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Coastal Curation: 10 Oceanic Research Facilities That Advocate Awareness

Found around the world, these buildings combine laboratories, libraries and exhibition spaces to further understanding of the world’s oceans..

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Water has emerged as the greatest challenge of the 21st century. Facing global scarcity, droughts, flooding and climate concerns, the world’s nations have begun investing substantial time and resources to address the dramatic shifts in global water dynamics. With the recent climate talks in Paris and the growing demands for systemic change, countries and organizations alike have started promoting new research initiatives to better understand the problems we face. Ideas like blue urbanism, ecological infrastructure and maritime spatial planning are being used to balance oceanic development and water management. Architects have begun working within these larger movements, designing integrated environments that connect to broader networks and systems.

The following collection takes a closer look at water through oceanic research facilities. Found around the world, these buildings combine laboratories, libraries and exhibition spaces to further understanding of the world’s oceans. Overlooking nearby coastlines and waterfronts, these buildings provide space for critical reflection and exchange. While they are formally and spatially diverse, the projects all establish powerful relationships to light and view. Using the building envelope to control views and support internal programs, the projects are largely hermetic and introspective in nature. Accommodating space for storage, archiving and display, they begin to curate the unique artifacts and ideas surrounding the future of our oceans.

© Mark Herboth Photography

UNC Coastal Studies Institute by Clark Nexsen , Wanchese, N.C., United States

Surrounded by wetlands, the Coastal Studies Studies Institute Research Building is located on the banks of Roanoke Island and the Croatan Sound. The facility includes offices, classrooms and research labs. The building is aligned with the simple bend of a nearby canal to capture views of the water and the sky.

© Assassi Productions

NOAA Southwest Fisheries Science Center by Gould Evans , San Diego, Calif., United States

This NOAA Fisheries Science Center was built in partnership with the University of California San Diego to create a world-class sustainable building for environmental stewardship. With an open interior and courtyards to encourage interaction, the facility takes advantage of the local microclimate. Designed to respect the needs of research scientists, the building includes a state-of-the-art ocean technology tank with a capacity of over half a million gallons.

© soma architecture

One Ocean by soma architecture , Yeosu-si, South Korea

Designed as a thematic Pavilion for EXPO 2012, this structure made to embody the Expo’s theme of The Living Ocean and Coast. Creating a multi-layered experience, the project includes a biomimetic kinetic façade that showcases forward-looking innovation.

© ZGF Architects

J. Craig Venter Institute La Jolla by ZGF Architects LLP , La Jolla, San Diego, Calif., United States

The Venter Institute at La Jolla was designed to encourage interaction while housing the programmatic space necessary for genomics research. Designed to champion sustainability, the building became the first net-zero energy biological laboratory in the United States. Labs and office space were positioned around a central courtyard and collaborative outdoor space designed to draw researchers together from various departments.

© Barré Lambot architectes

Institute of Marine Genomics by Barré Lambot architectes , Roscoff, France

The Institute of Marine Genomics was organized around an interior garden. A rational organizational strategy and simple construction combined to help integrate the project with the site and its surrounding context. Glass, concrete, granite and zinc were used to delineate separate areas of the program.

© Martín Hurtado Arquitectos Asociados

Coastal Marine Research Station by Martín Hurtado Arquitectos Asociados , Cartagena, Chile

A coastal research station, this facility overlooks the Pacific Ocean along the San Antonio Province of the Valparaíso Region. It was built to include space for prolonged research residences. Three partially buried volumes house the program, including a multipurpose space, international laboratory and research area.

© Steven Holl Architects

Cité de l’Ocean et du Surf by Steven Holl Architects , Biarritz, France

Designed to help raise awareness of oceanic issues, the Museum of Ocean and Surf combines plaza space, exhibition areas and collection space. Exploring the scientific and education aspects of the sea and its role in ecology, science and leisure, the museum integrates concept and topography. Together, the two elements establish unique spatial experiences around “glass boulders.”

© Hidalgo Hartman

CRAM Foundation by Hidalgo Hartman , Barcelona, Spain

This minimalist building in Barcelona was designed to house the CRAM Foundation, an organization that aims to protect the environment and marine animals. The building includes a clinic for the rescue, and eventual reintroduction, of endangered marine species along the Catalan coast. Research spaces are balanced with public program areas which support the foundation’s goal of raising social awareness.

