073” model represents the prospects of China’s elderly care and is therefore suitable for the long-term simulation in this study [ 29 , 62 ]. Specifically, proportion of HBDC ( \({\alpha _{\text{1}}}\) ), institutional care ( \({\alpha _2}\) ), and combination of HBDMC and nursing hospital care ( \({\alpha _3}\) + \({\alpha _4}\) ) are set at 90%, 3% and 7%, respectively. Disabled older people can choose to receive HBDMC at home or receive nursing hospital care at medical institutions when facing medical care needs. It is free to choose the locations for these two LTC services, and it is quite similar to receiving community care in nature, as it also allows the option of receiving services at home or at community centers. Additionally, the LTCI benefits of these two LTC services in Jiaxing are equal. Therefore, we grouped them together when determining the beneficiaries’ choice of LTC services type ( \({\alpha _3}\) + \({\alpha _4}\) ). We set the interest rate of LTCI fund at 2.5% based on current interest rate of 5-year time deposit in China’s banks [ 68 ]. The sources of each parameter for simulation framework of the study are demonstrated in Additional Fig.  1 (see Additional File 1 ).

The mortality pattern and life expectancy of Zhejiang

The estimated mortality of Zhejiang from 1990 to 2020 is demonstrated in Fig.  1 based on adjusted DCMD model. Overall, the mortality for male and female presents a declining trend. Specially, the child mortality had a continued decline during the estimation period, but the adult mortality and old-age mortality had a slight increase between 1990 and 2000, then with a sharp decline between 2000 and 2020 afterwards.

We further predict the life expectancy at birth with 95% confidential interval under the LC_ER model from 2020 to 2080. The estimated and predicted life expectancy is demonstrated in Fig.  2 . Life expectancy of female had a stable increase from 1990 to 2020. While there was a slight decline of life expectancy of male from 1990 to 2000, then there was a rapid increase until 2020. The model results based on historical information show that life expectancy of both female and male will have an upward trend from 2020 to 2080. Besides, the gender difference in life expectancy will remain relatively stable in the future. In 2020, life expectancy was 80.46 years for male, 84.66 years for female. In 2080, the life expectancy will reach 89.39 [86.61, 91.74] years for male, 91.24 [88.90, 93.25] years for female. Besides, the age-specific rates of mortality decline of Zhejiang from 2021 to 2080 estimated by LC_ER are illustrated in Additional Fig.  2 (see Additional File 1 ).

figure 1

Mortality pattern of Zhejiang in 1990–2020 based on adjusted DCMD model

figure 2

Estimated and predicted life expectancy of Zhejiang in 1990–2080

The simulation of long-term care demand and expenditures in Zhejiang

Based on CCP method, the study has projected the number of older people and the number of severely disabled older people with different scenarios of disability in Zhejiang from 2020 to 2080 (shown in Table  1 ). It is illustrated that the population aged 60 and above in Zhejiang will firstly expand to around 2060 and then shrink until 2080. The number of older people with disabilities, especially those with severe disability, reflects the long-term care demand from a demographic perspective. We found that the number of older people with severe disability will continue to increase to 2080 under both medium and high disability scenarios. However, the number of older people with different degrees of disability will increase before 2060, and then decline slightly in the following 20 years under the low disability scenario. We also found that the number of severely and moderately disabled older people will be of little difference before 2050, which means that severe and moderate LTC demand is roughly equal.

Besides, the results of LTC demand under the high and low life expectancy scenarios are illustrated in Additional Table  2 and Additional Table  3 (see Additional file 1 ). It can be seen that Zhejiang Province will have a higher LTC demand under the scenario of higher life expectancy. The number of older people with severe disability under 95% upper interval of life expectancy in 2080 is 154 thousands higher than that under the predicted mean of life expectancy. And the number of older people with severe disability under 95% lower interval of life expectancy in 2080 is 169 thousands lower than that under the predicted mean of life expectancy. This result demonstrates the importance of mortality level prediction for assessing LTC demand.

Our study further calculated the LTCI expenditure paid by insurance fund every year from 2020 to 2080 to analyze the future long-term care demand in our case area from a financial perspective. The expenditure from LTCI illustrates an upward trend from 2023 to 2080 (see Fig. 3 ), with the higher price of long-term care services and increasing number of severe disabled older people. The LTCI expenditure is still increasing although there will be a slight decline in severe disabled older people under low disability scenario.

figure 3

Projection of Long-term care insurance expenditure in Zhejiang, 2024–2080. Notes Results are based on the predicted mean of life expectancy

The simulation of LTCI fund under diverse disability and financing scenarios

The accumulated balance of LTCI fund from 2022 to 2080 is simulated on different dynamic financing growth scenarios in order to test how to make LTCI achieve actuarial balance in the long run. The accumulated balance and current balance of LTCI fund in Zhejiang are shown in Figs.  4 and 5 . When we set the annual premium growth rate at 2.25% which is equal to the average increase of healthcare CPI, there will be a deficit of current balance before 2028. As a result, the accumulated balance will become negative in 2032 under medium disability scenario, under high disability scenario in 2030 and under low disability scenario in 2036. This result shows that LTCI fund can only be sustainable within 12 years if the financing level grows at a low pace from 2024.

figure 4

Accumulated balance of LTCI fund under different financing and disability scenarios. Notes Results are based on the predicted mean of life expectancy

figure 5

Current balance of LTCI fund under different financing and disability scenarios. Notes Results are based on the predicted mean of life expectancy

The minimum annual premium growth is further tested to achieve the positive accumulated balance of LTCI fund under various scenarios from 2022 to 2080. We found that when the annual premium growth rate equals to 4.20%, LTCI fund will realize the long-term sustainable under low disability scenario, which means that the 4.20% financing growth standard is effective to make LTCI sustainable at a relatively low premium level under low disability scenario; however, it will still face the risk of the shortage of financing with 4.20% annual premium growth under the medium and high disability scenarios after 2039 and 2033.

Furthermore, the accumulate balance of LTCI fund remains at a moderate surplus and will not face a shortage until 2080 under the medium disability scenario when the annual premium growth rate equals 5.25%. Although the current balance of LTC fund will be negative in 2043 to 2058 under 5.25% annual premium growth (see Fig.  5 ), the accumulated surplus before 2042 and continuous interest will still realize the accumulated surplus of LTCI fund (5.83 billion CNY) in 2058. Overall, the annual premium growth rate at 5.25% is the best parameter choice if the age-specific prevalence rate of disability in Zhejiang Province is projected to remain stable. Finally, LTCI will be sustainable under all disability scenarios when the premium increases by 6.25% per year. However, this level will put a heavy payment burden on the residents, and there will be a large amount of fund redundancy if the disability does not continue to increase.

