what is case study evidence

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

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

Research question

• Conceptual framework
• Conceptual vs. theoretical framework

Data collection

• Qualitative research methods
• Focus groups
• Observational research

What is a case study?

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

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

Case studies

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

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

Definition of a case study

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

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

Characteristics of case studies

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

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

The role of case studies in research

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

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

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

What is the purpose of a case study?

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

Why use case studies in qualitative research?

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

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

The explanatory, exploratory, and descriptive roles of case studies

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

The impact of case studies on knowledge development

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

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

Types of case studies

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

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

Exploratory case studies

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

Descriptive case studies

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

Explanatory case studies

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

Intrinsic, instrumental, and collective case studies

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

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

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

Critical information systems research

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

Health research

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

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

Asthma research studies

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

Other fields

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

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

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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.

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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Case Study – Methods, Examples and Guide

Table of Contents

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

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

Types of Case Study

Types and Methods of Case Study are as follows:

Single-Case Study

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

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

Multiple-Case Study

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

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

Exploratory Case Study

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

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

Descriptive Case Study

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

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

Instrumental Case Study

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

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

Case Study Data Collection Methods

Here are some common data collection methods for case studies:

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

Observations

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

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

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

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

How to conduct Case Study Research

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

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

Examples of Case Study

Here are some examples of case study research:

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

Application of Case Study

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

Business and Management

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

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

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

Social Sciences

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

Law and Ethics

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

Purpose of Case Study

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

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

Case studies can also serve other purposes, including:

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

Advantages of Case Study Research

There are several advantages of case study research, including:

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

Limitations of Case Study Research

There are several limitations of case study research, including:

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

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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."

Cara Lustik is a fact-checker and copywriter.

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."

• Library databases
• Library website

Evidence-Based Research: Levels of Evidence Pyramid

Introduction.

One way to organize the different types of evidence involved in evidence-based practice research is the levels of evidence pyramid. The pyramid includes a variety of evidence types and levels.

• systematic reviews
• critically-appraised topics
• critically-appraised individual articles
• randomized controlled trials
• cohort studies
• case-controlled studies, case series, and case reports
• Background information, expert opinion

Levels of evidence pyramid

The levels of evidence pyramid provides a way to visualize both the quality of evidence and the amount of evidence available. For example, systematic reviews are at the top of the pyramid, meaning they are both the highest level of evidence and the least common. As you go down the pyramid, the amount of evidence will increase as the quality of the evidence decreases.

Text alternative for Levels of Evidence Pyramid diagram

EBM Pyramid and EBM Page Generator, copyright 2006 Trustees of Dartmouth College and Yale University. All Rights Reserved. Produced by Jan Glover, David Izzo, Karen Odato and Lei Wang.

Filtered Resources

Filtered resources appraise the quality of studies and often make recommendations for practice. The main types of filtered resources in evidence-based practice are:

Scroll down the page to the Systematic reviews , Critically-appraised topics , and Critically-appraised individual articles sections for links to resources where you can find each of these types of filtered information.

Systematic reviews

Authors of a systematic review ask a specific clinical question, perform a comprehensive literature review, eliminate the poorly done studies, and attempt to make practice recommendations based on the well-done studies. Systematic reviews include only experimental, or quantitative, studies, and often include only randomized controlled trials.

You can find systematic reviews in these filtered databases :

• Cochrane Database of Systematic Reviews Cochrane systematic reviews are considered the gold standard for systematic reviews. This database contains both systematic reviews and review protocols. To find only systematic reviews, select Cochrane Reviews in the Document Type box.
• JBI EBP Database (formerly Joanna Briggs Institute EBP Database) This database includes systematic reviews, evidence summaries, and best practice information sheets. To find only systematic reviews, click on Limits and then select Systematic Reviews in the Publication Types box. To see how to use the limit and find full text, please see our Joanna Briggs Institute Search Help page .

You can also find systematic reviews in this unfiltered database :

To learn more about finding systematic reviews, please see our guide:

• Filtered Resources: Systematic Reviews

Critically-appraised topics

Authors of critically-appraised topics evaluate and synthesize multiple research studies. Critically-appraised topics are like short systematic reviews focused on a particular topic.

You can find critically-appraised topics in these resources:

• Annual Reviews This collection offers comprehensive, timely collections of critical reviews written by leading scientists. To find reviews on your topic, use the search box in the upper-right corner.
• Guideline Central This free database offers quick-reference guideline summaries organized by a new non-profit initiative which will aim to fill the gap left by the sudden closure of AHRQ’s National Guideline Clearinghouse (NGC).
• JBI EBP Database (formerly Joanna Briggs Institute EBP Database) To find critically-appraised topics in JBI, click on Limits and then select Evidence Summaries from the Publication Types box. To see how to use the limit and find full text, please see our Joanna Briggs Institute Search Help page .
• National Institute for Health and Care Excellence (NICE) Evidence-based recommendations for health and care in England.
• Filtered Resources: Critically-Appraised Topics

Critically-appraised individual articles

Authors of critically-appraised individual articles evaluate and synopsize individual research studies.

You can find critically-appraised individual articles in these resources:

• EvidenceAlerts Quality articles from over 120 clinical journals are selected by research staff and then rated for clinical relevance and interest by an international group of physicians. Note: You must create a free account to search EvidenceAlerts.
• ACP Journal Club This journal publishes reviews of research on the care of adults and adolescents. You can either browse this journal or use the Search within this publication feature.
• Evidence-Based Nursing This journal reviews research studies that are relevant to best nursing practice. You can either browse individual issues or use the search box in the upper-right corner.

To learn more about finding critically-appraised individual articles, please see our guide:

• Filtered Resources: Critically-Appraised Individual Articles

Unfiltered resources

You may not always be able to find information on your topic in the filtered literature. When this happens, you'll need to search the primary or unfiltered literature. Keep in mind that with unfiltered resources, you take on the role of reviewing what you find to make sure it is valid and reliable.

Note: You can also find systematic reviews and other filtered resources in these unfiltered databases.

The Levels of Evidence Pyramid includes unfiltered study types in this order of evidence from higher to lower:

You can search for each of these types of evidence in the following databases:

TRIP database

Background information & expert opinion.

Background information and expert opinions are not necessarily backed by research studies. They include point-of-care resources, textbooks, conference proceedings, etc.

• Family Physicians Inquiries Network: Clinical Inquiries Provide the ideal answers to clinical questions using a structured search, critical appraisal, authoritative recommendations, clinical perspective, and rigorous peer review. Clinical Inquiries deliver best evidence for point-of-care use.
• Harrison, T. R., & Fauci, A. S. (2009). Harrison's Manual of Medicine . New York: McGraw-Hill Professional. Contains the clinical portions of Harrison's Principles of Internal Medicine .
• Lippincott manual of nursing practice (8th ed.). (2006). Philadelphia, PA: Lippincott Williams & Wilkins. Provides background information on clinical nursing practice.
• Medscape: Drugs & Diseases An open-access, point-of-care medical reference that includes clinical information from top physicians and pharmacists in the United States and worldwide.
• Virginia Henderson Global Nursing e-Repository An open-access repository that contains works by nurses and is sponsored by Sigma Theta Tau International, the Honor Society of Nursing. Note: This resource contains both expert opinion and evidence-based practice articles.
• Previous Page: Phrasing Research Questions
• Next Page: Evidence Types
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Organizing Your Social Sciences Research Assignments

• Annotated Bibliography
• Analyzing a Scholarly Journal Article
• Group Presentations
• Dealing with Nervousness
• Using Visual Aids
• Grading Someone Else's Paper
• Types of Structured Group Activities
• Group Project Survival Skills
• Leading a Class Discussion
• Multiple Book Review Essay
• Reviewing Collected Works
• Writing a Case Analysis Paper
• Writing a Case Study
• About Informed Consent
• Writing Field Notes
• Writing a Policy Memo
• Writing a Reflective Paper
• Writing a Research Proposal
• Generative AI and Writing
• Acknowledgments

A case study research paper examines a person, place, event, condition, phenomenon, or other type of subject of analysis in order to extrapolate  key themes and results that help predict future trends, illuminate previously hidden issues that can be applied to practice, and/or provide a means for understanding an important research problem with greater clarity. A case study research paper usually examines a single subject of analysis, but case study papers can also be designed as a comparative investigation that shows relationships between two or more subjects. The methods used to study a case can rest within a quantitative, qualitative, or mixed-method investigative paradigm.

Case Studies. Writing@CSU. Colorado State University; Mills, Albert J. , Gabrielle Durepos, and Eiden Wiebe, editors. Encyclopedia of Case Study Research . Thousand Oaks, CA: SAGE Publications, 2010 ; “What is a Case Study?” In Swanborn, Peter G. Case Study Research: What, Why and How? London: SAGE, 2010.

How to Approach Writing a Case Study Research Paper

General information about how to choose a topic to investigate can be found under the " Choosing a Research Problem " tab in the Organizing Your Social Sciences Research Paper writing guide. Review this page because it may help you identify a subject of analysis that can be investigated using a case study design.

However, identifying a case to investigate involves more than choosing the research problem . A case study encompasses a problem contextualized around the application of in-depth analysis, interpretation, and discussion, often resulting in specific recommendations for action or for improving existing conditions. As Seawright and Gerring note, practical considerations such as time and access to information can influence case selection, but these issues should not be the sole factors used in describing the methodological justification for identifying a particular case to study. Given this, selecting a case includes considering the following:

• The case represents an unusual or atypical example of a research problem that requires more in-depth analysis? Cases often represent a topic that rests on the fringes of prior investigations because the case may provide new ways of understanding the research problem. For example, if the research problem is to identify strategies to improve policies that support girl's access to secondary education in predominantly Muslim nations, you could consider using Azerbaijan as a case study rather than selecting a more obvious nation in the Middle East. Doing so may reveal important new insights into recommending how governments in other predominantly Muslim nations can formulate policies that support improved access to education for girls.
• The case provides important insight or illuminate a previously hidden problem? In-depth analysis of a case can be based on the hypothesis that the case study will reveal trends or issues that have not been exposed in prior research or will reveal new and important implications for practice. For example, anecdotal evidence may suggest drug use among homeless veterans is related to their patterns of travel throughout the day. Assuming prior studies have not looked at individual travel choices as a way to study access to illicit drug use, a case study that observes a homeless veteran could reveal how issues of personal mobility choices facilitate regular access to illicit drugs. Note that it is important to conduct a thorough literature review to ensure that your assumption about the need to reveal new insights or previously hidden problems is valid and evidence-based.
• The case challenges and offers a counter-point to prevailing assumptions? Over time, research on any given topic can fall into a trap of developing assumptions based on outdated studies that are still applied to new or changing conditions or the idea that something should simply be accepted as "common sense," even though the issue has not been thoroughly tested in current practice. A case study analysis may offer an opportunity to gather evidence that challenges prevailing assumptions about a research problem and provide a new set of recommendations applied to practice that have not been tested previously. For example, perhaps there has been a long practice among scholars to apply a particular theory in explaining the relationship between two subjects of analysis. Your case could challenge this assumption by applying an innovative theoretical framework [perhaps borrowed from another discipline] to explore whether this approach offers new ways of understanding the research problem. Taking a contrarian stance is one of the most important ways that new knowledge and understanding develops from existing literature.
• The case provides an opportunity to pursue action leading to the resolution of a problem? Another way to think about choosing a case to study is to consider how the results from investigating a particular case may result in findings that reveal ways in which to resolve an existing or emerging problem. For example, studying the case of an unforeseen incident, such as a fatal accident at a railroad crossing, can reveal hidden issues that could be applied to preventative measures that contribute to reducing the chance of accidents in the future. In this example, a case study investigating the accident could lead to a better understanding of where to strategically locate additional signals at other railroad crossings so as to better warn drivers of an approaching train, particularly when visibility is hindered by heavy rain, fog, or at night.
• The case offers a new direction in future research? A case study can be used as a tool for an exploratory investigation that highlights the need for further research about the problem. A case can be used when there are few studies that help predict an outcome or that establish a clear understanding about how best to proceed in addressing a problem. For example, after conducting a thorough literature review [very important!], you discover that little research exists showing the ways in which women contribute to promoting water conservation in rural communities of east central Africa. A case study of how women contribute to saving water in a rural village of Uganda can lay the foundation for understanding the need for more thorough research that documents how women in their roles as cooks and family caregivers think about water as a valuable resource within their community. This example of a case study could also point to the need for scholars to build new theoretical frameworks around the topic [e.g., applying feminist theories of work and family to the issue of water conservation].

Eisenhardt, Kathleen M. “Building Theories from Case Study Research.” Academy of Management Review 14 (October 1989): 532-550; Emmel, Nick. Sampling and Choosing Cases in Qualitative Research: A Realist Approach . Thousand Oaks, CA: SAGE Publications, 2013; Gerring, John. “What Is a Case Study and What Is It Good for?” American Political Science Review 98 (May 2004): 341-354; Mills, Albert J. , Gabrielle Durepos, and Eiden Wiebe, editors. Encyclopedia of Case Study Research . Thousand Oaks, CA: SAGE Publications, 2010; Seawright, Jason and John Gerring. "Case Selection Techniques in Case Study Research." Political Research Quarterly 61 (June 2008): 294-308.

Structure and Writing Style

The purpose of a paper in the social sciences designed around a case study is to thoroughly investigate a subject of analysis in order to reveal a new understanding about the research problem and, in so doing, contributing new knowledge to what is already known from previous studies. In applied social sciences disciplines [e.g., education, social work, public administration, etc.], case studies may also be used to reveal best practices, highlight key programs, or investigate interesting aspects of professional work.

In general, the structure of a case study research paper is not all that different from a standard college-level research paper. However, there are subtle differences you should be aware of. Here are the key elements to organizing and writing a case study research paper.

I.  Introduction

As with any research paper, your introduction should serve as a roadmap for your readers to ascertain the scope and purpose of your study . The introduction to a case study research paper, however, should not only describe the research problem and its significance, but you should also succinctly describe why the case is being used and how it relates to addressing the problem. The two elements should be linked. With this in mind, a good introduction answers these four questions:

• What is being studied? Describe the research problem and describe the subject of analysis [the case] you have chosen to address the problem. Explain how they are linked and what elements of the case will help to expand knowledge and understanding about the problem.
• Why is this topic important to investigate? Describe the significance of the research problem and state why a case study design and the subject of analysis that the paper is designed around is appropriate in addressing the problem.
• What did we know about this topic before I did this study? Provide background that helps lead the reader into the more in-depth literature review to follow. If applicable, summarize prior case study research applied to the research problem and why it fails to adequately address the problem. Describe why your case will be useful. If no prior case studies have been used to address the research problem, explain why you have selected this subject of analysis.
• How will this study advance new knowledge or new ways of understanding? Explain why your case study will be suitable in helping to expand knowledge and understanding about the research problem.