© Alan Karchmer

NOAA Daniel K. Inouye Regional Center by HOK , Pearl Harbor, Hawaii, United States

Reusing two historic, World War Two-era airplane hangars, the NOAA Inouye Regional Center was designed as a state-of-the-art sustainable research and administrative campus. Balancing various preservation demands and the desire to create an original space, the project uses simple forms and appropriate materials to complement the scale and materiality of the existing hangar buildings.

© Atelier Stéphane Fernandez

International Accommodation Centre for the Oceanological Observatory by Atelier Fernandez & Serres , Banyuls-sur-Mer, France

This project was designed as part of a complex of facilities which include the research center and observatory of Banyuls-sur-Mer. Accommodating students and scientists from around the world, the design includes space for short research stays and experimentation. The project’s rectangular volume was clad in pink-ochre coral, an undulating envelope with distinct “strands” created through modules and a mathematical algorithm.

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Sustainable Buildings Research Centre by Cox Architecture

Cox Architecture was established in Sydney in 1962. From the beginning, it can be seen that their priority is the environment, creating sustainable buildings, and spreading the ideas. Their understanding of sustainable buildings showed itself with these approaches; depth knowledge about the site and its surroundings, passive design , and use of long-lasting locally sourced materials . Sustainable Buildings Research Centre (SBRC) is one of the many projects they have completed with this mission. The Sustainable Buildings Research Centre is an evidence-based prototype of a sustainable building that also serves as a research centre for itself.  

University of Wollongong’s Sustainable Buildings Research Centre (SBRC)

Architect: Cox Architecture Year: 2014 Location: Wollongong, Australia Area: 2600 m2

The Sustainable Buildings Research Centre (SBRC) is a multidisciplinary organisation that brings together a wide range of researchers to address the challenges of making our buildings sustainable and effective places where we live and work. The mission of the SBRC is to support the rapid decarbonization of our built environment.

It was decided that the SBRC building, as the home of a sustainable buildings research centre, would go far beyond current Australian sustainability standards for educational and other facilities. The vision was that in a few years or decades, the occupants, visitors, and the wider community would be able to look back and know that the design of the SBRC had pushed the boundaries of what was possible at the time of its design and that this project represented a significant step forward in the delivery of highly sustainable buildings. With these aims, the Cox Architecture team collaborated with UoW and Living Building Challenge to create a structure worthy of these mottos. 

Knowledge About Site 

Cox Architecture’s primary approach to sustainable building starts with getting deep knowledge about the site. The selected site for the SBRC building was at the University of Wollongong’s Innovation Campus, which consisted of low-grade fill from surrounding mining operations in the region and was generally unproductive, with landscape cover primarily composed of native and exotic weeds. Even though this background can set a limit for growth, Cox Architecture’s lead set urban agricultural areas for production and student experience. The plant palette for the urban agriculture areas is decided from the local sources, what indigenous people grow in their gardens for food, medicine, etc. 

The SBRC gardens consist of 5 raised beds made from recycled bricks, five raised beds made from corrugated metal barrels, a vegetable bed on the green roof , and basic planting of fruit trees/vines and herbs in the garden. 

Passive Design

One of the approaches for sustainability that Cox Architecture has carried out is designing passive systems to minimise active use of energy and other sources. Passive design is a key element for sustainable buildings. For SBRC, Cox Architecture has taught about water management and net zero energy consumption and production.  

Water Management

The first decision for water management in SBRC is minimising water use. Most of the facility’s water needs to be provided with the captured rainwater. The grey water captured from the rooftops of the buildings is being collected in properly sized tanks. Collected rainwater goes through filtration without chemicals and is distributed to the showers, PV washings, hand basins, laboratories, and toilet flushes. 

The second approach of Cox Architecture’s water management is the general water flow. One of the essential things about circular, sustainable building is the remainder of what is used. Wastewater management is not what we usually see in a so-called sustainable building. To reach net zero water management, Cox Architecture has thought about this issue too. The approach is going with the natural process. All water sent to drains goes through the blackwater treating plant, and after the operation, the clean water is used to irrigate the garden. Design decisions about landscape also came from providing the stormwater runoff. Hardscapes have been minimised around the building to reach the natural water absorption process.