The simulation of LTCI fund under diverse life expectancy and financing scenarios

The impact of different life expectancy trend on the sustainability of LTCI schemes is further discussed. The simulation results of accumulated balance of LTCI fund under predicted mean, 95% upper confidential interval and lower confidential interval of life expectancy scenarios are demonstrated in Fig.  6 . It is learned that the sustainability of the LTCI fund will face a completely different situation in the long-term because of the difference trends in life expectancy even under the same disability level and financing level. Under the 5.25% annual premium growth rate and medium disability scenario, LTCI fund will become accumulated deficit under 95% upper interval of life expectancy after 2045. However, the LTCI fund will always remain in surplus before 2080 with the predicted mean or lower 95% interval of life expectancy. Therefore, the balance of LTCI fund is sensitive to life expectancy. In addition to affecting LTC expenditures when other conditions are the same, life expectancy is also related the total amount of financing by the number of contributors, thereby influencing the sustainability of LTCI fund.

figure 6

Current and accumulated balance of LTCI under different life expectancy scenarios. Notes Results are based on the 5.25% annual premium growth rate scenario and medium disability scenario

This study shows two novel contributions to the existing literature. The first contribution is that we have found an important but often overlooked point that LTCI financing is sensitive to the variability of life expectancy in the long-term. In 2080, the 95% upper interval of the life expectancy in Zhejiang Province will be 2.01 years for female (2.35 years for male) higher than the predicted mean, and its cumulative impact will make LTCI unsustainable 35 years in advance. This finding shows that the accurate estimation of life expectancy is critical for assessing the sustainability of social insurance schemes like LTCI [ 69 , 70 ], and also reveals the significance of life expectancy analysis in this study, because health factors can be dynamically monitored through the evaluation and reimbursement records within the LTCI system [ 34 , 71 ], but life expectancy estimation will become difficult due to the lack of timely statistical data. Besides, the study also finds that LTCI financing is also sensitive to the variability of prevalence rate of disability in the long-term. Only 4.20% annual growth of premium can make Zhejiang’s LTCI sustainable under a disability compression assumption. However, the 6.25% annual growth of premium is necessary for Zhejiang’s LTCI sustainability under disability expansion assumption. The results are consistent with some existing research with various disability scenarios [ 28 , 72 ]. The overall incidence of disability will face a growing trend with population aging [ 17 ]. Therefore, proposing health promotion and postponing disability actions to reduce the incidence and duration of severe disability among older people will mitigate the pressure of LTCI funding [ 73 ].

The second contribution is that Zhejiang’s LTCI financing needs to grow at a relative high speed annually (5.25% under the medium scenario) to achieve sustainability in the long-term. It should be noticed that the LTCI financing parameters to achieve short-term and long-term fund equilibrium are different, and it is clear that long-term fund balance is a necessary condition to ensure the sustainability of the system [ 22 , 29 ]. If the accumulated surplus of the LTCI fund in Zhejiang Province before 2050 is used as a criterion for determining sustainability, as many studies have done [ 19 , 74 ], our results indicate that Zhejiang LTCI fund is projected to experience an accumulating deficit for over 20 years after 2050. Like Zhejiang, there are also several pilot cities in China that have adopted the fixed amount of premium model without premium adjustment [ 32 ]. LTCI funds in these regions will run the risk of accumulating deficits in the short term [ 43 ]. China and other countries adopting social LTCI need to adjust the scale of premium in a timely and dynamic manner to cope with the long-term LTCI financing pressure since China’s aging plateau will continue after 2060 [ 47 ].

Our simulation results can also be used as a reference for countries and regions that adopt a fixed percentage of income model of LTCI financing although we focus on the fixed amount model of LTCI financing. The study finds that LTCI premium in Zhejiang needs to increase by 5.25% per year to ensure sustainability to 2080 under the assumption of disability with dynamic equilibrium. However, the growth rate may exceed the income growth rate of some countries in the context of declining global economic growth [ 75 ]. Therefore, even those countries based on a fixed percentage of income model need adjust financing parameters dynamically [ 1 ]. In LTCI fund management, China and other countries can learn from Germany’s experience to deal with the long-term impact of population aging, which has established a demographic reserve fund which saves 0.1% of premium every year for payment in the future [ 25 ].

Reasonable coverage and benefits are also important factors to achieve sustainable LTCI. Like developed countries, the LTCI pilot cities in Zhejiang Province cover all urban and rural residents. However, most of the LTCI pilot cities in China only cover urban employees [ 35 ]. Therefore, the analysis of LTCI in Zhejiang Province in this paper provides implications for other LTCI pilot cities in China to expand the coverage and promote the equity of receiving LTC. Besides, it should be noted that this study only considers the older adults with severe disabilities according to the rules when estimating LTC needs in Zhejiang Province [ 36 ]. Whereas, it is not only the families of severely disabled groups that face the burden of long-term care [ 17 ]. Moderately disabled people in some developed countries and pilot cities in China are also covered by LTCI [ 76 , 77 ]. Even considering only severe disability, our simulation results show that only a high premium growth rate can make the system sustainable in the long run. Therefore, LTCI policymakers need to comprehensively weigh residents’ payment pressure and long-term care benefits, and make a balance between expanding coverage and increasing financing with the aim of protecting the most vulnerable groups.

This study has explored and built a long-term care insurance system that can be a reference for China and other developing countries to provide LTC services for the disabled older adults in the future. The strength of this study is that a more accurate life expectancy estimation based on the DCMD model is adopted when estimating dynamic financing of LTCI. However, this paper still has some limitations. Firstly, the paper only considers the activities of daily living when estimating the prevalence rate of disability of older people in Zhejiang Province, but does not consider cognitive function, perception and communication function due to the lack of data. Secondly, this study only considers the expenditure cost of LTC in the simulation analysis, but does not consider the operating cost of the LTCI system. Thirdly, this study only considers the total amount of financing for LTCI, but does not discuss the financing structure including individual contributions, government subsidies, and pooling funds. Finally, this study focuses only on the case in Zhejiang, but does not simulate the LTCI financing standard for actuarial equilibrium in other LTCI pilot areas in China.

In summary, this study estimates and predicts the mortality rate in Zhejiang Province from 1990 to 2080 through the DCMD model and LC model, and further evaluates the increasing LTC need in Zhejiang Province in the future. The LTCI dynamic financing in Zhejiang Province under different disability scenarios and life expectancy scenarios is simulated on the LTCI expenditure forecast results, and it is found that only by maintaining a relatively high level (5.25% under medium scenario) of premium growth can Zhejiang’s LTCI be sustainable in the long run. Our empirical case in Zhejiang offers implications for developing countries and LTCI pilot areas that lack high-quality mortality information to establish and dynamically optimize LTCI financing. Therefore, policy makers are called upon to assess the sustainability of LTCI from a long-term perspective, and regularly monitor changes in residents’ health and life expectancy to ensure that LTCI fund can meet LTCI expenditure and control the financing burden.

Data availability

In this study, all the data sources are publicly available. The data calculated in this study is available upon request to the corresponding author.

Abbreviations

Long-term care

  • Long-term care insurance

China Health and Retirement Longitudinal Study

Center for Disease Control and Prevention

Consumer Price Index

Developing Country Mortality Database

Lee-Carter method extended with rotation

Cohort-component projection

Chinese Yuan

Home-based daily living care

Home-based daily living & medical care

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Acknowledgements

We would like to thank Professor Xiangming Fang from Zhejiang University, Professor Guangdi Chen from Zhejiang University and Chengxu Long from King’s College London for their constructive advice during the research process of the paper. We would also like to appreciate any comments from the 34th REVES meeting.

This work was supported by the Major Project of Zhejiang Provincial Natural Science Foundation of China (LD21G030001).

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Xu, X., Li, Y. & Mi, H. Life expectancy, long-term care demand and dynamic financing mechanism simulation: an empirical study of Zhejiang Pilot, China. BMC Health Serv Res 24 , 469 (2024). https://doi.org/10.1186/s12913-024-10875-7

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A scoping review of ‘Pacing’ for management of Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS): lessons learned for the long COVID pandemic

  • Nilihan E. M. Sanal-Hayes 1 , 7 ,
  • Marie Mclaughlin 1 , 8 ,
  • Lawrence D. Hayes 1 ,
  • Jacqueline L. Mair   ORCID: orcid.org/0000-0002-1466-8680 2 , 3 ,
  • Jane Ormerod 4 ,
  • David Carless 1 ,
  • Natalie Hilliard 5 ,
  • Rachel Meach 1 ,
  • Joanne Ingram 6 &
  • Nicholas F. Sculthorpe 1  

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Controversy over treatment for people with myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) is a barrier to appropriate treatment. Energy management or pacing is a prominent coping strategy for people with ME/CFS. Whilst a definitive definition of pacing is not unanimous within the literature or healthcare providers, it typically comprises regulating activity to avoid post exertional malaise (PEM), the worsening of symptoms after an activity. Until now, characteristics of pacing, and the effects on patients’ symptoms had not been systematically reviewed. This is problematic as the most common approach to pacing, pacing prescription, and the pooled efficacy of pacing was unknown. Collating evidence may help advise those suffering with similar symptoms, including long COVID, as practitioners would be better informed on methodological approaches to adopt, pacing implementation, and expected outcomes.