Each of these questions should be addressed in no more than a few paragraphs. Exceptions to this can be when you are addressing a complex research problem or subject of analysis that requires more in-depth background information.

II.  Literature Review

The literature review for a case study research paper is generally structured the same as it is for any college-level research paper. The difference, however, is that the literature review is focused on providing background information and  enabling historical interpretation of the subject of analysis in relation to the research problem the case is intended to address . This includes synthesizing studies that help to:

• Place relevant works in the context of their contribution to understanding the case study being investigated . This would involve summarizing studies that have used a similar subject of analysis to investigate the research problem. If there is literature using the same or a very similar case to study, you need to explain why duplicating past research is important [e.g., conditions have changed; prior studies were conducted long ago, etc.].
• Describe the relationship each work has to the others under consideration that informs the reader why this case is applicable . Your literature review should include a description of any works that support using the case to investigate the research problem and the underlying research questions.
• Identify new ways to interpret prior research using the case study . If applicable, review any research that has examined the research problem using a different research design. Explain how your use of a case study design may reveal new knowledge or a new perspective or that can redirect research in an important new direction.
• Resolve conflicts amongst seemingly contradictory previous studies . This refers to synthesizing any literature that points to unresolved issues of concern about the research problem and describing how the subject of analysis that forms the case study can help resolve these existing contradictions.
• Point the way in fulfilling a need for additional research . Your review should examine any literature that lays a foundation for understanding why your case study design and the subject of analysis around which you have designed your study may reveal a new way of approaching the research problem or offer a perspective that points to the need for additional research.
• Expose any gaps that exist in the literature that the case study could help to fill . Summarize any literature that not only shows how your subject of analysis contributes to understanding the research problem, but how your case contributes to a new way of understanding the problem that prior research has failed to do.
• Locate your own research within the context of existing literature [very important!] . Collectively, your literature review should always place your case study within the larger domain of prior research about the problem. The overarching purpose of reviewing pertinent literature in a case study paper is to demonstrate that you have thoroughly identified and synthesized prior studies in relation to explaining the relevance of the case in addressing the research problem.

III.  Method

In this section, you explain why you selected a particular case [i.e., subject of analysis] and the strategy you used to identify and ultimately decide that your case was appropriate in addressing the research problem. The way you describe the methods used varies depending on the type of subject of analysis that constitutes your case study.

If your subject of analysis is an incident or event . In the social and behavioral sciences, the event or incident that represents the case to be studied is usually bounded by time and place, with a clear beginning and end and with an identifiable location or position relative to its surroundings. The subject of analysis can be a rare or critical event or it can focus on a typical or regular event. The purpose of studying a rare event is to illuminate new ways of thinking about the broader research problem or to test a hypothesis. Critical incident case studies must describe the method by which you identified the event and explain the process by which you determined the validity of this case to inform broader perspectives about the research problem or to reveal new findings. However, the event does not have to be a rare or uniquely significant to support new thinking about the research problem or to challenge an existing hypothesis. For example, Walo, Bull, and Breen conducted a case study to identify and evaluate the direct and indirect economic benefits and costs of a local sports event in the City of Lismore, New South Wales, Australia. The purpose of their study was to provide new insights from measuring the impact of a typical local sports event that prior studies could not measure well because they focused on large "mega-events." Whether the event is rare or not, the methods section should include an explanation of the following characteristics of the event: a) when did it take place; b) what were the underlying circumstances leading to the event; and, c) what were the consequences of the event in relation to the research problem.

If your subject of analysis is a person. Explain why you selected this particular individual to be studied and describe what experiences they have had that provide an opportunity to advance new understandings about the research problem. Mention any background about this person which might help the reader understand the significance of their experiences that make them worthy of study. This includes describing the relationships this person has had with other people, institutions, and/or events that support using them as the subject for a case study research paper. It is particularly important to differentiate the person as the subject of analysis from others and to succinctly explain how the person relates to examining the research problem [e.g., why is one politician in a particular local election used to show an increase in voter turnout from any other candidate running in the election]. Note that these issues apply to a specific group of people used as a case study unit of analysis [e.g., a classroom of students].

If your subject of analysis is a place. In general, a case study that investigates a place suggests a subject of analysis that is unique or special in some way and that this uniqueness can be used to build new understanding or knowledge about the research problem. A case study of a place must not only describe its various attributes relevant to the research problem [e.g., physical, social, historical, cultural, economic, political], but you must state the method by which you determined that this place will illuminate new understandings about the research problem. It is also important to articulate why a particular place as the case for study is being used if similar places also exist [i.e., if you are studying patterns of homeless encampments of veterans in open spaces, explain why you are studying Echo Park in Los Angeles rather than Griffith Park?]. If applicable, describe what type of human activity involving this place makes it a good choice to study [e.g., prior research suggests Echo Park has more homeless veterans].

If your subject of analysis is a phenomenon. A phenomenon refers to a fact, occurrence, or circumstance that can be studied or observed but with the cause or explanation to be in question. In this sense, a phenomenon that forms your subject of analysis can encompass anything that can be observed or presumed to exist but is not fully understood. In the social and behavioral sciences, the case usually focuses on human interaction within a complex physical, social, economic, cultural, or political system. For example, the phenomenon could be the observation that many vehicles used by ISIS fighters are small trucks with English language advertisements on them. The research problem could be that ISIS fighters are difficult to combat because they are highly mobile. The research questions could be how and by what means are these vehicles used by ISIS being supplied to the militants and how might supply lines to these vehicles be cut off? How might knowing the suppliers of these trucks reveal larger networks of collaborators and financial support? A case study of a phenomenon most often encompasses an in-depth analysis of a cause and effect that is grounded in an interactive relationship between people and their environment in some way.

NOTE:   The choice of the case or set of cases to study cannot appear random. Evidence that supports the method by which you identified and chose your subject of analysis should clearly support investigation of the research problem and linked to key findings from your literature review. Be sure to cite any studies that helped you determine that the case you chose was appropriate for examining the problem.

IV.  Discussion

The main elements of your discussion section are generally the same as any research paper, but centered around interpreting and drawing conclusions about the key findings from your analysis of the case study. Note that a general social sciences research paper may contain a separate section to report findings. However, in a paper designed around a case study, it is common to combine a description of the results with the discussion about their implications. The objectives of your discussion section should include the following:

Reiterate the Research Problem/State the Major Findings Briefly reiterate the research problem you are investigating and explain why the subject of analysis around which you designed the case study were used. You should then describe the findings revealed from your study of the case using direct, declarative, and succinct proclamation of the study results. Highlight any findings that were unexpected or especially profound.

Explain the Meaning of the Findings and Why They are Important Systematically explain the meaning of your case study findings and why you believe they are important. Begin this part of the section by repeating what you consider to be your most important or surprising finding first, then systematically review each finding. Be sure to thoroughly extrapolate what your analysis of the case can tell the reader about situations or conditions beyond the actual case that was studied while, at the same time, being careful not to misconstrue or conflate a finding that undermines the external validity of your conclusions.

Relate the Findings to Similar Studies No study in the social sciences is so novel or possesses such a restricted focus that it has absolutely no relation to previously published research. The discussion section should relate your case study results to those found in other studies, particularly if questions raised from prior studies served as the motivation for choosing your subject of analysis. This is important because comparing and contrasting the findings of other studies helps support the overall importance of your results and it highlights how and in what ways your case study design and the subject of analysis differs from prior research about the topic.

Consider Alternative Explanations of the Findings Remember that the purpose of social science research is to discover and not to prove. When writing the discussion section, you should carefully consider all possible explanations revealed by the case study results, rather than just those that fit your hypothesis or prior assumptions and biases. Be alert to what the in-depth analysis of the case may reveal about the research problem, including offering a contrarian perspective to what scholars have stated in prior research if that is how the findings can be interpreted from your case.

Acknowledge the Study's Limitations You can state the study's limitations in the conclusion section of your paper but describing the limitations of your subject of analysis in the discussion section provides an opportunity to identify the limitations and explain why they are not significant. This part of the discussion section should also note any unanswered questions or issues your case study could not address. More detailed information about how to document any limitations to your research can be found here .

Suggest Areas for Further Research Although your case study may offer important insights about the research problem, there are likely additional questions related to the problem that remain unanswered or findings that unexpectedly revealed themselves as a result of your in-depth analysis of the case. Be sure that the recommendations for further research are linked to the research problem and that you explain why your recommendations are valid in other contexts and based on the original assumptions of your study.

V.  Conclusion

As with any research paper, you should summarize your conclusion in clear, simple language; emphasize how the findings from your case study differs from or supports prior research and why. Do not simply reiterate the discussion section. Provide a synthesis of key findings presented in the paper to show how these converge to address the research problem. If you haven't already done so in the discussion section, be sure to document the limitations of your case study and any need for further research.

The function of your paper's conclusion is to: 1) reiterate the main argument supported by the findings from your case study; 2) state clearly the context, background, and necessity of pursuing the research problem using a case study design in relation to an issue, controversy, or a gap found from reviewing the literature; and, 3) provide a place to persuasively and succinctly restate the significance of your research problem, given that the reader has now been presented with in-depth information about the topic.

Consider the following points to help ensure your conclusion is appropriate:

• If the argument or purpose of your paper is complex, you may need to summarize these points for your reader.
• If prior to your conclusion, you have not yet explained the significance of your findings or if you are proceeding inductively, use the conclusion of your paper to describe your main points and explain their significance.
• Move from a detailed to a general level of consideration of the case study's findings that returns the topic to the context provided by the introduction or within a new context that emerges from your case study findings.

Note that, depending on the discipline you are writing in or the preferences of your professor, the concluding paragraph may contain your final reflections on the evidence presented as it applies to practice or on the essay's central research problem. However, the nature of being introspective about the subject of analysis you have investigated will depend on whether you are explicitly asked to express your observations in this way.

Problems to Avoid

Overgeneralization One of the goals of a case study is to lay a foundation for understanding broader trends and issues applied to similar circumstances. However, be careful when drawing conclusions from your case study. They must be evidence-based and grounded in the results of the study; otherwise, it is merely speculation. Looking at a prior example, it would be incorrect to state that a factor in improving girls access to education in Azerbaijan and the policy implications this may have for improving access in other Muslim nations is due to girls access to social media if there is no documentary evidence from your case study to indicate this. There may be anecdotal evidence that retention rates were better for girls who were engaged with social media, but this observation would only point to the need for further research and would not be a definitive finding if this was not a part of your original research agenda.

Failure to Document Limitations No case is going to reveal all that needs to be understood about a research problem. Therefore, just as you have to clearly state the limitations of a general research study , you must describe the specific limitations inherent in the subject of analysis. For example, the case of studying how women conceptualize the need for water conservation in a village in Uganda could have limited application in other cultural contexts or in areas where fresh water from rivers or lakes is plentiful and, therefore, conservation is understood more in terms of managing access rather than preserving access to a scarce resource.

Failure to Extrapolate All Possible Implications Just as you don't want to over-generalize from your case study findings, you also have to be thorough in the consideration of all possible outcomes or recommendations derived from your findings. If you do not, your reader may question the validity of your analysis, particularly if you failed to document an obvious outcome from your case study research. For example, in the case of studying the accident at the railroad crossing to evaluate where and what types of warning signals should be located, you failed to take into consideration speed limit signage as well as warning signals. When designing your case study, be sure you have thoroughly addressed all aspects of the problem and do not leave gaps in your analysis that leave the reader questioning the results.

Case Studies. Writing@CSU. Colorado State University; Gerring, John. Case Study Research: Principles and Practices . New York: Cambridge University Press, 2007; Merriam, Sharan B. Qualitative Research and Case Study Applications in Education . Rev. ed. San Francisco, CA: Jossey-Bass, 1998; Miller, Lisa L. “The Use of Case Studies in Law and Social Science Research.” Annual Review of Law and Social Science 14 (2018): TBD; Mills, Albert J., Gabrielle Durepos, and Eiden Wiebe, editors. Encyclopedia of Case Study Research . Thousand Oaks, CA: SAGE Publications, 2010; Putney, LeAnn Grogan. "Case Study." In Encyclopedia of Research Design , Neil J. Salkind, editor. (Thousand Oaks, CA: SAGE Publications, 2010), pp. 116-120; Simons, Helen. Case Study Research in Practice . London: SAGE Publications, 2009;  Kratochwill,  Thomas R. and Joel R. Levin, editors. Single-Case Research Design and Analysis: New Development for Psychology and Education .  Hilldsale, NJ: Lawrence Erlbaum Associates, 1992; Swanborn, Peter G. Case Study Research: What, Why and How? London : SAGE, 2010; Yin, Robert K. Case Study Research: Design and Methods . 6th edition. Los Angeles, CA, SAGE Publications, 2014; Walo, Maree, Adrian Bull, and Helen Breen. “Achieving Economic Benefits at Local Events: A Case Study of a Local Sports Event.” Festival Management and Event Tourism 4 (1996): 95-106.

Writing Tip

At Least Five Misconceptions about Case Study Research

Social science case studies are often perceived as limited in their ability to create new knowledge because they are not randomly selected and findings cannot be generalized to larger populations. Flyvbjerg examines five misunderstandings about case study research and systematically "corrects" each one. To quote, these are:

Misunderstanding 1 :  General, theoretical [context-independent] knowledge is more valuable than concrete, practical [context-dependent] knowledge. Misunderstanding 2 :  One cannot generalize on the basis of an individual case; therefore, the case study cannot contribute to scientific development. Misunderstanding 3 :  The case study is most useful for generating hypotheses; that is, in the first stage of a total research process, whereas other methods are more suitable for hypotheses testing and theory building. Misunderstanding 4 :  The case study contains a bias toward verification, that is, a tendency to confirm the researcher’s preconceived notions. Misunderstanding 5 :  It is often difficult to summarize and develop general propositions and theories on the basis of specific case studies [p. 221].