Energy Management

Energy concern was one of the main challenges of the SBRC. From the construction to the life of the user has been thought to reach net zero energy. The building is created to sustain itself with the gained energy. A total of 600 PV panels have been used to gain enough power. A unique PVT system has been designed with the BlueScope team, and this system also contributes to the SBRC as an archive for a sustainable building approach.

Material Selection

Selecting long-lasting, locally sourced material is one one the key elements of sustainable buildings for Cox Architecture. In SBRC, which can be taught as an archive and research itself, the material selection was essential to show how to do more with less. For the material selection , the team went to appropriate sourcing for reusable materials, and all sources for the process were local. The idea of dematerialization was a key that every product could do more than one job, and locally reused materials were selected wherever possible. Bridge timbers, steel railway tracks, abandoned telegraph poles, reused bricks, and local timbers can be given as examples of the used materials. The richness of textures from the outside can make the building a material library where it proves the power of what can be done with reused materials.

The building itself became a research topic for sustainability, and it is a prototype for such an issue. Cox Architecture defines the structure as dynamic , adaptable, and retrofittable . All design decisions came from the idea of being site-specific and getting the maximum benefit from the surroundings rather than depending on wasteful systems. The orientation also influences the planning of the building. The thin floor plates and suitable orientation provide adequate natural ventilation and sunlight. The form of the building lets sea breezes in, and the eaves provide sun shading during the noon time. The dynamic approach of the building invites people into the building and semi-open social areas. The site is publicly open at all times and lets every curious one experience the natural aura of this education centre.  

References List:

• COX. (n.d.). Sustainable Buildings Research Centre. [online] Available at: https://www.coxarchitecture.com.au/project/sustainable-buildings-research-centre/ .
• COX. (n.d.). Practice. [online] Available at: https://www.coxarchitecture.com.au/practice.
• International Living Future Institute. (n.d.). Sustainable Buildings Research Centre. [online] Available at: https://living-future.org/case-studies/sustainable-buildings-research-centre/ [Accessed 28 Sep. 2022].
• Editor, J.G. – (n.d.). Sustainable Buildings Centre. [online] Available at: https://www.builtworks.com.au/sustainable-buildings-research-centre/ [Accessed 28 Sep. 2022].
• www.uow.edu.au. (n.d.). Research – University of Wollongong – UOW. [online] Available at: https://www.uow.edu.au/sbrc/research/ [Accessed 28 Sep. 2022].
• archiroots.net. (n.d.). University of Wollongong’s Sustainable Buildings Research Centre (SBRC) | archiroots. [online] Available at: https://archiroots.net/project/university-of-wollongong-s-sustainable-buildings-research-centre-sbrc/b

A graduate student who sees architecture as a way to think critically. Using her architectural background, she aims to draw attention to the ways of existing with the earth, not against earth with her writings. She believes that critical thinking will open different doors to both people and the world.

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What is case study research?

Last updated

8 February 2023

Reviewed by

Cathy Heath

Short on time? Get an AI generated summary of this article instead

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

Organization

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

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

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

Analyze case study research

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

• What are the different types of case study designs?

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

Here are the common types of case study design:

Explanatory

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

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

Descriptive

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

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

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

Exploratory

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

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

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

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

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

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

Critical instance

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

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

Instrumental

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

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

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

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

• When do you use case studies?

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

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

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

1. Select a case

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

2. Create a theoretical framework

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

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

3. Collect the data

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

4. Analyze your case

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

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

• What are some case study examples?

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

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

How can teachers enhance student participation in classrooms?

How does poverty affect literacy levels in children?

Case study topics

Case study of product marketing strategies in the Kenyan market

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

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

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

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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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Striking findings from 2021

As 2021 draws to a close, here are some of Pew Research Center’s most striking research findings from the past year. These 15 findings cover subjects ranging from extreme weather to the COVID-19 pandemic and ongoing demographic shifts in the United States. And they represent just a small slice of the year’s full list of research publications .

A growing share of childless Americans say it is unlikely they will ever have children, an October survey found. Some 44% of non-parents ages 18 to 49 say it is not too or not at all likely that they will have children someday, an increase from the 37% who said the same in 2018. Meanwhile, 74% of adults younger than 50 who are already parents say they are unlikely to have more kids, virtually unchanged since 2018.