In this scoping review of the literature, we aggregated type of, and outcomes of, pacing in people with ME/CFS.

Eligibility criteria

Original investigations concerning pacing were considered in participants with ME/CFS.

Sources of evidence

Six electronic databases (PubMed, Scholar, ScienceDirect, Scopus, Web of Science and the Cochrane Central Register of Controlled Trials [CENTRAL]) were searched; and websites MEPedia, Action for ME, and ME Action were also searched for grey literature, to fully capture patient surveys not published in academic journals.

A scoping review was conducted. Review selection and characterisation was performed by two independent reviewers using pretested forms.

Authors reviewed 177 titles and abstracts, resulting in 17 included studies: three randomised control trials (RCTs); one uncontrolled trial; one interventional case series; one retrospective observational study; two prospective observational studies; four cross-sectional observational studies; and five cross-sectional analytical studies. Studies included variable designs, durations, and outcome measures. In terms of pacing administration, studies used educational sessions and diaries for activity monitoring. Eleven studies reported benefits of pacing, four studies reported no effect, and two studies reported a detrimental effect in comparison to the control group.

Conclusions

Highly variable study designs and outcome measures, allied to poor to fair methodological quality resulted in heterogenous findings and highlights the requirement for more research examining pacing. Looking to the long COVID pandemic, our results suggest future studies should be RCTs utilising objectively quantified digitised pacing, over a longer duration of examination (i.e. longitudinal studies), using the core outcome set for patient reported outcome measures. Until these are completed, the literature base is insufficient to inform treatment practises for people with ME/CFS and long COVID.

Introduction

Post-viral illness occurs when individuals experience an extended period of feeling unwell after a viral infection [ 1 , 2 , 3 , 4 , 5 , 6 ]. While post-viral illness is generally a non-specific condition with a constellation of symptoms that may be experienced, fatigue is amongst the most commonly reported [ 7 , 8 , 9 ]. For example, our recent systematic review found there was up to 94% prevalence of fatigue in people following acute COVID-19 infection [ 3 ]. The increasing prevalence of long COVID has generated renewed interest in symptomology and time-course of post-viral fatigue, with PubMed reporting 72 articles related to “post-viral fatigue” between 2020 and 2022, but less than five for every year since 1990.

As the coronavirus pandemic developed, it became clear that a significant proportion of the population experienced symptoms which persisted beyond the initial viral infection, meeting the definition of a post-viral illness. Current estimates suggest one in eight people develop long COVID [ 10 ] and its symptomatology has repeatedly been suggested to overlap with clinical demonstrations of myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS). In a study by Wong and Weitzer [ 11 ], long COVID symptoms from 21 studies were compared to a list of ME/CFS symptoms. Of the 29 known ME/CFS symptoms the authors reported that 25 (86%) were reported in at least one long COVID study suggesting significant similarities. Sukocheva et al. [ 12 ] reported that long COVID included changes in immune, cardiovascular, metabolic, gastrointestinal, nervous and autonomic systems. When observed from a pathological stance, this list of symptoms is shared with, or is similar to, the symptoms patients with ME/CFS describe [ 13 ]. In fact, a recent article reported 43% of people with long COVID are diagnosed with ME/CFS [ 13 ], evidencing the analogous symptom loads.

A striking commonality between long COVID and similar conditions such as ME/CFS is the worsening of symptoms including fatigue, pain, cognitive difficulties, sore throat, and/or swollen lymph nodes following exertion. Termed post exertional malaise (PEM) [ 14 , 15 , 16 , 17 ], lasting from hours to several days, it is arguably one of the most debilitating side effects experienced by those with ME/CFS [ 16 , 17 , 18 ]. PEM is associated with considerably reduced quality of life amongst those with ME/CFS, with reduced ability to perform activities of daily living, leading to restraints on social and family life, mental health comorbidities such as depression and anxiety, and devastating employment and financial consequences [ 19 , 20 , 21 , 22 ]. At present, there is no cure or pharmacological treatments for PEM, and therefore, effective symptom management strategies are required. This may be in part because the triggers of PEM are poorly understood, and there is little evidence for what causes PEM, beyond anecdotal evidence. The most common approach to manage PEM is to incorporate activity pacing into the day-to-day lives of those with ME/CFS with the intention of reducing the frequency of severity of bouts of PEM [ 23 ]. Pacing is defined as an approach where patients are encouraged to be as active as possible within the limits imposed by the illness [ 23 , 24 , 25 ]. In practice, pacing requires individuals to determine a level at which they can function, but which does not lead to a marked increase in fatigue and other symptoms [ 26 , 27 ].

Although long COVID is a new condition [ 3 , 14 ], the available evidence suggests substantial overlap with the symptoms of conditions such as ME/CFS and it is therefore pragmatic to consider the utility of management strategies (such as pacing) used in ME/CFS for people with long COVID. In fact, a recent Delphi study recommended that management of long COVID should incorporate careful pacing to avoid PEM relapse [ 28 ]. This position was enforced by a multidisciplinary consensus statement considering treatment of fatigue in long COVID, recommending energy conservation strategies (including pacing) for people with long COVID [ 29 ]. Given the estimated > 2 million individuals who have experienced long COVID in the UK alone [ 30 , 31 , 32 ], there is an urgent need for evidence-based public health strategies. In this context, it seems pragmatic to borrow from the ME/CFS literature.

From a historical perspective, the 2007 NICE guidelines for people with ME/CFS advised both cognitive behavioural therapy (CBT) and graded exercise therapy (GET) should be offered to people with ME/CFS [ 33 ]. As of the 2021 update, NICE guidelines for people with ME/CFS do not advise CBT or GET, and the only recommended management strategy is pacing [ 34 ]. In the years between changes to these guidelines, the landmark PACE trial [ 35 ] was published in 2011. This large, randomised control trial (RCT; n = 639) compared pacing with CBT and reported GET and CBT were more effective than pacing for improving symptoms. Yet, this study has come under considerable criticism from patient groups and clinicians alike [ 36 , 37 , 38 , 39 ]. This may partly explain why NICE do not advise CBT or GET as of 2021, and only recommend pacing for symptom management people with ME/CFS [ 34 ]. There has been some controversy over best treatment for people with ME/CFS in the literature and support groups, potentially amplified by the ambiguity of evidence for pacing efficacy and how pacing should be implemented. As such, before pacing can be advised for people with long COVID, it is imperative previous literature concerning pacing is systematically reviewed. This is because a consensus is needed within the literature for implementing pacing so practitioners treating people with ME/CFS or long COVID can do so effectively. A lack of agreement in pacing implementation is a barrier to adoption for both practitioners and patients. Despite several systematic reviews concerning pharmacological interventions or cognitive behavioural therapy in people with ME/CFS [ 36 , 40 , 41 ], to date, there are no systematic reviews concerning pacing.

Despite the widespread use of pacing, the literature base is limited and includes clinical commentaries, case studies, case series, and few randomised control trials. Consequently, while a comprehensive review of the effects of pacing in ME/CFS is an essential tool to guide symptom management advice, the available literature means that effective pooling of data is not feasible [ 42 ] and therefore, a traditional systematic review and meta-analysis, with a tightly focussed research question would be premature [ 43 ]. Consequently, we elected to undertake a scoping review. This approach retains the systematic approach to literature searching but aims to map out the current state of the research [ 43 ]. Using the framework of Arksey and O'Malley [ 44 ], a scoping review aims to use a broad set of search terms and include a wide range of study designs and methods (in contrast to a systematic review [ 44 ]). This approach, has the benefit of clarifying key concepts, surveying current data collection approaches, and identifying critical knowledge gaps.