While writing your paper, think introspectively about how you addressed these misconceptions because to do so can help you strengthen the validity and reliability of your research by clarifying issues of case selection, the testing and challenging of existing assumptions, the interpretation of key findings, and the summation of case outcomes. Think of a case study research paper as a complete, in-depth narrative about the specific properties and key characteristics of your subject of analysis applied to the research problem.

Flyvbjerg, Bent. “Five Misunderstandings About Case-Study Research.” Qualitative Inquiry 12 (April 2006): 219-245.

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What is a case study?

Affiliations.

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

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

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• Case Study | Definition, Examples & Methods

Case Study | Definition, Examples & Methods

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

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

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

Table of contents

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

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

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

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

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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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Using Systems Thinking for Translating Evidence into Practice: A Case Study of Embedding Shared Decision Making within a Federally Qualified Health Center Network

The following is a mixed-methods case study that examines how Access Community Health Network (ACCESS), a large federally qualified health center located in the Chicago metropolitan area, used a systems approach to incorporate Shared Decision Making into its practice model. Using both qualitative and quantitative methods including a survey of ACCESS staff and providers, as well as interviews with a range of providers and leadership, the study sought to answer the question: How successfully has ACCESS, as a complex primary care system, made Shared Decision Making an integral part of its Patient Centered Medical Home practice model?

With a high degree of consistency across both the survey and interview data, the study concludes that ACCESS has successfully shifted its culture towards Shared Decision Making and, over the course of the past several years, made it a part of its PCMH practice model. At the same time, there are still areas for improvement and ways that ACCESS can further embed SDM within its practice model. Opportunities exist to use this study as a foundation for further exploring the impact of SDM on patients and health outcomes (not a part of this study). Further, the results can be used by other complex health systems as a model for how to successfully integrate and translate best practice or innovation into care models.

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• Published: 09 May 2024

Examining the feasibility of assisted index case testing for HIV case-finding: a qualitative analysis of barriers and facilitators to implementation in Malawi

• Caroline J. Meek 1 , 2 ,
• Tiwonge E. Mbeya Munkhondya 3 ,
• Mtisunge Mphande 4 ,
• Tapiwa A. Tembo 4 ,
• Mike Chitani 4 ,
• Milenka Jean-Baptiste 2 ,
• Dhrutika Vansia 4 ,
• Caroline Kumbuyo 4 ,
• Jiayu Wang 2 ,
• Katherine R. Simon 4 ,
• Sarah E. Rutstein 5 ,
• Clare Barrington 2 ,
• Maria H. Kim 4 ,
• Vivian F. Go 2 &
• Nora E. Rosenberg 2  

BMC Health Services Research volume  24 , Article number:  606 ( 2024 ) Cite this article

Metrics details

Assisted index case testing (ICT), in which health care workers take an active role in referring at-risk contacts of people living with HIV for HIV testing services, has been widely recognized as an evidence-based intervention with high potential to increase status awareness in people living with HIV. While the available evidence from eastern and southern Africa suggests that assisted ICT can be an effective, efficient, cost-effective, acceptable, and low-risk strategy to implement in the region, it reveals that feasibility barriers to implementation exist. This study aims to inform the design of implementation strategies to mitigate these feasibility barriers by examining “assisting” health care workers’ experiences of how barriers manifest throughout the assisted ICT process, as well as their perceptions of potential opportunities to facilitate feasibility.

In-depth interviews were conducted with 26 lay health care workers delivering assisted ICT in Malawian health facilities. Interviews explored health care workers’ experiences counseling index clients and tracing these clients’ contacts, aiming to inform development of a blended learning implementation package. Transcripts were inductively analyzed using Dedoose coding software to identify and describe key factors influencing feasibility of assisted ICT. Analysis included multiple rounds of coding and iteration with the data collection team.

Participants reported a variety of barriers to feasibility of assisted index case testing implementation, including sensitivities around discussing ICT with clients, privacy concerns, limited time for assisted index case testing amid high workloads, poor quality contact information, and logistical obstacles to tracing. Participants also reported several health care worker characteristics that facilitate feasibility (knowledge, interpersonal skills, non-stigmatizing attitudes and behaviors, and a sense of purpose), as well as identified process improvements with the potential to mitigate barriers.

Conclusions

Maximizing assisted ICT’s potential to increase status awareness in people living with HIV requires equipping health care workers with effective training and support to address and overcome the many feasibility barriers that they face in implementation. Findings demonstrate the need for, as well as inform the development of, implementation strategies to mitigate barriers and promote facilitators to feasibility of assisted ICT.

Trial registration

NCT05343390. Date of registration: April 25, 2022.

Peer Review reports

Introduction

To streamline progress towards its goal of ending AIDS as a public health threat by 2030, the Joint United Nations Programme on HIV/AIDS (UNAIDS) launched a set of HIV testing and treatment targets [ 1 ]. Adopted by United Nations member states in June 2021, the targets call for 95% of all people living with HIV (PLHIV) to know their HIV status, 95% of all PLHIV to be accessing sustained antiretroviral therapy (ART), and 95% of all people receiving ART to achieve viral suppression by 2025 [ 2 ]. Eastern and southern Africa has seen promising regional progress towards these targets in recent years, and the region is approaching the first target related to status awareness in PLHIV- in 2022, 92% of PLHIV in the region were aware of their status [ 3 ]. However, several countries in the region lag behind [ 4 ], and as 2025 approaches, it is critical to scale up adoption of evidence-based interventions to sustain and accelerate progress.

Index case testing (ICT), which targets provision of HIV testing services (HTS) for sexual partners, biological children, and other contacts of known PLHIV (“index clients”), is a widely recognized evidence-based intervention used to identify PLHIV by streamlining testing efforts to populations most at risk [ 5 , 6 , 7 ]. Traditional approaches to ICT rely on passive referral, in which index clients invite their contacts for testing [ 5 ]. However, the World Health Organization (WHO) and the President’s Emergency Plan for HIV/AIDS Relief (PEPFAR) have both recommended assisted approaches to ICT [ 6 , 8 , 9 , 10 ], in which health care workers (HCWs) take an active role in referral of at-risk contacts for testing, due to evidence of improved effectiveness in identifying PLHIV compared to passive approaches [ 10 , 11 , 12 , 13 , 14 ]. As a result, there have been several efforts to scale assisted ICT throughout eastern and southern Africa in recent years [ 15 , 16 , 17 , 18 , 19 , 20 ]. In addition to evidence indicating that assisted ICT can be effective in increasing HIV testing and case-finding [ 16 , 17 , 21 , 22 , 23 , 24 ], implementation evidence [ 25 ] from the region suggests that assisted ICT can be an efficient [ 14 ], acceptable [ 5 , 13 , 15 , 18 , 20 , 21 , 26 ], cost-effective [ 27 ], and low-risk [ 21 , 22 , 24 , 28 , 29 ] strategy to promote PLHIV status awareness. However, the few studies that focus on feasibility, or the extent to which HCWs can successfully carry out assisted ICT [ 25 ], suggest that barriers exist to feasibility of effective implementation [ 18 , 19 , 20 , 30 , 31 , 32 ]. Developing informed implementation strategies to mitigate these barriers requires more detailed examination of how these barriers manifest throughout the assisted ICT process, as well as of potential opportunities to facilitate feasibility, from the perspective of the HCWs who are doing the “assisting”.

This qualitative analysis addresses this need for further detail by exploring “assisting” HCWs’ perspectives of factors that influence the feasibility of assisted ICT, with a unique focus on informing development of effective implementation strategies to best support assisted ICT delivery in the context of an implementation science trial in Malawi.

This study was conducted in the Machinga and Balaka districts of Malawi. Malawi is a country in southeastern Africa in which 7.1% of the population lives with HIV and 94% of PLHIV know their status [ 4 ]. Machinga and Balaka are two relatively densely populated districts in the southern region of Malawi [ 33 ] with HIV prevalence rates similar to the national average [ 34 ]. We selected Machinga and Balaka because they are prototypical of districts in Malawi implementing Ministry of Health programs with support from an implementing partner.

Malawi has a long-established passive ICT program, and in 2019 the country also adopted an assisted component, known as voluntary assisted partner notification, as part of its national HIV testing policy [ 32 ]. In Malawi, ICT is conducted through the following four methods, voluntarily selected by the index client: 1) passive referral, in which HCWs encourage the index client to refer partners for voluntary HTS, 2) contract referral, in which HCWs establish an informal ‘contract’ with index clients that agrees upon a date that the HCW can contact the contact clients if they have not yet presented for HTS; 3) provider referral, in which HCWs contact and offer voluntary HTS to contact clients; and 3) dual referral, in which HCWs accompany and provide support to index clients in disclosing their status and offering HTS to their partners [ 8 ]. 

While Malawi has one of the lowest rates of qualified clinical HCWs globally (< 5 clinicians per 100,000 people) [ 35 ], the country has a strong track record of shifting HTS tasks to lay HCWs, who have been informally trained to perform certain health care delivery functions but do not have a formal professional/para-professional certification or tertiary education degree, in order to mitigate this limited medical workforce capacity [ 32 , 36 ]. In Malawi, lay HCW roles include HIV Diagnostic Assistants (who are primarily responsible for HIV testing and counseling, including index case counseling) and community health workers (who are responsible for a wider variety of tasks, including index case counseling and contact tracing) [ 32 ]. Non-governmental organization implementing partners, such as the Tingathe Program, play a critical role in harnessing Malawian lay HCW capacity to rapidly and efficiently scale up HTS, including assisted ICT [ 32 , 37 , 38 , 39 ].

Study design

Data for this analysis were collected as part of formative research for a two-arm cluster randomized control trial examining a blended learning implementation package as a strategy for building HCW capacity in assisted ICT [ 40 ]. Earlier work [ 32 ] established the theoretical basis for testing the blended learning implementation package, which combines individual asynchronous modules with synchronous small-group interactive sessions to enhance training and foster continuous quality improvement. The formative research presented in this paper aimed to further explore factors influencing feasibility of the assisted ICT from the perspective of HCWs in order to inform development of the blended learning implementation package.

Prior to the start of the trial (October-December 2021), the research team conducted 26 in-depth interviews (IDIs) with lay HCWs at 14 of the 34 facilities included in the parent trial. We purposively selected different types of facilities (hospitals, health centers, and dispensaries) in both districts and from both randomization arms, as this served as a qualitative baseline for a randomized trial. Within these facilities, we worked with facility supervisors to purposively select HCWs who were actively engaged in Malawi’s ICT program from the larger sample of HCWs eligible for the parent trial (had to be at least 18 years old, employed full-time at one of the health facilities included in the parent trial, and involved in counseling index clients and/or tracing their contacts). The parent trial enrolled 306 HCWs, who were primarily staff hired by Tingathe Program to support facilities implementing Malawi’s national HIV program.

Data collection

IDIs were conducted by three trained Malawian interviewers in a private setting using a semi-structured guide. IDIs were conducted over the phone when possible ( n  = 18) or in-person at sites with limited phone service ( n  = 8). The semi-structured guide was developed for this study through a series of rigorous, iterative discussions among the research team (Additional file 1 ). The questions used for this analysis were a subset of a larger interview. The interview guide questions for this analysis explored HCWs’ experiences with assisted ICT, including barriers and facilitators to implementation. Probing separately about the processes of counseling index clients and tracing their contacts, interviewers asked questions such as “What is the first thing that comes to mind when you think of counseling index clients/tracing contacts?”, “What aspects do you [like/not like] about…?” and “What do your colleagues say about…?”. When appropriate, interviewers probed further about how specific factors mentioned by the participant facilitate or impede the ICT implementation experience.

The IDIs lasted from 60–90 min and were conducted in Chichewa, a local language in Malawi. Eleven audio recordings were transcribed verbatim in Chichewa before being translated into English and 15 recordings were directly translated and transcribed into English. Interviewers summarized each IDI after it was completed, and these summaries were discussed with the research team routinely.

Data analysis

The research team first reviewed all of the interview summaries individually and then met multiple times to discuss initial observations, refining the research question and scope of analysis. A US-based analyst (CJM) with training in qualitative analysis used an inductive approach to develop a codebook, deriving broad codes from the implementation factors mentioned by participants throughout their interviews. Along with focused examination of the transcripts, she consulted team members who had conducted the IDIs with questions or clarifications. CJM regularly met with Malawian team members (TEMM, MM, TAT) who possess the contextual expertise necessary to verify and enhance meaning. She used the Dedoose (2019) web application to engage in multiple rounds of coding, starting with codes representing broad implementation factors and then further refining the codebook as needed to capture the nuanced manifestations of these barriers and facilitators. Throughout codebook development and refinement, the analyst engaged in memoing to track first impressions, thought processes, and coding decisions. The analyst presented the codebook and multiple rounds of draft results to the research team. All transcripts and applied codes were also reviewed in detail by additional team members (MJB, DV). Additional refinements to the codebook and results interpretations were iteratively made based on team feedback.

Ethical clearance

Ethical clearance was provided by UNC’s IRB, Malawi’s National Health Sciences Research Committee, and the Baylor College of Medicine IRB. Written informed consent was obtained from all participants in the main study and interviewers confirmed verbal consent before starting the IDIs.

Participant characteristics are described in Table  1 below.

Factors influencing feasibility of assisted ICT: barriers and facilitators

Participants described a variety of barriers and facilitators to feasibility of assisted ICT, manifesting across the index client counseling and contact client tracing phases of the implementation process. Identified barriers included sensitivities around discussing ICT with clients, privacy concerns, limited time for ICT amid high workloads, poor quality contact information, and logistical obstacles to tracing. In addition to these barriers, participants also described several HCW characteristics that facilitated feasibility: ICT knowledge, interpersonal skills, positive attitudes towards clients, and sense of purpose. Barriers and facilitators are mapped to the ICT process in Fig.  1 and described in greater detail in further sections.

Conceptual diagram mapping feasibility barriers and facilitators to the ICT process

Feasibility barriers

Sensitivities around discussing ict with clients.

Participants described ICT as a highly sensitive topic to approach with clients. Many expressed a feeling of uncertainty around how open index clients will be to sharing information about their contacts, as well as how contacts will react when approached for HTS. When asked about difficult aspects of counseling index clients, many HCWs mentioned clients’ hesitance or declination to participate in assisted ICT and share their contacts. Further, several HCWs mentioned that some index clients would provide false contact information. These index client behaviors were often attributed to confidentiality concerns, fear of unwanted status disclosure, and fear of the resulting implications of status disclosure: “They behave that way because they think you will be telling other people about their status…they also think that since you know it means their life is done, you will be looking at them differently .” Populations commonly identified as particularly likely to hesitate, refuse, or provide false information included youth (described as “ shy ” “ thinking they know a lot ” and “ difficult to reveal their contacts ”) and newly diagnosed clients (“it may be hard for them to accept [their HIV diagnosis]” ). One participant suggested that efforts to pair index clients with same-sex HCWs could make them more comfortable to discuss their contacts.