What’s behind the growing share of non-parents younger than 50 who expect not to have children? A majority (56%) say a major reason is that they just don’t want to. Among those who point to some other reason, about two-in-ten (19%) say it’s due to medical reasons, 17% say it’s for financial reasons and 15% say it’s because they do not have a partner. Roughly one-in-ten point to their age or their partner’s age (10%), or to the state of the world (9%).

Around seven-in-ten U.S. adults (72%) said in an August survey that they personally know someone who has been hospitalized or died from COVID-19. As has been the case throughout the COVID-19 outbreak , larger shares of Black (82%) and Hispanic (78%) adults than White (70%) and English-speaking Asian adults (64%) said they personally know someone who had been hospitalized or died as a result of the coronavirus.

Across other major demographic groups, there were modest or no differences in the shares who say this. Democrats and Democratic-leaning independents, for example, were about as likely as Republicans and GOP leaners to say they know someone who had been hospitalized or died (74% and 71%, respectively).

More than 600,000 Americans had died from the virus at the time of the August survey. Since then, the death toll has risen to more than 800,000 .

Americans voted in record numbers in the 2020 presidential election, as turnout rose in every state, according to a January analysis by the Center. Nearly two-thirds of the estimated number of eligible voters and more than six-in-ten people of voting age cast ballots in the election.

Nationwide, presidential election turnout was about 7 percentage points higher than in 2016, regardless of which of three different turnout metrics we looked at. Turnout rates increased in every state compared with 2016, but of the 10 states where it rose the most, seven conducted the vote entirely or mostly by mail.

Minnesota had the highest turnout of any state, with 79.4% of estimated eligible voters casting ballots for the presidential election. Colorado, Maine and Wisconsin all followed close behind at about 75.5%; Washington state, at 75.2%, rounded out the top five. The lowest-turnout states were Tennessee (59.6% of estimated eligible voters), Hawaii and West Virginia (57% each), Arkansas (55.9%) and Oklahoma (54.8%).

About eight-in-ten Asian Americans say violence against them is increasing in the U.S., an April survey found. The survey was fielded after the  fatal shooting  of six Asian women and two other people in the Atlanta area in March, and following  other assaults on Asian Americans .

Amid widespread reports of discrimination and violence against Asian Americans during the coronavirus outbreak , 45% of Asian adults said they had experienced at least one of five specific types of incidents since the start of the pandemic.

Around a third (32%) said they had feared someone might threaten or physically attack them – a greater share than among people in other racial or ethnic groups who said this. Some 27% of Asian adults said people had acted as if they were uncomfortable around them. Another 27% said they had been subject to slurs or jokes. Lower shares said someone had made a remark that they should go back to their home country (16%) or that they were to blame for the coronavirus outbreak (14%).

At the same time, 32% said someone has expressed support for them since the start of the pandemic.

Across 16 publics surveyed in spring 2021 , a median of just 17% of adults said democracy in the U.S. is a good example for other countries to follow. A median of 57% said American democracy used to be a good example for other countries to follow but has not been in recent years. A median of 23% said American democracy has never been a good example for other countries to follow.

Americans largely shared the view that their country is no longer a good model of democracy: 72% said U.S. democracy used to be a good example for others to follow but has not been recently. Democrats and Democratic leaners were twice as likely as their Republican and GOP leaning counterparts to say the U.S. has never been a good model of democracy.

More broadly, the U.S. political system also received generally lukewarm ratings across the 16 advanced economies surveyed. People were split on how the  system is functioning , with a median of 50% saying it works well and 48% who disagreed.

In just five years, the percentage of Republicans with at least some trust in national news organizations has fallen by half – dropping from 70% in 2016 to 35% this year, a June survey found.  

Democrats remain far more likely than Republicans to say they have a lot or some trust in the information that comes from national news organizations (78% vs. 35%). The 43-point partisan gap is the widest measured since at least 2016. 

Women in the U.S. are now more likely than men to have a four-year college degree, according to a November analysis . Around four-in-ten women ages 25 and older (39%) have a bachelor’s degree, compared with a slightly smaller share of men in the same age group (37%). Among those ages 25 to 34 specifically, women are now 10 percentage points more likely than men to have a bachelor’s degree (46% vs. 36%).