We aimed to provide an overview of existing literature concerning pacing in ME/CFS. Our three specific objectives of this scoping review were to (1) conduct a systematic search of the published literature concerning ME/CFS and pacing, (2) map characteristics and methodologies used, and (3) provide recommendations for the advancement of the research area.

Protocol and registration

The review was conducted and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews (PRISMA-ScR) guidelines [ 45 ] and the five-stage framework outlined in Arksey and O’Malley [ 44 ]. Registration is not recommended for scoping reviews.

Studies that met the following criteria were included in this review: (1) published as a full-text manuscript; (2) not a review; (3) participants with ME/CFS; (4) studies employed a pacing intervention or retrospective analysis of pacing or a case study of pacing. Studies utilising sub-analysis of the pacing, graded activity, and cognitive behaviour therapy: a randomised evaluation (PACE) trial were included as these have different outcome measures and, as this is not a meta-analysis, this will not influence effect size estimates. Additionally, due to the paucity of evidence, grey literature has also been included in this review.

Search strategy

The search strategy consisted of a combination of free-text and MeSH terms relating to ME/CFS and pacing, which were developed through an examination of published original literature and review articles. Example search terms for PubMed included: ‘ME/CFS’ OR ‘ME’ OR ‘CFS’ OR ‘chronic fatigue syndrome’ OR ‘PEM’ OR ‘post exertional malaise’ OR ‘pene’ OR ‘post-exertion neurogenic exhaust’ AND ‘pacing’ OR ‘adaptive pacing’. The search was performed within title/abstract. Full search terms can be found in Additional file 1 .

Information sources

Six electronic databases [PubMed, Scholar, ScienceDirect, Scopus, Web of Science, and the Cochrane Central Register of Controlled Trials (CENTRAL)] were searched to identify original research articles published from the earliest available date up until 02/02/2022. Additional records were identified through reference lists of included studies. ‘Grey literature’ repositories including MEPedia, Action for ME, and ME Action were also searched with the same terms.

Study selection and data items

Once each database search was completed and manuscripts were sourced, all studies were downloaded into a single reference list (Zotero, version 6.0.23) and duplicates were removed. Titles and abstracts were screened for eligibility by two reviewers independently and discrepancies were resolved through discussion between reviewers. Subsequently, full text papers of potentially relevant studies were retrieved and assessed for eligibility by the same two reviewers independently. Any uncertainty by reviewers was discussed in consensus meetings and resolved by agreement. Data extracted from each study included sample size, participant characteristics, study design, trial registration details, study location, pacing description (type), intervention duration, intervention adherence, outcome variables, and main outcome data. Descriptions were extracted with as much detail as was provided by the authors. Study quality was assessed using the Physiotherapy Evidence Database (PEDro) scale [ 46 , 47 ].

Role of the funding source

The study sponsors had no role in study design, data collection, analysis, or interpretation, nor writing the report, nor submitting the paper for publication.

Study selection

After the initial database search, 281 records were identified (see Fig.  1 ). Once duplicates were removed, 177 titles and abstracts were screened for inclusion resulting in 22 studies being retrieved as full text and assessed for eligibility. Of those, five were excluded, and 17 articles remained and were used in the final qualitative synthesis.

figure 1

Schematic flow diagram describing exclusions of potential studies and final number of studies. RCT = randomized control trial. CT = controlled trial. UCT = uncontrolled trial

Study characteristics

Study characteristics are summarised in Table 1 . Of the 17 studies included, three were randomised control trials (RCTs [ 35 , 48 , 49 ]); one was an uncontrolled trial [ 50 ]; one was a case series [ 51 ]; one was a retrospective observational study [ 52 ], two were prospective observational studies [ 53 , 54 ]; four were cross-sectional observational studies [ 25 , 55 , 56 ]; and five were cross-sectional analytical studies [ 57 , 58 , 59 , 60 , 61 ] including sub-analysis of the PACE trial [ 35 , 56 , 59 , 61 ]. Seven of the studies were registered trials [ 35 , 48 , 49 , 50 , 56 , 57 , 58 ]. Diagnostic criteria for ME/CFS are summarised in Table 2 .

Types of pacing

Pacing interventions.

Of the 17 studies included, five implemented their own pacing interventions and will be discussed in this section. Sample sizes ranged from n = 7 in an interventional case series [ 51 ] to n = 641 participants in the largest RCT [ 35 ]. The first of these five studies considered an education session on pacing and self-management as the ‘pacing’ group, and a ‘pain physiology education’ group as the control group [ 49 ]. Two studies included educational sessions provided by a therapist plus activity monitoring via ActiGraph accelerometers [ 51 ] and diaries [ 48 ] at baseline and follow-up. In the first of these two studies, Nijs and colleagues [ 51 ] implemented a ‘self-management program’ which asked patients to estimate their current physical capabilities prior to commencing an activity and then complete 25–50% less than their perceived energy envelope. They[ 51 ] did not include a control group and had a sample size of only n = 7. Six years later, the same research group [ 48 ] conducted another pacing study which utilised relaxation as a comparator group (n = 12 and n = 14 in the pacing and relaxation groups, respectively). The pacing group underwent a pacing phase whereby participants again aimed to complete 25–50% less than their perceived energy envelope, followed by a gradual increase in exercise after the pacing phase (the total intervention spanned three weeks, and it is unclear how much was allocated to pacing, and how much to activity increase). Therefore, it could be argued that Kos et al. [ 48 ] really assessed pacing followed by a gradual exercise increase as outcome measures were assessed following the graded activity phase. Another pacing intervention delivered weekly educational sessions for six weeks and utilised a standardised rehabilitation programme using the ‘activity pacing framework’ [ 50 ] in a single-arm, no comparator group feasibility study. Finally, the PACE trial adopted an adaptive pacing therapy intervention consisting of occupational therapists helping patients to plan and pace activities utilising activity diaries to identify activities associated with fatigue and staying within their energy envelope [ 35 ]. This study incorporated standard medical care, cognitive behavioural therapy (CBT) and graded exercise therapy (GET) as comparator groups [ 35 ]. It is worth noting that the pacing group and the CBT group were both ‘encouraged’ to increase physical activity levels as long as participants did not exceed their energy envelope. Although not all five intervention studies explicitly mentioned the “Energy Envelope Theory”, which dictates that people with ME/CFS should not necessarily increase or decrease their activity levels, but moderate activity and practice energy conservation [ 62 ], all intervention studies used language analogous to this theory, such as participants staying within limits, within capacity, or similar.

The interventions included in this review were of varying durations, from a single 30-min education session [ 49 ], a 3-week (one session a week) educational programme [ 51 ], a 3-week (3 × 60–90 min sessions/week) educational programme [ 48 ], a 6-week rehabilitation programme [ 50 ], to a 24-week programme [ 35 ]. Intervention follow-up durations also varied across studies from immediately after [ 49 ], 1-week [ 51 ], 3-weeks [ 48 ], 3-months [ 50 ], and 1-year post-intervention [ 35 ].

Observational studies of pacing

Eight studies were observational and, therefore, included no intervention. Observational study sample sizes ranged from 16 in a cross-sectional interview study [ 25 ] to 1428 in a cross-sectional survey [ 52 ]. One study involved a retrospective analysis of participants’ own pacing strategies varying from self-guided pacing or pacing administered by a therapist compared with implementation of CBT and GET [ 52 ]. Five involved a cross-sectional analysis of participants own pacing strategies which varied from activity adjustment, planning and acceptance [ 50 , 55 ], and the Energy Envelope method [ 58 , 60 ]. Two studies were prospective observational studies investigating the Energy Envelope theory [ 53 , 54 ]. Four studies [ 56 , 57 , 59 , 61 ] included in this review involved sub-analysis of results of the PACE trial [ 35 ].