When asked about the first things that come to mind when starting to trace contacts, many participants discussed wondering how they will be received by the contact and preparing themselves to approach the contact. When conducting provider or contract referral, HCWs described a variety of challenging reactions that can occur when they approach a contact for HTS- including delay or refusal of testing, excessive questioning about the identity of the index client who referred them for testing, and even anger or aggression. Particularly mentioned in the context of male clients, these kinds of reactions can lead to stress and uncertain next steps for HCWs: “I was very tensed up. I was wondering to myself what was going to happen…he was talking with anger.”

Participants also noted the unique sensitivities inherent in conducting dual referral and interacting with sexual partners of index clients, explaining that HIV disclosure can create acute conflict in couples due to perceived blame and assumptions of infidelity. They recounted these scenarios as particularly difficult to navigate, with high stakes that require high-quality counseling skills: “sometimes if you do not have good counseling the marriage happens to get to an end.” . Some participants discussed concern about index client risk of intimate partner violence (IPV) upon partner disclosure: “they think that if they go home and [disclose their HIV status], the marriage will end right there, or for some getting to a point of [being] beaten.”

Privacy concerns

Participants also reported that clients highly value privacy, which can be difficult to secure throughout the ICT process. In the facility, while participants largely indicated that counseling index clients was much more successful when conducted in a private area, many reported limited availability of private counseling space. One participant described this challenge: “ if I’m counseling an index client and people keep coming into the room…this compromises the whole thing because the client becomes uncomfortable in the end.” Some HCWs mentioned working around this issue through use of screens, “do-not-disturb” signs, outdoor spots, and tents.

Participants also noted maintaining privacy as a challenge when tracing contact clients in the field, as they sometimes find clients in a situation that is not conducive to private conversations. One participant described: “ we get to the house and find that there are 4, 5 people with our [contact client]…it doesn’t go well…That is a mission gone wrong. ” Participants also noted that HCWs are also often easily recognizable in the community due to their bikes and cars, which exacerbates the risk of compromising privacy. To address privacy challenges in the community, participants reported strategies to increase discretion, including dressing to blend in with the community, preparing an alternate reason to be looking for the client, and offering HTS to multiple people or households to avoid singling out one person.

Limited time for ICT amid high workloads

Some participants indicated that strained staffing capacity leads HCWs to have to perform multiple roles, expressing challenges in balancing their ICT work with their other tasks. As one participant described, “Sometimes it is found that you are assigned a task here at the hospital to screen anyone who comes for blood testing, but you are also supposed to follow up [with] the contacts the same day- so it becomes a problem…you fail to follow up [with] the contacts.” Some also described being the only, or one of few staff responsible for ICT: “You’re doing this work alone, so you can see that it is a big task to do it single-handedly.” The need to counsel each index client individually, as a result of confidentiality concerns, further increases workload for the limited staff assigned to this work. Further, HCWs often described contact tracing in the field as time-consuming and physically taxing, which leaves them less time and energy for counseling. Many HCWs noted the need to hire more staff dedicated to ICT work.

High workloads also resulted in shorter appointments and less time to counsel index clients, which participants reported limits the opportunity for rapport that facilitates openness or probes for detailed information about sexual partners. Participants emphasized the importance of having enough time to meaningfully engage with index clients: “For counseling you cannot have a limit to say, ‘I will talk to him for 5 min only.’ …That is not counseling then. You are supposed to stay up until…you feel that this [person] is fulfilled.” . In addition, high workload can reduce the capacity of HCWs to deliver quality counseling: “So you find that as you go along with the counseling, you can do better with the first three clients but the rest, you are tired and you do short cuts.”

High workloads also lead to longer queues, which may deter clients from coming into the clinic or cause them to leave before receiving services: “Sometimes because of shortage of staff, it happens that you have been assigned a certain task that you were supposed to do but at the same time there are clients who were supposed to be counseled. As a result, because you spent more time on the other task as a result you lose out some of the clients because you find that they have gone.” In response to long queues, several participants described ‘fast-tracking’ contact clients who come in for HTS in effort to maximize case-finding by prioritizing those who have been identified as at risk of HIV.

Poor quality contact information

Participants repeatedly discussed the importance of eliciting accurate information about a person’s sexual partners, including where, when, and how to best contact them. As one participant said, “ Once the index has given us the wrong information then everything cannot work, it becomes wrong…if he gives us full information [with] the right details then everything becomes successful and happens without a problem. ” Adequate information is a critical component of the ICT process, and incorrect or incomplete information delays or prevents communication with contact clients.

Inadequate information, which can include incorrect or incomplete names, phone numbers, physical addresses, and contextual details, can arise from a variety of scenarios. Most participants mentioned index clients providing incorrect information as a concern. This occurred either intentionally to avoid disclosure or unintentionally if information was not known. Poor quality contact information also results from insufficient probing and poor documentation, which is often exacerbated by aforementioned HCW time and energy constraints. In one participant’s words, “The person who has enlisted the contact…is the key person who can make sure that our tracing is made easy.” Participants noted the pivotal role of the original HCW who first interacts with the index client in not only eliciting correct locator information but also eliciting detailed contextual information. For example, details about a contact client’s profession are helpful to trace the client at a time when they will likely be at home. Other helpful information included nicknames, HIV testing history, and notes about confidentiality concerns.

Logistical obstacles to tracing

Some contact clients are reached by phone whereas others must be physically traced in the community. Some participants reported difficulty with tracing via phone, frequently citing network problems and lack of sufficient airtime allocated by the facility. Participants also reported that some clients were unreachable by phone, necessitating physical tracing. Physically tracing a contact client requires a larger investment of resources than phone tracing, especially when the client lives at a far distance from the clinic. Participants frequently discussed having to travel far distances to reach contact clients, an issue some saw as exacerbated by people who travel to clinics at far distances due to privacy concerns.

While most participants reported walking or biking to reach contact clients in the community, some mentioned using a motorcycle or Tingathe vehicle. However, access to vehicles is often limited and these transportation methods require additional expenses for fuel. Walking or biking was also reported to expose HCWs to inclement weather, including hot or rainy seasons, and potential safety risks such as violence.

Participants reported that traveling far distances can be physically taxing and time-consuming, sometimes rendering them too tired or busy to attend to other tasks. Frequent travel influenced HCW morale, particularly when a tracing effort did not result in successfully recruiting a contact client. Participants frequently described this perception of wasted time and energy as “ painful ”, with the level of distress often portrayed as increasing with the distance travelled. As one HCW said, “You [can] find out that he gave a false address. That is painful because it means you have done nothing for the person, you travelled for nothing.”

HCWs described multiple approaches used to strategically allocate limited resources for long distances. These approaches included waiting to physically trace until there are multiple clients in a particular area, reserving vehicle use for longer trips, and coordinating across HCWs to map out contact client locations. HCWs also mentioned provision of rain gear and sun protection to mitigate uncomfortable travel. Another approach involved allocating contact tracing to HCWs based in the same communities as the contact clients.

Feasibility facilitators

Hcw knowledge about ict.

Participants reported that HCWs with a thorough understanding of ICT’s rationale and purpose can facilitate client openness. Clients were more likely to engage with HCWs about assisted ICT if they understood the benefits to themselves and their loved ones. One HCW stated, “If the person understands why we need the information, they will give us accurate information.”

Participants also discussed the value of deep HCW familiarity with ICT procedures and processes, particularly regarding screening clients for IPV and choosing referral method. One participant described the importance of clearly explaining various referral methods to clients: “So…people come and choose the method they like…when you explain things clearly it is like the index client is free to choose a method which the contact can use for testing”. Thorough knowledge of available referral methods allows HCWs to actively engage with index clients to discuss strategies to refer contacts in a way that fits their unique confidentiality needs, which was framed as particularly important when IPV is identified as a concern. Multiple participants suggested the use of flipcharts or videos, saying these would save limited HCW time and energy, fill information gaps, and provide clients with a visual aid to supplement the counseling. Others suggested recurring opportunities for training, to continuously “refresh” their ICT knowledge in order to facilitate implementation.

HCW interpersonal skills

In addition, HCWs’ ability to navigate sensitive conversations about HIV was noted as a key facilitator of successful implementation. Interpersonal skills were mentioned as mitigating the role’s day-to-day uncertainty by preparing HCWs to engage with clients, especially newly diagnosed clients: “ I need to counsel them skillfully so that they understand what I mean regardless that they have just tested positive for HIV.”

When discussing strategies to build HCW skills in counseling index clients and tracing contact clients, participants suggested establishing regular opportunities to discuss challenges and share approaches to address these challenges: “ I think that there should be much effort on the [HCWs] doing [ICT]. For example, what do I mean, they should be having a meeting with the facility people to ask what challenges are you facing and how can we end them?”. Another participant further elaborated, saying “We should be able to share experiences with our [colleagues] so that we can all learn from one another. And also, there are other people who are really brilliant at their job. Those people ought to come visit us and see how we are doing. That is very motivating.”

HCW non-stigmatizing attitudes and behaviors

Participants also highlighted the role of empathy and non-judgement in building trust with clients: “ Put yourself in that other person’s shoes. In so doing, the counseling session goes well. Understanding that person, that what is happening to them can also happen to you. ”. Participants viewed trust-building as critical to facilitating client comfort and openness: “if they trust you enough, they will give you the right information.” Further, participants associated HCW assurance of confidentiality with promoting trust and greater information sharing: “ Also assuring them on the issue of confidentiality because confidentiality is a paramount. If there will not be confidentiality then the clients will not reveal.”

HCW sense of purpose

Lastly, several participants reported that a sense of purpose and desire to help people motivated them to overcome the challenges of delivering assisted ICT. One participant said, “ Some of these jobs are a ministry. Counseling is not easy. You just need to tell yourself that you are there to help that person. ” Many seemed to take comfort in the knowledge that their labors, however taxing, would ultimately allow people to know their status, take control of their health, and prevent the spread of HIV. Participants framed the sense of fulfillment from successful ICT implementation as a mitigating factor amidst challenges: “ If [the contact client] has accepted it then I feel that mostly I have achieved the aim of being in the health field…that is why it is appealing to me ”.

Participants described a variety of barriers to assisted ICT implementation, including sensitivities around discussing ICT with clients, privacy concerns, limited time for ICT amid high workloads, poor quality contact information, and logistical obstacles to tracing. These barriers manifested across each step of the process of counseling index clients and tracing contacts. However, participants also identified HCW characteristics and process improvements that can mitigate these barriers.

Further, participants’ descriptions of the assisted ICT process revealed the intimately interconnected nature of factors that influence feasibility of assisted ICT. Sensitivities around HIV, privacy limitations, time constraints, and HCW characteristics all contribute to the extent to which counseling index clients elicits adequate information to facilitate contact tracing. Information quality has implications for HCW capacity, as inadequate information can lead to wasted resources, including HCW time and energy, on contact tracing. The opportunity cost of wasted efforts, which increases as the distance from which the contact client lives from the clinic increases, depletes HCW morale. The resulting acceleration of burnout, which is already fueled by busy workloads and the inherent uncertainty of day-to-day ICT work, further impairs HCW capacity to effectively engage in quality counseling that elicits adequate information from index clients. This interconnectedness suggests that efforts to mitigate barriers at any step of the assisted ICT process may have the potential to ripple across the whole process.

Participants’ descriptions of client confidentiality and privacy concerns, as well as fear of consequences of disclosure, align with previous studies that emphasize stigma as a key barrier to assisted ICT [ 15 , 18 , 19 , 20 , 30 , 31 ] and the overall HIV testing and treatment cascade [ 41 ]. Our findings suggest that anticipated stigma, or the fear of discrimination upon disclosure [ 42 ], drives several key barriers to feasibility of assisted ICT implementation. Previous studies also highlight the key role of HCWs in mitigating barriers related to anticipated stigma; noting the key role of HCW ICT knowledge, interpersonal skills, and non-stigmatizing attitudes/behaviors in securing informed consent from clients for ICT, tailoring the referral strategy to minimize risk to client confidentiality and safety, building trust and rapport with the client, and eliciting accurate contact information from index clients to facilitate contact tracing [ 18 , 19 , 20 , 30 ].

Our findings also reflect previous evidence of logistical challenges related to limited time, space, and resources that can present barriers to feasibility for HCWs [ 18 , 19 , 20 , 30 , 31 ]. Participants in the current study described these logistical challenges as perpetuating HCW burnout, making it harder for them to engage in effective counseling. Cumulative evidence of barriers across different settings (further validated by this study) suggests that assisted ICT implementation may pose greater burden on HCWs than previously thought [ 7 ]. However, our findings also suggest that strategic investment in targeted implementation strategies has the potential to help overcome these feasibility barriers.

In our own work, these findings affirmed the rationale for and informed the development of the blended learning implementation package tested in our trial [ 40 , 43 ]. Findings indicated the need for evidence-based training and support to promote HCW capacity to foster facilitating characteristics. Participants discussed the value of "refresher" opportunities in building knowledge, as well as the value of learning from other’s experiences. The blended learning implementation package balances both needs by providing time for HCWs to master ICT knowledge and skills with a combination of asynchronous, digitally delivered content (which allows for continuous review as a "refresher") and in-person sessions (which allow for sharing, practicing, and feedback). Our findings also highlight the value of flexible referral methods that align with the client’s needs, so our training content includes a detailed description of each referral method process. Further, our training content emphasizes client-centered, non-judgmental counseling as our findings add to cumulative evidence of stigma as a key barrier to assisted ICT implementation [ 41 ].

In addition, participants frequently mentioned informal workarounds currently in use to mitigate barriers or offered up ideas for potential solutions to try. Our blended learning implementation package streamlines these problem-solving processes by offering monthly continuous quality improvement sessions at each facility in our enhanced arm. These sessions allow for structured time to discuss identified barriers, share ideas to mitigate barriers, and develop solutions for sustained process improvement tailored to their specific setting. Initial focus areas for continuous quality improvement discussions include use of space, staffing, allocation of airtime and vehicles, and documentation, which were identified as barriers to feasibility in the current study.