The reasons for not completing a four-year degree differ for men and women, according to an accompanying survey of adults who do not have such a degree and are not currently enrolled in college. Men are more likely than women to point to factors that have more to do with personal choice. Roughly a third of men without a bachelor’s degree (34%), for example, say a major reason they didn’t complete college is that they just didn’t want to. Only one-in-four women say the same.

Most Democrats in the U.S. see voting as a fundamental right, while most Republicans view it as a privilege that comes with responsibilities, according to a July survey .

The vast majority of Democrats (78%) say voting is a “fundamental right for every adult U.S. citizen and should not be restricted in any way.” Two-thirds of Republicans say voting is “a privilege that comes with responsibilities and can be limited if adult U.S. citizens don’t meet some requirements.”

Overall, a majority of Americans (57%) say voting is a fundamental right that should not be restricted while 42% express the view that voting is a privilege that comes with responsibilities.

About three-in-ten Americans are religiously unaffiliated, a 10 percentage point rise from a decade ago, according to a survey conducted between May and August . Currently, 29% of U.S. adults are religious “nones” – those who describe themselves as atheists, agnostics or “nothing in particular.” By comparison, 16% described themselves this way when the Center first asked the question in 2007.

Christians continue to make up a majority of the U.S. population (63%), but their share is 12 points lower in 2021 than it was in 2011. Christians now outnumber religious “nones” by a ratio of a little more than two-to-one. In 2007, when the Center began asking its current question about religious identity, Christians outnumbered “nones” by almost five-to-one (78% vs. 16%).

Democrats and Republicans were deeply divided over former President Donald Trump’s role in the events of Jan. 6, according to a March survey .

The vast majority of Democrats (87%) said Trump’s conduct surrounding the riot at the U.S. Capitol was wrong and that senators should have voted to convict him during his impeachment trial, while just 11% of Republicans said the same. Around two-thirds of Republicans (65%) said Trump’s conduct was not wrong and that he should not have been impeached by the U.S. House of Representatives; just 4% of Democrats said the same.

Overall, about half of Americans (52%) said Trump’s conduct was wrong and that senators should have voted to convict him, while 31% said his conduct was not wrong and that he should not have been impeached by the U.S. House. Some Americans (15%) said Trump’s conduct was wrong but that senators should not have voted to convict him.

For the first time, the number of Americans who identify as non-Hispanic White declined between 2010 and 2020, according to the Center’s analysis of U.S. Census Bureau data. The White population of the United States declined by about 5.1 million people during that timespan.

In a related Pew Research Center survey in July , about six-in-ten U.S. adults (61%) said the decline in the White share of the U.S. population is neither good nor bad for society. About two-in-ten (22%) said it is bad, including 9% who said it is very bad. Slightly fewer (15%) said it is good, including 7% who said it is very good.

Only 34% of U.S. adults under the age of 30 now get TV through cable or satellite, down from 65% in 2015, according to a survey fielded in January and February . There were declines in other age groups, too, with decreases of 27 percentage points among those ages 30 to 49 and 14 points among those 50 to 64.

Adults under 30 who are nonsubscribers are also much more likely than older nonsubscribers to have never received TV at home via cable or satellite – and to say they don’t currently subscribe because they can find the content they want online instead.

Two-thirds of U.S. adults say extreme weather events across the country have been occurring more often than in the past, a September survey found. Far fewer Americans say they’re happening about as often (28%), and only 4% say they are happening less often.

Nearly half of Americans (46%) also say the area where they live has had an extreme weather event over the past 12 months, according to the same survey.

Nearly three-quarters of U.S. adults (73%) in the West South Central  census division , which includes Texas, Louisiana, Arkansas and Oklahoma, say they’ve experienced extreme weather within the past year. A majority of adults (59%) say the same in the Mid-Atlantic region, which includes Pennsylvania, New York and New Jersey. By contrast, far fewer say they’ve experienced extreme weather in other regions over the past year.

In most census regional divisions, Democrats are more likely than Republicans to report experiencing extreme weather within the past year. Overall, 51% of Democrats say the area where they live has experienced this, compared with 39% of Republicans.