Outcome measures

Quantitative health outcomes.

ME/CFS severity and general health status were the most common outcome measures across studies (16/17) [ 35 , 48 , 49 , 50 , 51 , 52 , 53 , 54 , 55 , 56 , 57 , 58 , 59 , 60 , 61 , 63 ]. Studies utilised different instruments, including the Short-Form 36 (SF-36; 8/16) [ 35 , 51 , 53 , 54 , 56 , 57 , 58 , 60 ], SF-12 (2/16) [ 50 , 63 ], ME symptom and illness severity (2/16) [ 52 , 55 ], Patient health (PHQ-15; 1/16) [ 59 ], DePaul symptom questionnaire (DSQ; 1/16) [ 58 ], and the Patient health questionnaire-9 (1/16) [ 50 ]. Additionally, some studies used diagnostic criteria for ME/CFS as an outcome measure to determine recovery [ 57 , 59 , 61 ].

Pain was assessed by most included studies (11/17) [ 35 , 49 , 50 , 51 , 53 , 54 , 55 , 57 , 59 , 60 , 61 , 63 ]. Two studies [ 59 , 61 ] included the international CDC criteria for CFS which contain five painful symptoms central to a diagnosis of CFS: muscle pain and joint pain. Other methods of assessment included Brief Pain Inventory (1/11) [ 53 ], Chronic Pain Coping Inventory (CPCI; 1/11) [ 49 ], Pain Self Efficacy Questionnaire (PSEQ; 1/11) [ 50 ], Tampa Scale for Kinesiophobia–version CFS (1/11) [ 49 ], algometry (1/11) [ 49 ], Knowledge of Neurophysiology of Pain Test (1/12) [ 49 ], Pain Catastrophizing Scale (1/11) [ 49 ], Pain Anxiety Symptoms Scale short version (PASS-20; 1/11) [ 50 ], Pain Numerical Rating Scale (NRS; 1/11) [ 63 ].

Fatigue or post-exertional malaise was assessed by 11 of the 17 studies [ 35 , 48 , 50 , 51 , 53 , 54 , 56 , 57 , 60 , 61 , 63 ]. Again, measurement instruments were divergent between studies and included the Chalder Fatigue Questionnaire (CFQ; 4/11) [ 35 , 50 , 57 , 63 ], Fatigue Severity Scale (2/11) [ 53 , 60 ], the Chronic Fatigue Syndrome Medical Questionnaire (1/11) [ 60 ], and Checklist Individual Strength (CIS; 2/11) [ 48 , 51 ].

Anxiety and depression were also common outcome measures, utilised by four studies (4/17) [ 50 , 53 , 59 , 63 ]. These were also assessed using different instruments including Hospital Anxiety and Depression Scale (HADS; 2/4) [ 59 , 63 ], Generalised Anxiety Disorder Assessment (1/4 [ 50 ]), Beck Depression Inventory (BDI-II; 1/4) [ 53 ], Beck Anxiety Inventory (BAI; 1/4) [ 53 ], and Perceived Stress Scale (PSS; 1/4) [ 53 ].

Outcome measures also included sleep (2/17) [ 53 , 59 ], assessed by The Pittsburgh Sleep Quality Index (1/2) [ 53 ] and Jenkins sleep scale (1/2) [ 59 ]; and quality of life (2/17) [ 50 , 53 ] as assessed by the EuroQol five-dimensions, five-levels (EQ-5D-5L; 1/2) [ 50 ] and The Quality-of-Life Scale (1/2) [ 53 ]. Self-Efficacy was measured in four studies [ 50 , 53 , 59 , 60 ], assessed by the Brief Coping Orientation to Problems Experienced Scale (bCOPE; 1/4) [ 60 ] and the Chronic Disease Self-Efficacy measure (3/4) [ 50 , 53 , 59 ].

Quantitative evaluation of pacing

Some studies (4/17) [ 25 , 50 , 52 , 63 ] included assessments of the participants’ experiences of pacing, using the Activity Pacing Questionnaire (APQ-28; 1/4 [ 50 ], APQ-38 (2/4) [ 25 , 63 ]), a re-analysis of the 228 question survey regarding treatment (1/4) [ 52 ] originally produced by the ME Association [ 55 ], and qualitative semi-structured telephone interviews regarding appropriateness of courses in relation to individual patient needs (1/4) [ 25 ]. The APQ-28 and -38 have been previously validated, but the 228-question survey has not. When outcome measures included physical activity levels (4/17), the Canadian Occupational Performance Measure (COPM) was used in two studies [ 48 , 51 ], and two studies used accelerometers to record physical activity [ 51 , 54 ]. Of these two studies, Nijs [ 51 ] examined accelerometery after a 3-week intervention based on the Energy Envelope Theory and Brown et al. [ 54 ] evaluated the Energy Envelope Theory of pacing over 12 months.

Other outcomes

Two [ 53 , 59 ] of the 17 studies included structured clinical interviews for the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV) to assess psychiatric comorbidity and psychiatric exclusions. One study included a disability benefits questionnaire [ 55 ], and one study included employment and education questionnaire [ 55 ]. Additionally, satisfaction of primary care was also used as an outcome measure (2/17) [ 25 , 55 ] assessed using the Chronic Pain Coping Inventory (CPCI).

Efficacy of pacing interventions

The majority of studies (12/17) [ 25 , 48 , 50 , 51 , 52 , 53 , 54 , 55 , 56 , 58 , 60 , 63 ] highlighted improvements in at least one outcome following pacing (Fig.  2 ). When the effect of pacing was assessed by ME symptomology and general health outcomes, studies reported pacing to be beneficial [ 25 , 50 , 51 , 53 , 54 , 55 , 56 , 58 ]. It is worth noting however that pacing reportedly worsened ME symptoms in 14% of survey respondents, whilst improving symptoms in 44% of respondents [ 52 ]. Most studies using fatigue as an outcome measure reported pacing to be efficacious (7/10) [ 50 , 51 , 53 , 54 , 56 , 60 , 63 ]. However, one study reported no change in fatigue with a pacing intervention (1/10) [ 35 ], and 2/10 studies [ 53 , 63 ] reported a worsening of fatigue with pacing. Physical function was used to determine the efficacy of pacing in 11 studies [ 35 , 48 , 50 , 51 , 53 , 54 , 56 , 58 , 59 , 60 , 63 ]. Of these, the majority found pacing improved physical functioning (8/10) [ 48 , 50 , 51 , 53 , 54 , 56 , 58 , 60 ], with 1/10 [ 35 ] studies reporting no change in physical functioning, and 1/10 [ 59 ] reporting a worsening of physical functioning from pre- to post-pacing. Of the seven studies [ 35 , 49 , 50 , 51 , 53 , 54 , 60 ] which used pain to assess pacing efficacy, 4/7 [ 50 , 51 , 53 , 60 ] reported improvements in pain and 3/7 [ 35 , 51 , 53 ] reported no change in pain scores with pacing. All studies reporting quality of life (1/1) [ 53 ], self-efficacy (3/3) [ 50 , 53 , 59 ], sleep (2/2) [ 53 , 59 ], and depression and anxiety (4/4) [ 50 , 53 , 59 , 63 ], found pacing to be efficacious for ME/CFS participants.