Our study provides a uniquely in-depth examination of HCWs’ experiences implementing assisted ICT, exploring how barriers can manifest and interact with each other at each step of the process to hinder successful implementation. Further, our study has a highly actionable focus on informing development of implementation strategies to support HCWs implementing assisted ICT. Our study also has limitations. Firstly, while our sole focus on HCWs allowed for deeper exploration of assisted ICT from the perspective of those actually implementing it on the ground, this meant that our analysis did not include perspectives of index or contact clients. In addition, we did not conduct sub-group analyses as interpretation of results would be limited by our small sample size.

Assisted ICT has been widely recognized as an evidence-based intervention with high promise to increase PLHIV status awareness [ 5 , 6 , 7 , 10 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , 23 , 24 , 26 , 27 , 28 , 29 ], which is important as countries in eastern and southern Africa strive to reach global UNAIDS targets. Study findings support cumulative evidence that HCWs face a variety of feasibility barriers to assisted ICT implementation in the region; further, the study’s uniquely in-depth focus on the experiences of those doing the “assisting” enhances understanding of how these barriers manifest and informs the development of implementation strategies to mitigate these barriers. Maximizing assisted ICT’s potential to increase HIV testing requires equipping HCWs with effective training and support to address and overcome the many feasibility barriers they face in implementation. Findings demonstrate the need for, as well as inform the development of, implementation strategies to mitigate barriers and promote facilitators to feasibility of assisted ICT.

Availability of data and materials

Qualitative data on which this analysis is based, as well as data collection materials and codebooks, are available from the last author upon reasonable request. The interview guide is included as an additional file.

Abbreviations

Acquired Immunodeficiency Syndrome

Antiretroviral Therapy

Health Care Worker

Human Immunodeficiency Virus

HIV Testing Services

Index Case Testing

In-Depth Interview

Intimate Partner Violence

Institutional Review Board

President’s Emergency Plan for HIV/AIDS Relief

People Living With HIV

Joint United Nations Programme on HIV/AIDS

World Health Organization

UNAIDS. Prevailing against pandemics by putting people at the centre. Geneva: UNAIDS; 2020.

Google Scholar  

Frescura L, Godfrey-Faussett P, Feizzadeh AA, El-Sadr W, Syarif O, Ghys PD, et al. Achieving the 95 95 95 targets for all: A pathway to ending AIDS. PLoS One. 2022;17(8):e0272405.

Article   CAS   PubMed   PubMed Central   Google Scholar  

UNAIDS. UNAIDS global AIDS update 2023: The path that ends AIDS. New York: United Nations; 2023.

Book   Google Scholar  

UNAIDS. UNAIDS data 2023. Geneva: Joint United Nations Programme on HIV/AIDS; 2023.

Kahabuka C, Plotkin M, Christensen A, Brown C, Njozi M, Kisendi R, et al. Addressing the first 90: A highly effective partner notification approach reaches previously undiagnosed sexual partners in Tanzania. AIDS Behav. 2017;21(8):2551–60.

Article   PubMed   PubMed Central   Google Scholar  

Lasry A, Medley A, Behel S, Mujawar MI, Cain M, Diekman ST, et al. Scaling up testing for human immunodeficiency virus infection among contacts of index patients - 20 countries, 2016–2018. MMWR Morb Mortal Wkly Rep. 2019;68(21):474–7.

Onovo A, Kalaiwo A, Agweye A, Emmanuel G, Keiser O. Diagnosis and case finding according to key partner risk populations of people living with HIV in Nigeria: A retrospective analysis of community-led index partner testing services. EClinicalMedicine. 2022;43:101265.

World Health Organization (WHO). Guidelines on HIV self-testing and partner notification : supplement to Consolidated guidelines on HIV testing services. 2016. https://apps.who.int/iris/bitstream/handle/10665/251655/9789241549868-eng.pdf?sequence=1 . Accessed 19 Apr 2024.

Watts H. Why PEPFAR is going all in on partner notification services. 2019. https://programme.ias2019.org/PAGMaterial/PPT/1934_117/Why%20PEPFAR%20is%20all%20in%20for%20PNS%2007192019%20rev.pptx . Accessed 19 Apr 2024.

Dalal S, Johnson C, Fonner V, Kennedy CE, Siegfried N, Figueroa C, et al. Improving HIV test uptake and case finding with assisted partner notification services. AIDS. 2017;31(13):1867–76.

Article   PubMed   Google Scholar  

Mathews C, Coetzee N, Zwarenstein M, Lombard C, Guttmacher S, Oxman A, et al. A systematic review of strategies for partner notification for sexually transmitted diseases, including HIV/AIDS. Int J STD AIDS. 2002;13(5):285–300.

Hogben M, McNally T, McPheeters M, Hutchinson AB. The effectiveness of HIV partner counseling and referral services in increasing identification of HIV-positive individuals a systematic review. Am J Prev Med. 2007;33(2 Suppl):S89-100.

Brown LB, Miller WC, Kamanga G, Nyirenda N, Mmodzi P, Pettifor A, et al. HIV partner notification is effective and feasible in sub-Saharan Africa: opportunities for HIV treatment and prevention. J Acquir Immune Defic Syndr. 2011;56(5):437–42.

Sharma M, Ying R, Tarr G, Barnabas R. Systematic review and meta-analysis of community and facility-based HIV testing to address linkage to care gaps in sub-Saharan Africa. Nature. 2015;528(7580):S77-85.

Edosa M, Merdassa E, Turi E. Acceptance of index case HIV testing and its associated factors among HIV/AIDS Clients on ART follow-up in West Ethiopia: A multi-centered facility-based cross-sectional study. HIV AIDS (Auckl). 2022;14:451–60.

PubMed   Google Scholar  

Williams D, MacKellar D, Dlamini M, Byrd J, Dube L, Mndzebele P, et al. HIV testing and ART initiation among partners, family members, and high-risk associates of index clients participating in the CommLink linkage case management program, Eswatini, 2016–2018. PLoS ONE. 2021;16(12):e0261605.

Remera E, Nsanzimana S, Chammartin F, Semakula M, Rwibasira GN, Malamba SS, et al. Brief report: Active HIV case finding in the city of Kigali, Rwanda: Assessment of voluntary assisted partner notification modalities to detect undiagnosed HIV infections. J Acquir Immune Defic Syndr. 2022;89(4):423–7.

Article   CAS   PubMed   Google Scholar  

Quinn C, Nakyanjo N, Ddaaki W, Burke VM, Hutchinson N, Kagaayi J, et al. HIV partner notification values and preferences among sex workers, fishermen, and mainland community members in Rakai, Uganda: A qualitative study. AIDS Behav. 2018;22(10):3407–16.

Monroe-Wise A, Maingi Mutiti P, Kimani H, Moraa H, Bukusi DE, Farquhar C. Assisted partner notification services for patients receiving HIV care and treatment in an HIV clinic in Nairobi, Kenya: a qualitative assessment of barriers and opportunities for scale-up. J Int AIDS Soc. 2019;22 Suppl 3(Suppl Suppl 3):e25315.

Liu W, Wamuti BM, Owuor M, Lagat H, Kariithi E, Obong’o C, et al. “It is a process” - a qualitative evaluation of provider acceptability of HIV assisted partner services in western Kenya: experiences, challenges, and facilitators. BMC Health Serv Res. 2022;22(1):616.

Myers RS, Feldacker C, Cesar F, Paredes Z, Augusto G, Muluana C, et al. Acceptability and effectiveness of assisted human immunodeficiency virus partner services in Mozambique: Results from a pilot program in a public. Urban Clinic Sex Transm Dis. 2016;43(11):690–5.

Rosenberg NE, Mtande TK, Saidi F, Stanley C, Jere E, Paile L, et al. Recruiting male partners for couple HIV testing and counselling in Malawi’s option B+ programme: an unblinded randomised controlled trial. Lancet HIV. 2015;2(11):e483–91.

Mahachi N, Muchedzi A, Tafuma TA, Mawora P, Kariuki L, Semo BW, et al. Sustained high HIV case-finding through index testing and partner notification services: experiences from three provinces in Zimbabwe. J Int AIDS Soc. 2019;22 Suppl 3(Suppl Suppl 3):e25321.

Cherutich P, Golden MR, Wamuti B, Richardson BA, Asbjornsdottir KH, Otieno FA, et al. Assisted partner services for HIV in Kenya: a cluster randomised controlled trial. Lancet HIV. 2017;4(2):e74–82.

Proctor E, Silmere H, Raghavan R, Hovmand P, Aarons G, Bunger A, et al. Outcomes for implementation research: conceptual distinctions, measurement challenges, and research agenda. Adm Policy Ment Health. 2011;38(2):65–76.

Kamanga G, Brown L, Jawati P, Chiwanda D, Nyirenda N. Maximizing HIV partner notification opportunities for index patients and their sexual partners in Malawi. Malawi Med J. 2015;27(4):140–4.

Rutstein SE, Brown LB, Biddle AK, Wheeler SB, Kamanga G, Mmodzi P, et al. Cost-effectiveness of provider-based HIV partner notification in urban Malawi. Health Policy Plan. 2014;29(1):115–26.

Wamuti BM, Welty T, Nambu W, Chimoun FT, Shields R, Golden MR, et al. Low risk of social harms in an HIV assisted partner services programme in Cameroon. J Int AIDS Soc. 2019;22 Suppl 3(Suppl Suppl 3):e25308.

Henley C, Forgwei G, Welty T, Golden M, Adimora A, Shields R, et al. Scale-up and case-finding effectiveness of an HIV partner services program in Cameroon: an innovative HIV prevention intervention for developing countries. Sex Transm Dis. 2013;40(12):909–14.

Klabbers RE, Muwonge TR, Ayikobua E, Izizinga D, Bassett IV, Kambugu A, et al. Health worker perspectives on barriers and facilitators of assisted partner notification for HIV for refugees and Ugandan nationals: A mixed methods study in West Nile Uganda. AIDS Behav. 2021;25(10):3206–22.

Mugisha N, Tirera F, Coulibaly-Kouyate N, Aguie W, He Y, Kemper K, et al. Implementation process and challenges of index testing in Cote d’Ivoire from healthcare workers’ perspectives. PLoS One. 2023;18(2):e0280623.

Rosenberg NE, Tembo TA, Simon KR, Mollan K, Rutstein SE, Mwapasa V, et al. Development of a Blended Learning Approach to Delivering HIV-Assisted Contact Tracing in Malawi: Applied Theory and Formative Research. JMIR Form Res. 2022;6(4):e32899.

Government of Malawi National Statistical Office. 2018 Malawi population and housing census : main report. 2019.  https://malawi.unfpa.org/sites/default/files/resource-pdf/2018%20Malawi%20Population%20and%20Housing%20Census%20Main%20Report%20%281%29.pdf . Accessed 19 April 2024. 

Wolock TM, Flaxman S, Chimpandule T, Mbiriyawanda S, Jahn A, Nyirenda R, et al. Subnational HIV incidence trends in Malawi: large, heterogeneous declines across space. medRxiv (PREPRINT). 2023. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9915821/ . Accessed 19 Apr 2024.

World Health Organization (WHO). Medical doctors (per 10,000). 2020. https://www.who.int/data/gho/data/indicators/indicator-details/GHO/medical-doctors-(per-10-000-population . Accessed 19 Apr 2024.

Flick RJ, Simon KR, Nyirenda R, Namachapa K, Hosseinipour MC, Schooley A, et al. The HIV diagnostic assistant: early findings from a novel HIV testing cadre in Malawi. AIDS. 2019;33(7):1215–24.

Kim MH, Ahmed S, Buck WC, Preidis GA, Hosseinipour MC, Bhalakia A, et al. The Tingathe programme: a pilot intervention using community health workers to create a continuum of care in the prevention of mother to child transmission of HIV (PMTCT) cascade of services in Malawi. J Int AIDS Soc. 2012;15(Suppl 2):17389.

Simon KR, Hartig M, Abrams EJ, Wetzel E, Ahmed S, Chester E, et al. The Tingathe Surge: a multi-strategy approach to accelerate HIV case finding in Malawi. Public Health Action. 2019;9(3):128–34.

Ahmed S, Kim MH, Dave AC, Sabelli R, Kanjelo K, Preidis GA, et al. Improved identification and enrolment into care of HIV-exposed and -infected infants and children following a community health worker intervention in Lilongwe, Malawi. J Int AIDS Soc. 2015;18(1):19305.

Tembo TA, Mollan K, Simon K, Rutstein S, Chitani MJ, Saha PT, et al. Does a blended learning implementation package enhance HIV index case testing in Malawi? A protocol for a cluster randomised controlled trial. BMJ Open. 2024;14(1):e077706.

Nyblade L, Mingkwan P, Stockton MA. Stigma reduction: an essential ingredient to ending AIDS by 2030. Lancet HIV. 2021;8(2):e106–13.

Nyblade L, Stockton M, Nyato D, Wamoyi J. Perceived, anticipated and experienced stigma: exploring manifestations and implications for young people’s sexual and reproductive health and access to care in North-Western Tanzania. Cult Health Sex. 2017;19(10):1092–107.

Tembo TA, Simon KR, Kim MH, Chikoti C, Huffstetler HE, Ahmed S, et al. Pilot-Testing a Blended Learning Package for Health Care Workers to Improve Index Testing Services in Southern Malawi: An Implementation Science Study. J Acquir Immune Defic Syndr. 2021;88(5):470–6.

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Acknowledgements

We are grateful to the Malawian health care workers who shared their experiences through in-depth interviews, as well as to the study team members in Malawi and the United States for their contributions.

Research reported in this publication was funded by the National Institutes of Health (R01 MH124526) with support from the University of North Carolina at Chapel Hill Center for AIDS Research (P30 AI50410) and the Fogarty International Center of the National Institutes of Health (D43 TW010060 and R01 MH115793-04). The funders had no role in trial design, data collection and analysis, decision to publish or preparation of the manuscript.