A growing share of U.S. adults are neither married nor living with a partner , according to an October study . In 2019, roughly four-in-ten adults ages 25 to 54 (38%) were unpartnered – that is, neither married nor living with a partner, according to a Pew Research Center analysis of Census Bureau data for that year (the most recent available). This share was up sharply from 29% in 1990. Men were more likely to be unpartnered than women.

All of the growth in the unpartnered population since 1990 has come from a rise in the number who have never been married, although the unpartnered population does include some adults who were previously married (those who are separated, divorced or widowed).

Around the world, more people mention their family as a source of meaning in their lives than any other factor, according to an open-ended survey question the Center posed to people in 17 advanced economies in the spring.

In 14 of the 17 nations surveyed, more people mentioned their family as a source of meaning than anything else. Respondents highlighted their relationships with parents, siblings, children and grandchildren; quality time spent with their relatives; and the pride they get from family members’ accomplishments. Many also expressed the desire to live a life that leaves an improved world for their offspring.

Read the other posts in our striking findings series:

• 20 striking findings from 2020
• 19 striking findings from 2019
• 18 striking findings from 2018
• 17 striking findings from 2017
• 16 striking findings from 2016
• 15 striking findings from 2015
• Asian Americans
• Climate, Energy & Environment
• Coronavirus (COVID-19)
• Discrimination & Prejudice
• Donald Trump
• Election 2020
• Political & Civic Engagement
• Politics & Policy
• Racial & Ethnic Shifts
• Racial Bias & Discrimination
• Voter Participation

Katherine Schaeffer is a research analyst at Pew Research Center .

Income inequality is greater among Chinese Americans than any other Asian origin group in the U.S.

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Officials toast groundbreaking of $335M research center in Detroit

Detroit — Over 100 people gathered Monday morning with leaders of Detroit, Henry Ford Health, Michigan State University, and the Detroit Pistons to witness the groundbreaking ceremony of the new Henry Ford Health+ Michigan State University Health Sciences Research Center.

The $335 million facility is the first physical representation of a $3 billion investment and partnership between Henry Ford Health, MSU and the Detroit Pistons, Henry Ford President and CEO Bob Riney said. Work on the research facility officially began late last month in what used to be a New Center parking lot at the corner of Amsterdam and Third Street, and it is scheduled to open in 2027.

"The research center we're here today to celebrate is much more than a new building," Riney said. "This facility will come to serve as a beacon of hope and well-being for our Detroit community and beyond. And that's because the discoveries and advancements that can happen here have the capability to indelibly change healthcare as we know it."

The seven story, 335,000-square-foot research center will contain state of the art laboratory spaces to expand research in cancer, neuroscience, immunology and hypertension and house the Nick Gilbert Neurofibromatosis Research Institute, named for the son of Detroit investor and billionaire Dan Gilbert and his wife Jennifer.

Neurofibromatosis is a rare genetic disorder that cases tumors to grow throughout the body. Nick Gilbert died from complications from neurofibromatosis last year at age 26. Through the Gilbert Family Foundation, the Gilberts have invested $125 million into finding a cure for the disease and hope to continue building their son's legacy with the new research institute. It is the first brick and mortar research institution dedicated to researching the condition.

"At the Gilbert Family Foundation, we maintain for and every search initiatives focused on addressing unmet clinical needs of NF patients," Jennifer Gilbert said at Monday's groundbreaking celebration. "Each initiative is about bringing people together to think differently each one of our focus areas boasts a dream team of multidisciplinary scientific experts. ... With the Nick Gilbert neurofibromatosis Research Institute we are giving our dream team a home to centralize their efforts and help accelerate a cure."

Detroit has made "outstanding progress" recently because it's not afraid to make big bets, Dan Gilbert said at Monday's event, referencing recent developments like the Hudson's Project, the Book Tower and Michigan Central Station.

"Nick believed in Detroit's future, which is another way this research institute will carry out his legacy," Dan Gilbert said. "These investments will attract talent from across the world and provide an opportunity for Detroit residents to build successful careers right here in their own city. I don't know how else you can say Detroit is hot, but Detroit is hot right now."

Michigan Lt. Gov. Garlin Gilchrist II, Detroit Mayor Mike Duggan, and several City Council members including Council President Mary Sheffield joined in the celebration Monday morning.

America's great cities have several world class colleges and universities that serve as anchors for young people, Duggan said.