figure 2

Bubble plot displaying number of studies reporting each domain (x-axis) and the percentage of studies reporting improvement with pacing (y-axis), including a coloured scale of improvement from 0–100%. PEM = post-exertional malaise, 6MWT = 6-min walk time, CFS = chronic fatigue syndrome, DSQ = DePaul Symptom Questionnaire, PA = Physical Activity, HRQOL = Health-related quality of life, COPM = The Canadian Occupational Performance Measure

Participant characteristics

The majority of studies (10/17) [ 25 , 50 , 52 , 53 , 54 , 58 , 59 , 60 , 61 , 63 ] did not report age of the participants. For those which did report age, this ranged from 32 ± 14 to 43 ± 13 years. Where studies reported sex (11/17) [ 35 , 48 , 49 , 50 , 51 , 54 , 55 , 56 , 57 , 58 , 60 ], this was predominantly female, ranging from 75 to 100% female. Only six studies [ 35 , 54 , 56 , 57 , 58 , 60 ] reported ethnicity, with cohorts predominantly Caucasian (94–98%). Time since diagnosis was mostly unreported (12/17) [ 25 , 48 , 49 , 50 , 52 , 53 , 54 , 58 , 59 , 60 , 61 , 63 ] but ranged from 32 to 96 months, with a cross-sectional survey reporting 2% of the participants were diagnosed 1–2 years previously; 6% 3–4 years since diagnosis; 13% 3–4 years since diagnosis; 12% 5–6 years since diagnosis; 20% 7–10 years since diagnosis; 29% 11–21 years since diagnosis; 13% 21–30 years since diagnosis; and 5% > 30 years since diagnosis. Of the studies which reported comorbidities of the participants (6/17) [ 25 , 35 , 50 , 56 , 57 , 63 ], the comorbidities were chronic pain, depressive disorder, psychiatric disorder.

Study location

Of the 17 studies, 14 were from Europe [ 25 , 35 , 48 , 49 , 50 , 51 , 52 , 55 , 56 , 57 , 58 , 59 , 61 , 63 ], and three from North America [ 53 , 54 , 60 ]. Of the 14 studies[ 25 , 35 , 48 , 49 , 50 , 51 , 52 , 55 , 56 , 57 , 58 , 59 , 61 , 63 ] from Europe, ten [ 25 , 35 , 50 , 52 , 55 , 56 , 57 , 58 , 59 , 61 , 63 ] were conducted in the United Kingdom, three in Belgium [ 48 , 49 , 51 ], and one was a multicentred study between the United Kingdom and Norway [ 58 ].

Recruitment strategy

Of the 17 studies, three [ 53 , 54 , 60 ] used announcements in a newspaper and physician referrals to recruit participants, two [ 50 , 63 ] recruited patients referred by a consultant from a National Health Service (NHS) Trust following a pain diagnosis, two [ 52 , 55 ] concerned online platforms on the web, two [ 59 , 61 ] recruited from secondary care clinics, and two used the PACE trial databases [ 56 , 57 ]. Moreover, one study recruited from the hospital [ 58 ], one from physiotherapist referrals [ 25 ], two from specialist clinic centres [ 35 , 64 ], one from waiting list of rehabilitation centre [ 48 ], and one from medical files [ 49 ].

Study settings

Ten studies were carried out in hospital and clinic setting [ 25 , 35 , 48 , 49 , 50 , 51 , 58 , 59 , 61 , 63 ]. Two studies were performed on online platforms [ 52 , 55 ]. Three studies did not report study setting [ 53 , 54 , 60 ]. Two studies generated output from PACE trial databases [ 56 , 57 ]

Adherence and feasibility

All five intervention studies reported adherence rates (which they defined as number of sessions attended), which ranged from 4–44% (4% [ 49 ], 8% [ 35 ], 25% [ 48 ], 29% [ 51 ], and 44% [ 50 ]). One study reported the median number of rehabilitation programme sessions attended was five out of six possible sessions, with 58.9% [ 50 ] participants attending ≥ 5 sessions; 83.2% participants attending at least one educational session on activity pacing and 56.1% attending both activity pacing sessions.

This scoping review summarises the existing literature, with a view to aid physicians and healthcare practitioners better summarise evidence for pacing in ME/CFS and use this knowledge for other post-viral fatiguing conditions. Overall, studies generally reported pacing to be beneficial for people with ME/CFS. The exception to this trend is the controversial PACE trial [ 36 , 37 , 38 , 39 ], which we will expand on in subsequent sections. We believe information generated within this review can facilitate discussion of research opportunities and issues that need to be addressed in future studies concerning pacing, particularly given the immediate public health issue of the long COVID pandemic. As mentioned, we found some preliminary evidence for improved symptoms following pacing interventions or strategies. However, we wish to caution the reader that the current evidence base is extremely limited and hampered by several limitations which preclude clear conclusions on the efficacy of pacing. Firstly, studies were of poor to fair methodological quality (indicated by the PEDro scores), often with small sample sizes, and therefore unknown power to detect change. Moreover, very few studies implemented pacing, with most studies merely consulting on people’s views on pacing. This may of course lead to multiple biases such as reporting, recruitment, survivorship, confirmation, availability heuristic, to name but a few. Thus, there is a pressing need for more high-quality intervention studies. Secondly, the reporting of pacing strategies used was inconsistent and lacked detail, making it difficult to describe current approaches, or implement them in future research or symptom management strategies. Furthermore, outcome evaluations varied greatly between studies. This prevents any appropriate synthesis of research findings.

The lack of evidence concerning pacing is concerning given pacing is the only NICE recommended management strategy for ME/CFS following the 2021 update [ 34 ]. Given the analogous nature of long COVID with ME/CFS, patients and practitioners will be looking to the ME/CFS literature for guidance for symptom management. There is an urgent need for high quality studies (such as RCTs) investigating the effectiveness of pacing and better reporting of pacing intervention strategies so that clear recommendations can be made to patients. If this does not happen soon, there will be serious healthcare and economic implications for years to come [ 65 , 66 ].

Efficacy of pacing

Most studies (12/17) highlighted improvements in at least one outcome measure following pacing. Pacing was self-reported to be the most efficacious, safe, acceptable, and preferred form of activity management for people with ME/CFS [ 55 ]. Pacing was reported to improve symptoms and improve general health outcomes [ 25 , 50 , 52 , 58 , 63 ], fatigue and PEM [ 48 , 50 , 51 , 53 , 54 , 55 , 56 , 60 , 63 ], physical functioning [ 48 , 50 , 51 , 53 , 56 , 58 , 60 , 63 ], pain [ 25 , 50 , 55 , 63 ], quality of life [ 50 ], self-efficacy [ 50 , 53 ], sleep [ 53 , 55 ], and depression and anxiety [ 50 , 53 , 63 ]. These positive findings provide hope for those with ME/CFS, and other chronic fatiguing conditions such as long COVID, to improve quality of life through symptom management.

Conversely, some studies reported no effects of pacing on ME/CFS symptoms [ 52 ], fatigue, physical functioning [ 35 ], or pain scores [ 49 , 61 ]. Some studies even found pacing to have detrimental effects in those with ME/CFS, including a worsening of symptoms in 14% of survey participants recalling previous pacing experiences [ 52 ]. Furthermore, a worsening of fatigue [ 35 , 59 ], and physical functioning from pre- to post-pacing [ 35 , 57 , 59 , 61 ] was reported by the PACE trial and sub-analysis of the PACE trial [ 56 , 57 , 61 ]. The PACE trial [ 35 ], a large RCT (n = 639) comparing pacing with CBT and GET, reported GET and CBT were more effective for reducing ME/CFS-related fatigue and improving physical functioning than pacing. However, the methodology and conclusions from the PACE trial have been heavily criticised, mainly due to the authors lowering the thresholds they used to determine improvement [ 36 , 37 , 38 , 67 ]. With this in mind, Sharpe et al. [ 56 ] surveyed 75% of the participants from the PACE trial 1-year post-intervention and reported pacing improved fatigue and physical functioning, with effects similar to CBT and GET.