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Caroline J. Meek

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Caroline J. Meek, Milenka Jean-Baptiste, Jiayu Wang, Clare Barrington, Vivian F. Go & Nora E. Rosenberg

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Tiwonge E. Mbeya Munkhondya

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Mtisunge Mphande, Tapiwa A. Tembo, Mike Chitani, Dhrutika Vansia, Caroline Kumbuyo, Katherine R. Simon & Maria H. Kim

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TAT, KRS, SER, MHK, VFG, and NER contributed to overall study conceptualization, with CJM, CB, and NER leading conceptualization of the analysis presented in this study. Material preparation and data collection were performed by TEMM, MM, TAT, MC, and CK. Analysis was led by CJM with support from MJB and DV. The first draft of the manuscript was written by CJM with consultation from NER, TEMM, MM, TAT, MJB, and DV. JW provided quantitative analysis support for participant characteristics. All authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

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Meek, C.J., Munkhondya, T.E.M., Mphande, M. et al. Examining the feasibility of assisted index case testing for HIV case-finding: a qualitative analysis of barriers and facilitators to implementation in Malawi. BMC Health Serv Res 24 , 606 (2024). https://doi.org/10.1186/s12913-024-10988-z

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Cinco de Mayo 2024: History, meaning and why we celebrate it

On cinco de mayo, take some time to learn about the history and meaning of this day of remembrance — and how and where it’s celebrated now, by nbc staff • published may 3, 2024.

Sunday marks the 162nd anniversary of Cinco de Mayo. While it's a relatively minor holiday in Mexico , the annual fiesta is an excuse in the United States to indulge in margaritas,  cervezas  (beer), guacamole and tacos.

But what exactly does Cinco de Mayo celebrate? Brush up on its rich history and modern traditions below.

Is Cinco de Mayo the same as Mexican Independence Day?

Many people tend to confuse Cinco de Mayo with “Día de la Independencia,” or Mexico’s Independence Day. That holiday, also known as “El Grito de la Independencia,” is actually observed on Sept. 16, when Mexico celebrates its independence from Spain.

Get Southern California news, weather forecasts and entertainment stories to your inbox. Sign up for NBC LA newsletters.

Why Is Cinco de Mayo celebrated?

In Mexico, Cinco de Mayo is not a celebration but a day of remembrance, commemorating Mexico’s victory over the French during the 1862 Battle of Puebla. An outnumbered Mexican army — led by Ignacio Zaragoza, a 33-year-old Texan from Goliad — defeated the invading French forces at the small town of Puebla de Los Angeles during the Franco-Mexico War.

The retreat of the French troops represented a great victory for the people of Mexico, symbolizing the country’s ability to defend its sovereignty against a powerful foreign nation.

What is the history behind Cinco de Mayo?

The first American Cinco de Mayo celebrations date back to the 1860s, when Mexicans living in California commemorated the victory over France in Puebla. At that time, the United States was embroiled in a Civil War. News of the underdog Mexican army beating back Napoleon III’s forces gave new strength to California’s Latinos, who sought to stop the advances of the Confederate army.

"For Mexicans in the U.S., the Civil War and the French invasion of Mexico were like one war with two fronts. They were concerned about France, which sided with the Confederacy, being on America's doorstep,” David Hayes-Bautista, professor of medicine and director of the Center for the Study of Latino Health and Culture at the University of California Los Angeles,  told NBC News .

The tradition of celebrating Cinco de Mayo has continued in Los Angeles without interruption since 1862, according to Hayes-Bautista, although the original reason and the history have gotten lost.

Mexican Independence Day is September 16 — NOT May 5!

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Why did cinco de mayo become popular in the us.

About a century later, Chicano activists rediscovered the holiday and embraced it as a symbol of ethnic pride. But the party-filled Cinco de Mayo that Americans celebrate today didn’t become popular until U.S. beer companies began targeting the Spanish-speaking population in the 1970s and 1980s, Jose Alamillo, a California professor of Chicano studies,  told Time.com .

Today, Cinco de Mayo in the U.S. is primarily a celebration of Mexican-American culture, with the largest event in Los Angeles.

What are some authentic Cinco de Mayo recipes?

If you want to do Cinco de Mayo right, put down the taco,  por favor . Contrary to popular belief, you won’t find ground beef tacos, nachos and frozen margaritas in Mexico on Cinco de Mayo. The traditional dish eaten in the town of Puebla on their big holiday is mole poblano,  according to the Smithsonian.  

Invented in the late 17th century, mole is a thick sauce made with chocolate, chiles, nuts and other spices. Traditionally, the sauce covers succulent chicken or turkey.

While mole recipes differ from family to family and by state in Mexico, they all have one thing in common: mole represents the heart of Mexican culture because it’s served on the most special of occasions, including weddings, baby showers and holidays.

To make this classic Mexican sauce, try this TODAY recipe from Lourdes Juarez.

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Lawsuits test Tesla claim that drivers are solely responsible for crashes

Multiple civil cases — and a federal investigation — contend that Tesla’s technology invites ‘drivers to overly trust the automation’

SAN FRANCISCO — As CEO Elon Musk stakes the future of Tesla on autonomous driving, lawyers from California to Florida are picking apart the company’s most common driver assistance technology in painstaking detail, arguing that Autopilot is not safe for widespread use by the public.

At least eight lawsuits headed to trial in the coming year — including two that haven’t been previously reported — involve fatal or otherwise serious crashes that occurred while the driver was allegedly relying on Autopilot. The complaints argue that Tesla exaggerated the capabilities of the feature, which controls steering, speed and other actions typically left to the driver. As a result, the lawsuits claim, the company created a false sense of complacency that led the drivers to tragedy.

Evidence emerging in the cases — including dash-cam video obtained by The Washington Post — offers sometimes-shocking details: In Phoenix, a woman allegedly relying on Autopilot plows into a disabled car and is then struck and killed by another vehicle after exiting her Tesla. In Tennessee, an intoxicated man allegedly using Autopilot drives down the wrong side of the road for several minutes before barreling into an oncoming car, killing the 20-year-old inside.

Tesla maintains that it is not liable for the crashes because the driver is ultimately in control of the vehicle. But that contention is coming under increasing pressure, including from federal regulators. Late Thursday, the National Highway Traffic Safety Administration (NHTSA) launched a new review of Autopilot, signaling concern that a December recall failed to significantly improve misuse of the technology and that drivers are misled into thinking the “automation has greater capabilities than it does.”

Meanwhile, in a twist, Tesla this month settled a high-profile case in Northern California that claimed Autopilot played a role in the fatal crash of an Apple engineer, Walter Huang. The company’s decision to settle with Huang’s family — along with a ruling from a Florida judge concluding that Tesla had “knowledge” that its technology was “flawed” under certain conditions — is giving fresh momentum to cases once seen as long shots, legal experts said.

“A reckoning is coming as more and more of these cases are going to see the light of a jury trial,” said Brett Schreiber, a lawyer with Singleton Schreiber who is representing the family of Jovani Maldonado, 15, who was killed in Northern California when a Tesla in Autopilot rear-ended his family’s pickup truck in 2019.

Tesla did not respond to multiple requests for comment on the lawsuits.

The outcomes of the cases could be critical for the company. Tesla’s stock has lost more than a third of its value since the beginning of the year. Last week, the company reported a steeper-than-expected 55 percent plunge in first-quarter profit as it struggles with falling sales of electric vehicles and stiff competition from China. To allay investors’ concerns, Musk has made lofty promises about launching a fully autonomous “robotaxi” in August. Soon, he said during Tuesday’s earnings call, driving a car will be like riding an elevator: You get on and get out at your destination.

“We should be thought of as an AI or robotics company,” Musk told investors. “If somebody doesn’t believe Tesla is going to solve autonomy, I think they should not be an investor in the company. But we will.”

Meanwhile, the company has defended itself in court documents by arguing that its user manuals and on-screen warnings make “extremely clear” that drivers must be fully in control while using Autopilot. Many of the upcoming court cases involve driver distraction or impairment.

Autopilot “is not a self-driving technology and does not replace the driver,” Tesla said in response to a 2020 case filed in Florida. “The driver can and must still brake, accelerate and steer just as if the system is not engaged.”

But the Huang case also potentially involved a distracted driver: Huang was allegedly playing a video game when his Tesla plowed into a highway barrier in 2018. Tesla has not said why it decided to settle the lawsuit, and details of the settlement have not been disclosed in court documents.

More fatal crash details emerge

Meanwhile, federal regulators appear increasingly sympathetic to claims that Tesla oversells its technology and misleads drivers. Even the decision to call the software Autopilot “elicits the idea of drivers not being in control” and invites “drivers to overly trust the automation,” NHTSA said Thursday, revealing that a two-year investigation into Autopilot had identified 467 crashes linked to the technology, 13 of them fatal.

NHTSA did not offer specific information about those crashes. But two fatal crashes from 2022 are detailed in lawsuits that have not been previously reported.

In Phoenix, Iwanda Mitchell, 49, was driving a Tesla in May 2022 when she struck a Toyota Camry that had stalled on the highway, according to court documents and dash-cam footage obtained by The Post. According to the Mitchell family’s lawyer, Jonathan Michaels with MLG Attorneys at Law, Autopilot and the car’s other features — including forward collision warning and automatic emergency braking — failed to result in Mitchell’s Tesla taking evasive action and prevent the vehicle from barreling into the stalled sedan.

Mitchell was then struck and killed by an oncoming vehicle when she got out of her car.

Tesla did not respond to a request for comment regarding this case. In response to the complaint in January 2024, Tesla said it denies the allegation and “has not yet had an opportunity to inspect” Mitchell’s vehicle.

About a month later in Sumner County, Tenn., Jose Roman Jaramillo Cortez drank two beers and three tequila shots after his shift at a local restaurant, and then hopped into his Tesla Model 3, court documents say. He plugged his address into the Tesla’s GPS and flicked on Autopilot, it said.

According to the lawsuit filed in June 2023 and dash-cam footage obtained by The Post, the car then pulled onto the wrong side of the road. After driving south in a northbound lane for several minutes, the Tesla rammed into a car driven by Christian Malone, 20, who died from the impact. In its response to the complaint, Tesla said “the crash was caused by the negligence and/or recklessness of the driver.”

Trial dates for both cases will be set later next year, Michaels said.

In another case — set for trial in November in Key Largo, Fla. — a Tesla in Autopilot allegedly failed to detect an approaching T-intersection while its driver searched for a dropped phone. The Tesla barreled through flashing lights and a physical barricade before crashing into a vehicle parked on the side of the road, killing a woman and seriously injuring a man.

In court documents, Tesla has argued that the driver was ultimately responsible for the trajectory of the car. Tesla also states in user manuals that Autopilot may not operate as intended “when unable to accurately determine lane markings” or when “bright light is interfering with the camera’s view.”

When these cases head to trial, juries may be asked to consider whether Tesla’s many driver warnings are sufficient to spare the company from liability. Ross Gerber, CEO of Gerber Kawasaki Wealth and Investment Management, said the last thing the company needs is a highly publicized courtroom battle that focuses attention on such questions.

At a trial, “the defense would dig into the weeds … and it would become very clear that the perception of the Autopilot software was very different from the reality,” Gerber said. “Every day would be a headline, and it would be embarrassing.”

So far, Tesla has faced a jury only once over the role Autopilot may have played in a fatal crash. In Riverside, Calif., last year, a jury heard the case of Micah Lee, 37, who was allegedly using Autopilot when his Tesla Model 3 suddenly veered off the highway at 65 mph, crashed into a palm tree and burst into flames. Lee died of his injuries, while his fiancée and her son were severely injured.

Because of the extensive damage to the car, Tesla said it could not be proved that Autopilot was engaged at the time of the crash. During the trial, Michael Carey, the attorney for Tesla, argued the technology was not at fault, and that the crash “is classic human error.” According to a toxicology report taken after the crash, Lee had alcohol in his system but it was within the legal limit in California.

“This case is not about Autopilot. Autopilot didn’t cause the crash,” Carey said during opening statements. “This is a bad crash with bad injuries and may have resulted from bad mistakes — but you can’t blame the car company when that happens. This is a good car with a good design.”

Ultimately, Tesla’s arguments prevailed, and a jury found the company not liable.

But the company appears to face headwinds in some other cases. Last year, Florida Circuit Judge Reid Scott upheld a plaintiff’s request to seek punitive damages in a case concerning a fatal crash in Delray Beach, Fla., in 2019 when Jeremy Banner and his Tesla in Autopilot failed to register a semi truck crossing its path. The car plowed under the truck at full speed, killing Banner on impact.

In the ruling, Scott said the family’s lawyers “sufficiently” presented evidence to reasonably seek punitive damages at trial, which could run millions of dollars.

The plaintiffs’ evidence included that Tesla “knew the vehicle at issue had a defective Autopilot system,” according to the order. Citing other fatal crashes involving Autopilot, Scott wrote that there is a “genuine” dispute over whether Tesla “created a foreseeable zone of risk that posed a general threat of harm to others.”

Tesla’s appeal of the ruling is pending.

Change in defense strategy?

As the spate of lawsuits churns forward, Tesla has shown a fresh willingness to settle such cases — despite Musk’s vow on Twitter in 2022 to never settle “an unjust case against us even if we will probably lose.”

In addition to settling the Huang case, Tesla “indicated” that it was open to discussing a potential settlement in the Riverside case as it was being presented to a jury last fall, said Michaels, the MLG lawyer who represented Lee’s family.

The month-long trial featured testimony from an accident reconstructionist, a top engineer at Tesla and a paramedic who responded to the crash and said it was among the most horrific accidents he had ever seen. Michaels said he declined to engage in settlement talks because he wanted to continue to “make this a really public issue.” He said he also “did not have confidence in our ability to come to an agreeable amount.”

Tesla and its lawyer in the case, Carey, did not respond to a request for comment.

After four days of deliberations, the jury decided the case in Tesla’s favor.

Though he lost, Michaels said the trial attracted media attention and gave other lawyers with cases against Tesla insight into the company’s defense strategy. Plus, he said, his law firm’s phone has since been blowing up with potential clients.

“We walked away from guaranteed money,” Michaels said, “but that wasn’t what it was about.”

The Effect of HIV on the Association of Hyperglycaemia and Active Tuberculosis in Zambia, a Case–Control Study

• Research Article
• Open access
• Published: 07 May 2024

Cite this article

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• Sarah Lou Bailey   ORCID: orcid.org/0000-0002-8425-3472 1 , 2 ,
• Sian Floyd 1 ,
• Maina Cheeba-Lengwe 2 ,
• Kwitaka Maluzi 2 ,
• Kasanda Chiwele-Kangololo 2 ,
• Deborah Kaluba-Milimo 2 ,
• Modupe Amofa-Sekyi 2 ,
• John S. Yudkin 3 ,
• Peter Godfrey-Faussett 1 &
• Helen Ayles 1 , 2  

To determine if HIV modifies the association between hyperglycaemia and active tuberculosis in Lusaka, Zambia.