"We've been lucky to have Wayne State University right up the street, we've been lucky to have U of D Mercy, we've been lucky to have the art design programs in the College for Creative Studies, but today with a $335 million investment for Michigan State — this raises Detroit to another level," Duggan said.

By emphasizing translational research, the new center will ensure that the people of Detroit get access to the latest medical breakthroughs as soon as they become available, Duggan said. The mayor, a proud University of Michigan alum, joined the many choruses of "go green" and "go white" at Monday's ceremony which also featured a visit from Sparty, the MSU mascot.

MSU President Kevin Guskiewicz said the partnership will advance the health of Detroiters and all Michiganians. The research institute will be a "talent magnet" for top tier clinicians and scientists, he said, reaffirming a commitment to recruiting the best scientists and provide 50 full tuition scholarships for students from the Detroit area.

"We're going to attract talented people that are going to want to come and study and work here in this new research center where we're going to... address some of the greatest challenges of our time. Those around cancer, neuroscience immunology, infectious disease and yes, neurofibromatosis," Guskiewicz said.

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Research from the Legatum Center

The Women-Waste Climate Nexus in the Middle East and North Africa

Delila Khaled

This technical brief is a supplement to the white paper, The Women-Waste-Climate Nexus: Unlocking the potential of women entrepreneurs to combat the global waste crisis and Accelerate the Race to Net Zero (Khaled, 2023). Using the paper as a point of departure, it provides a brief analysis of the wo...

15 Year Impact

The Legatum Center for Development and Entrepreneurship at the Massachusetts Institute of Technology (MIT) was founded in 2007 with its vision and mission centered on the belief that entrepreneurs and their innovation-driven solutions are key to advancing global prosperity.

Pan-African Deeptech: Key to Sustainable Prosperity

Haitham Khoury, Ph.D.,

Embracing deeptech innovation – innovation grounded in advances at the frontier of science and technology – in Africa has the potential to drive sustainable economic growth, improve living standards, and bring stability and resilience. As the wellspring of new solutions, deeptech has the power to a...

Digital Health Entrepreneurship in Vietnam

Nourhan Shaaban

Despite Vietnam’s transition to an emerging economy, the healthcare sector has not witnessed the same progress seen in other sectors. Vietnam is a country of innovators and entrepreneurs, and this should be leveraged to address the country’s healthcare challenges.

On the Back of the Gray Rhino

Dina Sherif

By harnessing the power of "the gray rhino" and using the crisis as an opportunity, entrepreneurs are uniquely positioned to mitigate the myriad effects of the financial crisis.

The Women Waste-Climate Nexus

Women waste entrepreneurs were recognized as an untapped but potentially transformational force in the fight against climate change and the transition to a gender-just, net-zero future.

Print Case Studies

Our free case studies focus on innovative emerging market ventures, led by principled entrepreneurs, which have high potential for sustainable and scalable socioeconomic impact.

Research Writing and Analysis

• NVivo Group and Study Sessions
• SPSS This link opens in a new window
• Statistical Analysis Group sessions
• Using Qualtrics
• Dissertation and Data Analysis Group Sessions
• Defense Schedule - Commons Calendar This link opens in a new window
• Research Process Flow Chart
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• Step 1: Seek Out Evidence
• Step 2: Explain
• Step 3: The Big Picture
• Step 4: Own It
• Step 5: Illustrate
• Annotated Bibliography
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• Systematic Reviews & Meta-Analyses
• How to Synthesize and Analyze
• Synthesis and Analysis Practice
• Synthesis and Analysis Group Sessions
• Problem Statement
• Purpose Statement
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• Theoretical Framework
• Locating Theoretical and Conceptual Frameworks This link opens in a new window
• Quantitative Research Questions
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• Thematic Data Analysis in Qualitative Design
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• Journal of Research in Innovative Teaching & Learning (JRIT&L) This link opens in a new window

Writing a Case Study

What is a case study?

A Case study is: 

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

What are the different types of case studies?

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

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

Who are your case study participants?

What is triangulation ? 

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

How to write a Case Study?