Lessons for pacing implementation

All pacing intervention studies (5/5) implemented educational or coaching sessions. These educational components were poorly reported in terms of the specific content and how and where they had been developed, with unclear pedagogical approaches. Consequently, even where interventions reported reduction in PEM or improved symptoms, it would be impossible to transfer that research into practice, future studies, or clinical guidance, given the ambiguity of reporting. Sessions typically contained themes of pacing such as activity adjustment (decrease, break-up, and reschedule activities based on energy levels), activity consistency (maintaining a consistently low level of activity to prevent PEM), activity planning (planning activities and rest around available energy levels), and activity progression (slowly progressing activity once maintaining a steady baseline) [ 35 , 48 , 49 , 50 , 51 ]. We feel it is pertinent to note here that although activity progression has been incorporated as a pacing strategy in these included studies, some view activity progression as a form of GET. The NICE definition of GET is “first establishing an individual's baseline of achievable exercise or physical activity, then making fixed incremental increases in the time spent being physically active” [ 34 ]. Thus, this form of pacing can also be considered a type of ‘long-term GET’ in which physical activity progression is performed over weeks or months with fixed incremental increases in time spent being physically.

Intervention studies attempted to create behaviour change, through educational programmes to modify physical activity, and plan behaviours. However, none of these studies detailed integrating any evidence-based theories of behaviour change [ 68 ] or reported using any frameworks to support behaviour change objectives. This is unfortunate since there is good evidence that theory-driven behaviour change interventions result in greater intervention effects [ 69 ]. Indeed, there is a large body of work regarding methods of behaviour change covering public health messaging, education, and intervention design, which has largely been ignored by the pacing literature. Interventions relied on subjective pacing (5/5 studies), with strategies including keeping an activity diary (3/5 studies) to identify links between activity and fatigue [ 35 , 48 , 50 ]. Given the high prevalence of ‘brain fog’ within ME/CFS [ 70 , 71 , 72 , 73 ], recall may be extremely difficult and there is significant potential for under-reporting. Other strategies included simply asking participants to estimate energy levels available for daily activities (2/5 studies [ 48 , 51 ]). Again, this is subjective and relies on participants’ ability to recall previous consequences of the activity. Other methods of activity tracking and measuring energy availability, such as wearable technology [ 74 , 75 , 76 , 77 , 78 ] could provide a more objective measure of adherence and pacing strategy fidelity in future studies. Despite technology such as accelerometers being widely accessible since well-before the earliest interventional study included in this review (which was published in 2009), none of the interventional studies utilised objective activity tracking to track pacing and provide feedback to participants. One study considered accelerometery alongside an activity diary [ 51 ]. However, accelerometery was considered the outcome variable, to assess change in activity levels from pre- to post-intervention and was not part of the intervention itself (which was one pacing coaching sessions per week for 3 weeks). Moreover, most research-grade accelerometers cannot be used as part of the intervention since they have no ability to provide continuous feedback and must be retrieved by the research team in order to access any data. Consequently, their use is mostly limited to outcome assessments only. As pacing comprises a limit to physical activity to prevent push-crash cycles, it is an astonishing observation from this scoping review that only two studies objectively measured physical activity to quantify changes to activity as a result of pacing [ 51 , 54 ]. If the aim of pacing is to reduce physical activity, or reduce variations in physical activity (i.e., push-crash cycles), only two studies have objectively quantified the effect pacing had on physical activity, so it is unclear whether pacing was successfully implemented in any of the other studies.

By exploring the pacing strategies previously used, in both intervention studies and more exploratory studies, we can identify and recommend approaches to improve symptoms of ME/CFS. These approaches can be categorised as follows: activity planning, activity consistency, activity progression, activity adjustment and staying within the Energy Envelope [ 50 , 53 , 60 , 63 ]. Activity planning was identified as a particularly effective therapeutic strategy, resulting in improvement of mean scores of all symptoms included in the APQ-28, reducing current pain, improvement of physical fatigue, mental fatigue, self-efficacy, quality of life, and mental and physical functioning [ 50 ]. Activity planning aligns with the self-regulatory behaviour change technique ‘Action Planning’ [ 79 ] which is commonly used to increase physical activity behaviour. In the case of ME/CFS, activity planning is successfully used to minimise rather than increase physical activity bouts to prevent expending too much energy and avoid PEM. Activity consistency, meaning undertaking similar amounts of activity each day, was also associated with reduced levels of depression, exercise avoidance, and higher levels of physical function [ 63 ]. Activity progression was associated with higher levels of current pain. Activity adjustment associated with depression and avoidance, and lower levels of physical function [ 63 ]. Staying within the Energy Envelope was reported to reduce PEM severity [ 53 , 60 ], improve physical functioning [ 53 , 60 ] and ME/CFS symptom scores [ 53 ], and more hours engaged in activity than individuals with lower available energy [ 53 ]. These results suggest that effective pacing strategies would include activity planning, consistency, and energy management techniques while avoiding progression. This data is, of course, limited by the small number of mostly low-quality studies and should be interpreted with some caution. Nevertheless, these are considerations that repeatedly appear in the literature and, as such, warrant deeper investigation. In addition, and as outlined earlier, most studies are relatively old, and we urgently need better insight into how modern technologies, particularly longitudinal activity tracking and contemporaneous heart-rate feedback, might improve (or otherwise) adaptive pacing. Such longitudinal tracking would also enable activities and other behaviours (sleep, diet, stress) to be linked to bouts of PEM. Linking would enable a deeper insight into potential PEM triggers and mitigations that might be possible.

The PACE trial

We feel it would be remiss of us to not specifically address the PACE trial within this manuscript, as five of the 17 included studies resulted from the PACE trial [ 35 , 56 , 57 , 59 , 61 ]. There has been considerable discussion around the PACE trial, which has been particularly divisive and controversial [ 37 , 38 , 39 , 59 , 67 , 80 , 81 ]. In the PACE trial, GET and CBT were deemed superior to pacing by the authors. Despite its size and funding, the PACE trial has received several published criticisms and rebuttals. Notably, NICE's most recent ME/CFS guideline update removed GET and CBT as suggested treatment options, which hitherto had been underpinned by the PACE findings. While we will not restate the criticisms and rebuttals here, what is not in doubt, is that the PACE trial has dominated discussions of pacing, representing almost a third of all the studies in this review. However, the trial results were published over a decade ago, with the study protocol devised almost two decades ago [ 82 ]. The intervening time has seen a revolution in the development of mobile and wearable technology and an ability to remotely track activity and provide real-time feedback in a way which was not available at that time. Furthermore, there has been no substantive research since the PACE trial that has attempted such work. Indeed, possibly driven by the reported lack of effect of pacing in the PACE trial, this review has demonstrated the dearth of progress and innovation in pacing research since its publication. Therefore, regardless of its findings or criticisms, the pacing implementation in the PACE trial is dated, and there is an urgent need for more technologically informed approaches to pacing research.