A case–control study among newly—diagnosed adult tuberculosis cases and population controls in three areas of Lusaka. Hyperglycaemia is determined by random blood glucose (RBG) concentration measured at the time of recruitment; active tuberculosis disease by clinical diagnosis, and HIV status by serological result. Multivariable logistic regression is used to explore the primary association and effect modification by HIV.

The prevalence of RBG concentration ≥ 11.1 mmol/L among 3843 tuberculosis cases was 1.4% and among 6977 controls was 1.5%. Overall, the adjusted odds ratio of active tuberculosis was 1.60 (95% CI 0.91–2.82) comparing those with RBG concentration ≥ 11.1– < 11.1 mmol/L. The corresponding adjusted odds ratio among those with and without HIV was 5.47 (95% CI 1.29–23.21) and 1.17 (95% CI 0.61–2.27) respectively; p -value for effect modification by HIV = 0.042. On subgroup analysis, the adjusted odds ratio of smear/Xpert-positive tuberculosis was 2.97 (95% CI 1.49–5.90) comparing RBG concentration ≥ 11.1– < 11.1 mmol/L.

Conclusions

Overall, no evidence of association between hyperglycaemia and active tuberculosis was found, though among those with HIV and/or smear/Xpert-positive tuberculosis there was evidence of association. Differentiation of hyperglycaemia caused by diabetes mellitus and stress-induced hyperglycaemia secondary to tuberculosis infection is important for a better understanding of these findings.

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1 Introduction

HIV and hyperglycaemia are independently associated with an increased risk of active tuberculosis (TB) [ 1 , 2 ]. However, the dual effect of HIV and hyperglycaemia on the risk of developing TB disease is unclear. A systematic review [ 3 ] identified two prior studies investigating the effect of HIV on the association between hyperglycaemia or diabetes mellitus (DM) and tuberculosis [ 4 , 5 ]. Another systematic review [ 6 ] identified a further two studies that stratified their estimates by HIV status [ 7 , 8 ], and we identified one additional study that has investigated these associations [ 9 ]. The findings differed for each study depending on the analysis strategy and the method used to measure glycaemia.

Global guidelines exist for the care and control of co-existing diabetes mellitus and tuberculosis, but these were developed using evidence from studies largely based in low HIV prevalence settings [ 2 , 10 , 11 ]. If HIV does modify the association, this could lead to a different overall association in areas of high HIV prevalence. Understanding this could allow location-specific guidelines to be developed and implemented, to optimise the care and control of DM and TB.

This study aims to determine whether HIV modifies the association between hyperglycaemia and active TB in Lusaka, Zambia.

2.1 Study Design and Setting

This unmatched case–control study took place among adults in three urban communities in Lusaka, Zambia. Each community has a high incidence of TB and a high prevalence of HIV. The exposure of interest was hyperglycaemia and the outcome was diagnosed active TB disease.

Consecutive newly—diagnosed TB cases who had not yet started TB treatment or were within 2 days of starting TB treatment were recruited from National TB Programme government clinics between September 2013 and September 2015. A TB case was defined as any person presenting to a TB clinic with a clinical diagnosis of TB (pulmonary or extra-pulmonary) with or without microbiological confirmation of TB and prescribed a full course of antitubercular chemotherapy [ 12 ]. This is the definition used in the study clinics—use of this aimed to facilitate translation of results to the clinical setting. At the time of data collection the study clinics were using sputum smear, Xpert MTB/RIF or both to diagnose TB, depending on the availability of reagents and equipment. Exclusion criteria for cases were age < 18 years, commenced TB treatment > 2 days prior to recruitment or inability to give consent due to disability/incapacitation. All eligible cases were identified in the TB clinic and invited to participate during a routine clinic attendance.

2.3 Controls

Unmatched controls were recruited between January and December 2010 as part of a cross-sectional survey that measured prevalent TB for a large cluster randomised trial (the ZAMSTAR trial) [ 13 , 14 ]. They were sampled randomly from all adults living in the catchment areas of the clinics, using a 2-stage cluster sampling technique within each community. Exclusion criteria for controls were age < 18 years, refusal to submit a respiratory sample, diagnosed TB at the time of the survey (culture positive sputum for Mycobacterium tuberculosis ), currently on treatment for TB at the time of the survey (self-report), inability to give consent due to disability/incapacitation or any persons living in institutional settings. All eligible controls were recruited in their homes.

2.4 Data Collection

Glycaemia was determined by random capillary blood glucose (RBG) sampling measured at the time of recruitment. An Optium Xceed point-of-care glucometer was used for controls and an Accu-Chek Aviva point-of-care glucometer was used for cases. Manufacture of the former had been discontinued between the start of data collection for controls and cases so the Aviva was identified as being a similar and well-performing option instead. The time of last oral intake (excluding water) was recorded. RBG concentration was measured during daylight hours and throughout the year. Research staff were trained on the use of the glucometers and were required to undergo proficiency testing. Standardised control solution was used for performance checks on test strips and meters. The validity of glucose measurement was assessed for the Aviva glucometer, giving an intraclass correlation of 0.996 (95% CI 0.991–0.999) for intra-operator variability and 0.983 (95% CI 0.954–0.995) for inter-operator variability. All research assistants contributed to this assessment, using known normoglycaemic volunteers and a standard hyperglycaemic specimen. For intra-operator variability each research assistant repeated the test 5 consecutive times on 13 subjects/specimens. For inter-operator variability research assistants each performed the test on a single subject/specimen in the same place at the same time for 7 subjects/specimens.

For a stratified subset of cases, fasting blood glucose (FBG) concentration was measured within 3 days of commencement of TB treatment and again 3 months later, to indicate if the hyperglycaemia was transient or persistent.

HIV was measured using point-of-care rapid blood-based kits. Determine™ HIV-1/2 was used as the first line test and if positive Uni-Gold™ HIV was used as a confirmatory test. Self-reported use of antiretroviral therapy (ART) was recorded for individuals who were already known to be infected with HIV.

Participants who tested positive for HIV or were identified to have abnormal blood glucose were referred to local healthcare facilities for management.

In order to adjust for potential confounding factors, a structured questionnaire was used to obtain information on age, sex, smoking history, household socio-economic position and education level. Height, weight and waist circumference were measured using standardised methods.

Data were electronically entered directly onto personal digital assistants by research assistants at the time of data collection, using pre-programmed questionnaires and result sheets with error and range checks. All data were downloaded into a SQL (structured query language) database and exported into Stata.

All questions, measurement tools (HIV testing kits but not glucometers) and test standard operating procedures were identical for cases and controls.

Each participant was required to give written informed consent. Ethics approval was granted from the London School of Hygiene and Tropical Medicine Ethics Committee and the University of Zambia Biomedical Research Ethics Committee.

2.6 Statistical Analysis

The study sample size was calculated to give sufficient power for determination of effect modification by HIV. Principal components analysis was used to create a measure of household socio-economic position. Hyperglycaemia was initially examined with RBG concentration as an ordered categorical variable. We then used the RBG cut-off 11.1 mmol/L to explore hyperglycaemia as a binary variable.

Unadjusted and adjusted odds ratios of the association between hyperglycaemia and active TB were estimated using logistic regression analysis. Interaction terms were used to assess for effect modification by HIV, adjusting for variables considered a priori as potential confounding factors.

Restriction of the outcome definition separately to sputum smear-positive or Xpert MTB/RIF positive tuberculosis, smear-negative and Xpert MTB/RIF negative pulmonary TB, and extrapulmonary TB were identified a priori for sub-group analyses, as was exploration of the impact of ART use on HIV as an effect modifier.

Potential bias was assessed using chi-squared tests of association of glycaemia with time of last oral intake before measurement and time of day of measurement of RBG concentration, each comparing cases to controls. Intra- and inter-operator variability were assessed for absolute agreement using a one-way and a two-way random-effects model respectively [ 15 ].

There were 3909 eligible TB cases identified, of whom 3843 (98.3%) consented to participate. There were 11,271 adults randomly selected from the three study communities and enrolled in the ZAMSTAR survey, of whom 6977 (61.9%) were eligible to be control participants for this study (Fig.  1 ).

Number and flow of cases and controls

The characteristics of participants are shown in Table  1 . Among cases and controls 1.4% and 1.5% respectively had a RBG concentration ≥ 11.1 mmol/L (Table  1 ). 65% of cases and 18% of controls were living with HIV.

Comparing participants with RBG ≥ 11.1 mmol/L to those with RBG < 11.1 mmol/L, the unadjusted odds ratio of TB was 0.91 (95% CI 0.65–1.28). When analysed with RBG concentration as an ordered categorical variable, there was evidence of an association between hyperglycaemia and tuberculosis, but there was strong evidence that the association did not follow a linear trend. We therefore did not examine the association with RBG concentration as a continuous variable. On unadjusted analysis there was no evidence to suggest that the odds of TB for the effect of hyperglycaemia differed between individuals infected and uninfected with HIV (Table  1 ).

The adjusted odds of TB was 1.60 times higher in those with RBG ≥ 11.1 mmol/L compared to those with RBG < 11.1 mmol/L (95% CI 0.91–2.82), adjusting for the effect of age, gender, education, socioeconomic position, body mass index, smoking history and community. As a categorical variable there remained strong evidence of a non-linear association. Among individuals with HIV, the adjusted odds of TB was 5.47 times higher in those with RBG ≥ 11.1 mmol/L compared to those with RBG < 11.1 mmol/L (95% CI 1.29–23.21). Among individuals without HIV, the adjusted odds of TB was 1.17 times higher for the same comparison (95% CI 0.61–2.27). The p -value for interaction was 0.042. The main confounding factors were age, sex and body mass index.

When the analysis was restricted to separate TB categories, there was evidence of association between hyperglycaemia and sputum smear/Xpert-positive tuberculosis, and this association was stronger in individuals infected than uninfected with HIV ( p -value for interaction = 0.028, Table  2 ).

Among individuals infected with HIV, 36.7% of cases and 21.2% of controls were taking ART. There was evidence of association between hyperglycaemia and active tuberculosis among individuals who were HIV-positive and not currently taking ART, but not among individuals who were HIV-positive and taking ART (Table  3 ).

FBG concentration was measured in 232 participants with TB at baseline and 3 months later. Nine participants had hyperglycaemia at baseline (FBG ≥ 7.0 mmol/L) and 4 (44.4%) of these had persistent hyperglycaemia 3 months later. Three (75%) participants with persistent hyperglycaemia were uninfected with HIV. Four (80%) participants with transient hyperglycaemia were infected with HIV.

Participants reported the time of last oral intake prior to measurement of RBG concentration to be a mean of 4.9 h (standard deviation 4.6 h). There was no evidence of a difference in time (< or ≥ 6 h) of last oral intake between participants with RBG < and ≥ 11.1 mmol/L ( p  = 0.815), nor between individuals with and without TB ( p  = 0.793). There was no evidence of a difference in the time (hour) of measurement between participants with RBG < and ≥ 11.1 mmol/L ( p  = 0.832).

4 Discussion

In this case–control study in Lusaka, Zambia, we found no evidence of association between hyperglycaemia and active tuberculosis, except for when TB was restricted to individuals with smear/Xpert-positive pulmonary TB. There was evidence of effect modification by HIV for the association between hyperglycaemia and active TB. When adjusted for confounding factors, the association was stronger among individuals infected with HIV than among uninfected individuals.

When analysed as an ordered categorical variable with pre-defined categories, there was evidence of a non-linear association between hyperglycaemia and tuberculosis in our study population, as individuals with RBG concentration 7.0–8.9 mmol/L had a lower odds of TB than individuals with lower or higher RBG concentration ( p  < 0.001). This was an unexpected finding and may be due to chance as there is no biological reason to explain this pattern.

Although our primary association findings are not in keeping with the findings of the most recent systematic review, which reported a pooled odds ratio of 2.77 for the association between hyperglycaemia and tuberculosis in Africa [ 6 ], they do mirror the findings of some studies in nearby communities in Guinea-Bissau [ 16 ], South Africa [ 9 ] and Tanzania [ 5 ]. Boillat-Blanco et al. in Tanzania found a positive association between hyperglycaemia and tuberculosis at the time of TB treatment initiation, but the association disappeared when measurement of diabetes was repeated 5 months after TB treatment initiation, suggesting that the initial positive association was due to an increase in stress-induced hyperglycaemia among TB cases secondary to acute TB infection rather than due to DM [ 5 ].

Our findings of a stronger association among HIV infected than uninfected individuals are in keeping with Oni’s findings [ 9 ] and could suggest that HIV and hyperglycaemia work synergistically to increase an individual’s risk of TB. Another possible explanation is an increase in stress-induced hyperglycaemia among newly—diagnosed TB cases, as seen in Boillat-Blanco’s study [ 5 ]. It is plausible that the most unwell newly diagnosed TB cases, and therefore the most likely to have stress-induced hyperglycaemia, could be found among individuals with HIV and smear/Xpert-positive pulmonary TB.

This study used a single RBG concentration to measure hyperglycaemia. This method is simple, quick, and minimises participant inconvenience, so is ideal for use in large community-based studies. However, use of this method is also a limitation of the study as it is not as sensitive for diabetes diagnosis as other glycaemia measures. We chose to go ahead with using this method because all other methods would have been challenging to perform on a large scale in the community and could have led to selection bias if considered to be unacceptable to healthy control participants. An alternative could have been the use of a clinic-based control population as a proxy to community controls, but this too could have led to selection bias. Assessing shifts in proportions of glucose concentration between cases and controls in addition to using a binary cut-off definition of hyperglycaemia has limited potential misclassification error that could exist with the use of this less sensitive measurement.

Our assessment of intra- and inter-operator variability suggests that measurement of point-of-care RBG among cases in this study was consistent and valid. We explored the possibility of also undertaking laboratory validation of glucose measurements but this was not possible in our setting, as point-of-care glucose measurement is the principal method for measuring glycaemia in the community and centrally. The laboratory alternatives were therefore not equipped to offer a reliable benchmark. This lack of laboratory validation of glucose measurements is a limitation of our study. Finding a solution to this challenge in our setting would be valuable for future similar studies.

The temporal space between recruitment of controls and cases is another potential source of bias and limitation of our study, though the study communities have relatively stable populations and to our knowledge there were no major changes in the prevalence of hyperglycaemia, diabetes or HIV, or the incidence of TB during the study period. Any potential change in use of ART is unlikely to have had a major impact on hyperglycaemia, as protease inhibitors—which are associated with the development of glucose disorders [ 17 ]—are not included among first-line ART regimes in Zambia [ 18 ]. This is supported by exploration of the impact of ART on the associations studied. Any bias introduced by the recruitment gap is therefore likely to have been, at the most, minimal. However, an unforeseen consequence of the gap was the discontinuation of the initial glucometer model used for control participants. It was therefore necessary to use a different model for case participants. We chose a similar model to minimise any potential variability between models and so any difference in measurement of glycaemia is likely to be small rather than large.

Complete data were unavailable for analysis for a substantial proportion of control participants, reasons for which are discussed elsewhere [ 8 , 19 , 20 ]. This has resulted in reduced study power but is unlikely to have introduced bias to our study results.

Control participants are representative of the general population and case participants are representative of TB cases in each community. The findings from this study are therefore generalizable to the study communities and likely also to communities elsewhere in sub-Saharan Africa with similar high incidence of TB and high prevalence of HIV.

5 Conclusions

Overall, no evidence of association between hyperglycaemia and active tuberculosis was found in this study population, though among those with HIV and those with smear/Xpert-positive pulmonary TB there was evidence of an association. Differentiation of hyperglycaemia caused by diabetes mellitus and stress-induced hyperglycaemia secondary to tuberculosis infection is important to understand these data further. Future similar studies should aim to minimise the potential sources of bias that we have identified in our study.

Availability of Data and Materials

The dataset generated and analysed during the current study is not publicly available because it could be possible to identify individuals from the dataset despite the dataset being anonymised.

Abbreviations

Antiretroviral therapy

Confidence interval

• Diabetes mellitus

Fasting blood glucose

Human immunodeficiency virus

Random blood glucose

Structured query language

• Tuberculosis

Aaron L, et al. Tuberculosis in HIV-infected patients: a comprehensive review. Clin Microbiol Infect. 2004;10(5):388–98.

Article   CAS   PubMed   Google Scholar  

Jeon CY, Murray MB. Diabetes mellitus increases the risk of active tuberculosis: a systematic review of 13 observational studies. PLoS Med. 2008;5(7):e152.

Article   PubMed   PubMed Central   Google Scholar  

Bailey SL, Ayles H. Association between diabetes mellitus and active tuberculosis in Africa and the effect of HIV. Trop Med Int Health. 2017;22(3):261–8.

Article   CAS   PubMed   PubMed Central   Google Scholar  

Faurholt-Jepsen D, et al. Diabetes is a risk factor for pulmonary tuberculosis: a case-control study from Mwanza, Tanzania. PLoS ONE. 2011;6(8):e24215.

Boillat-Blanco N, et al. Transient hyperglycemia in patients with tuberculosis in tanzania: implications for diabetes screening algorithms. J Infect Dis. 2016;213(7):1163–72.

Obels I, et al. Tuberculosis risk among people with diabetes mellitus in Sub-Saharan Africa: a systematic review. Trop Med Int Health. 2022;27(4):369–86.

Kubjane M, et al. Tuberculosis, human immunodeficiency virus, and the association with transient hyperglycemia in Periurban South Africa. Clin Infect Dis. 2020;71(4):1080–8.

Article   PubMed   Google Scholar  

Bailey SL, et al. The association of hyperglycaemia with prevalent tuberculosis: a population-based cross-sectional study. BMC Infect Dis. 2016;16(1):733.

Oni T, et al. Trilateral overlap of tuberculosis, diabetes and HIV-1 in a high-burden African setting: implications for TB control. Eur Respir J. 2017;50(1):1.

Article   Google Scholar  

Jeon CY, et al. Bi-directional screening for tuberculosis and diabetes: a systematic review. Trop Med Int Health. 2010;15(11):1300–14.

WHO & IUTLD. Collaborative framework for care and control of tuberculosis and diabetes. Geneva: World Health Organization; 2011.

Google Scholar  

World Health Organization, Treatment of tuberculosis: guidelines . 4th ed. 2010, Geneva, Switzerland: World Health Organization.

Ayles HM, et al. ZAMSTAR, The Zambia South Africa TB and HIV reduction study: design of a 2 × 2 factorial community randomized trial. Trials. 2008;9:63.

Ayles H, et al. Effect of household and community interventions on the burden of tuberculosis in southern Africa: the ZAMSTAR community-randomised trial. Lancet. 2013;2013:1.

Koo TK, Li MY. A guideline of selecting and reporting intraclass correlation coefficients for reliability research. J Chiropr Med. 2016;15(2):155–63.

Haraldsdottir TL, et al. Diabetes mellitus prevalence in tuberculosis patients and the background population in Guinea-Bissau: a disease burden study from the capital Bissau. Trans R Soc Trop Med Hyg. 2015;109(6):400–7.

Larson R, et al. Disorders of glucose metabolism in the context of human immunodeficiency virus infection. J Am Acad Nurse Pract. 2006;18(3):92–103.

Republic of Zambia Ministry of Health, Zambia Consolidated Guidelines for Treatment and Prevention of HIV Infection . 2014, The Government of Zambia: Lusaka, Zambia.

Ayles H, et al. Effect of household and community interventions on the burden of tuberculosis in southern Africa: the ZAMSTAR community-randomised trial. Lancet. 2013;382(9899):1183–94.

Bailey SL, et al. Diabetes mellitus in Zambia and the Western Cape province of South Africa: prevalence, risk factors, diagnosis and management. Diabetes Res Clin Pract. 2016;118:1–11.

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Acknowledgements

We thank all the members of all study teams who contributed to data collection. We thank the Zambian Ministry of Health, the Zambian National TB Programme, the Lusaka District Medical Officer and all health facility staff for allowing us to work in the TB clinics. The work presented in this paper contributed to SLB’s Ph.D. work, the thesis for which can be accessed via an open access repository ( https://researchonline.lshtm.ac.uk/id/eprint/4646636/ ).

SLB was supported by a Wellcome Trust Clinical Ph.D. Fellowship (100141/Z/12/Z), and this study was funded by the fellowship. The contents of this manuscript are solely the responsibility of the authors and do not necessarily represent the official views of the Wellcome Trust.

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Sarah Lou Bailey, Sian Floyd, Peter Godfrey-Faussett & Helen Ayles

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Sarah Lou Bailey, Maina Cheeba-Lengwe, Kwitaka Maluzi, Kasanda Chiwele-Kangololo, Deborah Kaluba-Milimo, Modupe Amofa-Sekyi & Helen Ayles

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All authors contributed to initial study concept and study design. SLB and HA oversaw participant recruitment and data collection. SLB performed the data analysis. SLB wrote initial drafts and all authors contributed to final editing of the paper.

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Bailey, S.L., Floyd, S., Cheeba-Lengwe, M. et al. The Effect of HIV on the Association of Hyperglycaemia and Active Tuberculosis in Zambia, a Case–Control Study. J Epidemiol Glob Health (2024). https://doi.org/10.1007/s44197-024-00236-2

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DOI : https://doi.org/10.1007/s44197-024-00236-2

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• Is tooth extraction as proxy for periodontal disease related to the development of RA? Lessons from a longitudinal study in the at-risk stage of clinically suspect arthralgia
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• http://orcid.org/0000-0001-5953-6844 Sarah J H Khidir 1 ,
• http://orcid.org/0000-0002-9618-6414 René E M Toes 1 ,
• http://orcid.org/0000-0003-1900-790X Elise van Mulligen 1 , 2 ,
• http://orcid.org/0000-0001-8572-1437 Annette H M van der Helm-van Mil 1 , 2
• 1 Rheumatology , Leiden University Medical Center , Leiden , The Netherlands
• 2 Rheumatology , Erasmus Medical Center , Rotterdam , The Netherlands
• Correspondence to Sarah J H Khidir, Leiden University Medical Center, Leiden, The Netherlands; s.j.h.khidir{at}lumc.nl

https://doi.org/10.1136/ard-2024-225688

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• Anti-Citrullinated Protein Antibodies
• Arthritis, Rheumatoid
• Autoimmunity

Emerging evidence points to the involvement of periodontal disease (PD) in the pathogenesis of rheumatoid arthritis (RA), especially in anti-citrullinated protein antibodies (ACPA)-positive RA. The bacteria Porphyromonas gingivalis , involved in oral mucosal inflammation and PD, can citrullinate proteins via prokaryotic peptidylarginine deiminase. 1 Systemic translocation of oral bacteria has been found in RA-patients with PD. These bacterial translocations have been implicated in the generation of anti-modified protein antibodies (AMPAs) as ACPA can also recognise modified bacterial proteins. 2 Nevertheless, the ‘cause-consequence’ relation between PD and RA remains debatable as PD may be a risk factor (PD→RA; scenario 1; figure 1A ) but also a consequence of RA (RA→PD; scenario 2). 3 Additionally, the relation PD→RA may be confounded by related factors (eg, body mass index (BMI), smoking or other factors related to socioeconomic status (SES); scenario 3). Increased prevalence of periodontitis and P. gingivalis were reported in ACPA-positive/autoantibody-positive at-risk individuals in case–control/cross-sectional studies. 4 5 Longitudinal studies on PD in at-risk individuals could elucidate temporal relationships and provide further insight into the relation of PD in RA-development. Therefore, we longitudinally analysed the relation between tooth loss as proxy for (preceding) PD and progression to clinically apparent inflammatory arthritis (IA) and RA in patients with clinically suspect arthralgia (CSA). We also studied whether this relation is independent of SES and SES-related factors.

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Conceptual framework of hypotheses on periodontal disease and RA (A) and the development of inflammatory arthritis in ACPA-positive and ACPA-negative clinically suspect arthralgia according to tooth extraction (B). (A) The coloured circles represent the three hypotheses on the relation between PD and RA, inspired by de Pablo et al. 3 Scenario 1 in blue: PD is a risk factor for RA. Scenario 2 in orange: RA is a risk factor for PD. Scenario 3 in green: the association between PD and RA is driven by confounding factors such as smoking and SES. (B) Development of IA in ACPA-positive and ACPA-negative patients with clinically suspect arthralgia is shown according to tooth extraction, which is a late-stage of periodontal disease, showing a relation between tooth extraction and IA-development in ACPA-positive CSA-patients. ACPA, anti-citrullinated protein antibody; CSA, clinically suspect arthralgia; IA, inflammatory arthritis; PD, periodontal disease; RA, rheumatoid arthritis; SES, socioeconomic status.

Supplemental material

At baseline, 306 CSA-patients (44%) had previous tooth extraction. These patients were older than patients without tooth extraction (48.7 vs 41.4 years; online supplemental S2 ), more often had a low educational attainment (15% vs 8%), a higher BMI (27.8 vs 26.3), more often smoked (66% vs 51%) and had subclinical joint-inflammation (57% vs 47%). ACPA-positive CSA-patients with tooth extraction more often progressed to IA than ACPA-positive patients without tooth extraction (HR=1.91, 95% CI 1.10–3.32, p=0.022), while this association was not significant in ACPA-negative CSA (HR=1.41, 95% CI 0.85–2.34, p=0.19; figure 1B ). After correcting for SES, smoking, BMI and age, tooth extraction remained significantly associated with IA-development in ACPA-positive CSA-patients (HR=2.22, 95% CI 1.23–4.00, p=0.008). This association remained after additional adjustment for subclinical joint-inflammation (HR=3.10, 95% CI 1.57–6.10, p=0.001). The association between tooth extraction and RA-development was similar, as every ACPA-positive CSA-patient who developed IA also developed RA according to classification criteria. Within ACPA-positive CSA-patients (n=96), ACPA-levels, RF-positivity and number of AMPA-isotypes did not differ between individuals with and without tooth extraction ( online supplemental S3 ). Analyses stratified for autoantibody-positivity/autoantibody-negativity (negative for ACPA and RF) showed similar findings ( online supplemental S4 ).

To our best knowledge, this is the first study that longitudinally evaluates individuals with arthralgia at-risk of RA. We show that tooth extraction is a risk factor for progression to ACPA-positive RA and that this association is not confounded by environmental or SES-related factors. We acknowledge that tooth extraction has different causes among which end-stage periodontitis. This means it is a proxy, but not a perfect proxy. The finding that the risk effect is only present in developing ACPA-positive RA and not in ACPA-negative RA, suggests that tooth loss is partly related to prior PD (potentially present long before CSA-onset or recently). Future clinical and translational studies are needed to substantiate this finding. Interestingly, there were no differences in ACPA-levels and number of AMPA-isotypes as markers of autoantibody-maturation between ACPA-positive patients with and without tooth extraction. Whether antigenic triggering of autoreactive B-cells by bacteraemia plays a role in the trajectory towards ACPA-positive RA remains to be determined. 7

In conclusion, this is the first longitudinal study with data on tooth extraction as proxy for late-stage PD in both ACPA-positive and ACPA-negative at-risk patients. Tooth extraction, a late-stage of PD, associated with RA-development in ACPA-positive CSA-patients. Although our study does not show causality, it deductively supports the hypothesis that PD could confer risk for ACPA-positive RA and provides clues for future clinical and translational studies.

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Patient consent for publication.

Not applicable.

Ethics approval

• Pisetsky DS
• Brewer RC ,
• Hale CR , et al
• de Pablo P ,
• Chapple ILC ,
• Buckley CD , et al
• Do T , et al
• Mikuls TR ,
• Thiele GM ,
• Deane KD , et al
• Broers DLM ,
• de Lange J , et al
• Kristyanto H ,
• Blomberg NJ ,
• Slot LM , et al

Supplementary materials

Supplementary data.

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• Data supplement 1

Handling editor Josef S Smolen

Contributors SJHK and AvdH-vM designed the study. SJHK and EvM accessed and verified the data. SJHK analysed the data and acted as guarantor. All authors interpreted the data and wrote the report. AvdH-vM was the principal investigator. All authors approved the final version of the manuscript and were responsible for the decision to submit the manuscript for publication.

Funding This work was supported by the European Research Council (ERC) under the European Union’s Horizon 2020 research and innovation program (Starting grant, agreement No. 714312) and by the Dutch Arthritis Society.

Competing interests None declared.

Patient and public involvement Patient partners were involved in the design of the CSA-cohort, and in the design and execution of the TREAT EARLIER-trial

Provenance and peer review Not commissioned; externally peer reviewed.

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

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