Limitations of the current evidence

The first limitation to the literature included in this scoping review is that not all studies followed the minimum data set (MDS) of patient-reported outcome measures (PROMs) agreed upon by the British Association of CFS/ME Professionals (BACME) (fatigue, sleep quality, self-efficacy, pain/discomfort, anxiety/depression, mobility, activities of daily living, self-care, and illness severity) [ 83 , 84 ]. All but one study included in this review measured illness severity, most studies included fatigue and pain/discomfort, and some studies included assessments of anxiety/depression. There was a lack of quantitative assessment of sleep quality, self-efficacy, mobility, activities of daily living, and self-care. Therefore, studies did not consistently capture the diverse nature of the symptoms experienced, with crucial domains missing from the analyses. The MDS of PROMs were established in 2012 [ 83 , 84 ] and therefore, for studies published out prior to 2012, these are not applicable [ 35 , 49 , 51 , 53 , 54 ]. However, for the 12 studies carried out after this time, the MDS should have been considered elucidate the effects of pacing on ME/CFS. Importantly, despite PEM being a central characteristic of ME/CFS, only two studies included PEM as an outcome measure [ 55 , 60 ]. This may be because of the difficulty of accurately measuring fluctuating symptoms, as PEM occurs multiple times over a period of months, and therefore pre- to post- studies and cross-sectional designs cannot adequately capture PEM incidence. Therefore, it is likely studies opted for measuring general fatigue instead. More appropriate longitudinal study designs are required to track PEM over time to capture a more representative picture of PEM patterns. Secondly, reporting of participant characteristics was inadequate, but in the studies that did describe participants, characteristics were congruent with the epidemiological literature and reporting of ME/CFS populations (i.e., 60–65% female) [ 85 ]. Therefore, in this respect, studies included herein were representative samples. However, the lack of reporting of participant characteristics limits inferences we can draw concerning any population-related effects (i.e. whether older, or male, or European, or people referred by a national health service would be more or less likely to respond positively to pacing). Thirdly, comparison groups (where included) were not ideal, with CBT or GET sometimes used as comparators to pacing [ 35 ], and often no true control group included. Penultimately, there is a distinct lack of high-quality RCTs (as mentioned throughout this manuscript). Finally, in reference to the previous section, inferences from the literature are dated and do not reflect the technological capabilities of 2023.

Recommendations for advancement of the investigative area

It is clear from the studies included in this scoping review for the last decade or more, progress and innovation in pacing research have been limited. This is unfortunate for several reasons. People with ME/CFS or long COVID are, of course, invested in their recovery. From our patient and public involvement (PPI) group engagement, it is clear many are ahead of the research and are using wearable technology to track steps, heart rate, and, in some cases, heart rate variability to improve their own pacing practice. While the lack of progress in the research means this is an understandable response by patients, it is also problematic. Without underpinning research, patients may make decisions based on an individual report of trial-and-error approaches given the lack of evidence-based guidance.

A more technologically-informed pacing approach could be implemented by integrating wearable trackers [ 77 , 78 , 86 , 87 ] to provide participants with live updates on their activity and could be integrated with research-informed messaging aimed at supporting behaviour change, as has been trialled in other research areas [ 88 , 89 , 90 , 91 ]. However, more work is needed to evaluate how to incorporate wearable activity trackers and which metrics are most helpful.

A more technologically-informed approach could also be beneficial for longitudinal symptom tracking, particularly useful given the highly variable symptom loads of ME/CFS and episodic nature of PEM. This would overcome reliance on assessments at a single point in time (as the studies within this review conducted). Similarly, mobile health (mHealth) approaches also allow questionnaires to be digitised to make it easier for participants to complete if they find holding a pen or reading small font problematic [ 92 ]. Reminders and notifications can also be helpful for patients completing tasks [ 77 , 93 , 94 , 95 ]. This approach has the added advantage of allowing contemporaneous data collection rather than relying on pre- to post-intervention designs limited by recall bias. Future work must try to leverage these approaches, as unless we collect large data sets on symptoms and behaviours (i.e. activity, diet, sleep, and pharmacology) in people with conditions like ME/CFS we will not be able to leverage emerging technologies such as AI and machine learning to improve the support and care for people with these debilitating conditions. The key areas for research outline in the NICE guidelines (2021 update) speaks to this, with specific mention of improved self-monitoring strategies, sleep strategies, and dietary strategies, all of which can be measured using mHealth approaches, in a scalable and labour-inexpensive way.

The potential for existing pacing research to address the long COVID pandemic

There is now an urgent public health need to address long COVID, with over 200 million sufferers worldwide [ 30 ]. Given the analogous symptomology between ME/CFS and long COVID, and the lack of promising treatment and management strategies in ME/CFS, pacing remains the only strategy for managing long COVID symptoms. This is concerning as the quality of evidence to support pacing is lacking. Given long COVID has reached pandemic proportions, scalable solutions will be required. In this context, we propose that technology should be harnessed to a) deliver, but also b) evaluate, pacing. We recently reported on a just-in-time adaptive intervention to increase physical activity during the pandemic [ 78 ]. However, this method could be adapted to decrease or maintain physical activity levels (i.e., pacing) in long COVID. This method has the advantage of scalability and remote data collection, reducing resource commitments and participant burden, essential for addressing a condition with so many sufferers.

This review highlights the need for more studies concerning pacing in chronic fatiguing conditions. Future studies would benefit from examining pacing’s effect on symptomology and PEM with objectively quantified pacing, over a longer duration of examination, using the MDS. It is essential this is conducted as an RCT, given that in the case of long COVID, participants may improve their health over time, and it is necessary to determine whether pacing exerts an additional effect over time elapsing. Future studies would benefit from digitising pacing to support individuals with varying symptom severity and personalise support. This would improve accessibility and reduce selection bias, in addition to improving scalability of interventions. Finally, clinicians and practitioners should be cognisant of the strength of evidence reported in this review and should exert caution when promoting pacing in their patients, given the varying methods utilised herein.

Availability of data and materials

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Abbreviations

Activity Pacing Questionnaire

Beck Anxiety Inventory

Beck Depression Inventory

Brief Coping Orientation to Problems Experienced Scale

Canadian Occupational Performance Measure

Centers for disease control and prevention

Chalder Fatigue Questionnaire

Checklist Individual Strength

Chronic Pain Coping Inventory

Cognitive behavioural therapy

Cochrane Central Register of Controlled Trials

DePaul symptom questionnaire

EuroQol five-dimensions, five-levels questionnaire

Graded exercise therapy

Hospital Anxiety and Depression Scale

Myalgic encephalomyelitis/chronic fatigue syndrome

Pain Self Efficacy Questionnaire

Pain Anxiety Symptoms Scale short version

Pain Numerical Rating Scale

Patient health questionnaire

Patient reported outcome measures

Physiotherapy Evidence Database

Perceived Stress Scale

Post exertional malaise

Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews

Randomised control trial

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Authors’ contributions are given according to the CRediT taxonomy as follows: Conceptualization, N.E.M.S–H., M.M., L.D.H, and N.F.S.; methodology, N.E.M.S–H., M.M., L.D.H., and N.F.S.; software, N.E.M.S–H., M.M., L.D.H., and N.F.S.B.; validation, N.E.M.S–H., M.M., L.D.H, and N.F.S.; formal analysis, N.E.M.S–H., M.M., L.D.H., and N.F.S.; investigation, N.E.M.S–H., M.M., L.D.H., and N.F.S.; resources, L.D.H., J.O., D.C., N.H., J.L.M., and N.F.S.; data curation, N.E.M.S.-H., M.M., L.D.H., and N.F.S.; writing—original draft preparation, N.E.M.S.-H., M.M., L.D.H., and N.F.S.; writing—review and editing, N.E.M.S–H., M.M., L.D.H., J.O., D.C., N.H., R.M., J.L.M., J.I., and N.F.S.; visualisation, N.E.M.S–H. and M.M., supervision, N.F.S; project administration, N.E.M.S–H., M.M., L.D.H., and N.F.S.; funding acquisition, L.D.H., J.O., D.C., N.H., J.L.M., J.I., and N.F.S. All authors have read and agreed to the published version of the manuscript.

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Sanal-Hayes, N.E.M., Mclaughlin, M., Hayes, L.D. et al. A scoping review of ‘Pacing’ for management of Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS): lessons learned for the long COVID pandemic. J Transl Med 21 , 720 (2023). https://doi.org/10.1186/s12967-023-04587-5

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