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

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PEER Report 2024/05: "A Granular Framework for Modeling the Capacity Loss and Recovery of Regional Transportation Networks under Seismic Hazards: A Case Study on the Port of Los Angeles"

PEER has published Report No. 2024/05: "A Granular Framework for Modeling the Capacity Loss and Recovery of Regional Transportation Networks under Seismic Hazards: A Case Study on the Port of Los Angeles." It was authored by Michael Benedict Virtucio, Department of Civil and Environmental Engineering, University of California, Berkeley; Barbaros Cetiner, NHERI SimCenter; Bingyu Zhao, University of California, Berkeley; Kenichi Soga, TU Wien, Austria; Ertugrul Taciroglu, Department of Civil and Environmental Engineering University of California, Los Angeles.

Access the report and 2 page summary . Access the full listing of PEER reports .

Earthquakes, being both unpredictable and potentially destructive, pose great risks to critical infrastructure systems like transportation. It becomes crucial, therefore, to have both a fine-grained and holistic understanding of how the current state of a transportation system would fare during hypothetical hazard scenarios. This paper introduces a synthesis approach to assessing the impacts of earthquakes by coupling an image-based structure-and-site-specific bridge fragility generation methodology with regional-scale traffic simulations and economic loss prediction models. The proposed approach’s use of context-rich data such as OpenStreetMap and Google Street View enables incorporating information that is abstracted in standard loss analysis tools like HAZUS in order to construct nonlinear bridge models and corresponding fragility functions. The framework uses a semi-dynamic traffic assignment model run on a regional traffic network that includes all freeways and local roads (1,444,790 edges) and outputs traffic volume on roads before and after bridge closures due to an earthquake as well as impacts to individual trips (42,056,426 trips). The combination of these models enables granularity, facilitating a bottom-up approach to estimating costs incurred solely due to physical damage to the transportation network. As a case study, the proposed framework is applied to the road network surrounding the Port of Los Angeles---an infrastructure of crucial importance---for assessing resilience and losses at a high resolution. It is found that the port area is disproportionately impacted in the hypothetical earthquake scenario, and delays in bridge repair can lead to a 50% increase in costs.

• PEER Reports topic page

• Open access
• Published: 11 June 2024

Using unfolding case studies to develop critical thinking for Graduate Entry Nursing students: an educational design research study

• Rachel Macdiarmid   ORCID: orcid.org/0000-0003-4791-7417 1 ,
• Eamon Merrick   ORCID: orcid.org/0000-0003-4269-6360 2 , 3 &
• Rhona Winnington   ORCID: orcid.org/0000-0002-6504-2856 1  

BMC Nursing volume  23 , Article number:  399 ( 2024 ) Cite this article

217 Accesses

Metrics details

Graduate Entry Nursing (GEN) programmes have been introduced as another entry point to nurse registration. In the development of a new GEN programme, a problem-based approach to learning was used to develop critical thinking and clinical reasoning skills of motivated and academically capable students.

To explore and evaluate the design and delivery of course material delivered to GEN students embedded in authentic learning pedagogy from the perspectives of both GEN students and academic staff using an unfolding case study approach.

An educational design research approach was used to explore the learning experiences of GEN students using an unfolding case study approach situated in experiential pedagogy and the teaching experiences of the academics who designed it. Data were collected through semi-structured interviews with students once they had finished the course and weekly reflective diary recordings by academic staff throughout implementation. Thematic analysis was used to analyse the data.

Student reflections highlighted that this cohort had insight into how they learned and were comfortable voicing their needs to academic staff. While the unfolding case studies were not liked by all participants, for some it offered a unique learning opportunity; particularly when scaffolded with podcasts, simulation labs, tutorials and clinical placements. Staff reflections primarily aligned with student experiences.

The gaps highlighted in the delivery of the course suggest that a blended pedagogical approach to graduate entry nurse education is required. Specifically, GEN students are aware of the learning needs and are happy to express these to academic staff, thus suggesting that engaging with a co-design curriculum approach will benefit future cohorts.

Peer Review reports

Graduate entry nursing students begin their degrees as experienced learners and must develop critical thinking skills within the shortened degree time frame.

What is already known

Graduate entry students are experienced and academically capable learners who begin with a diverse range of life and career experiences.

What this paper adds

Graduate entry students would benefit by being involved in curriculum design to acknowledge the unique skill set that they bring.

Introduction

Graduate Entry Nursing (GEN) degrees, or second degrees leading to eligibility for nursing registration, have recently been introduced to New Zealand. GEN students are known to be academically capable, motivated, and driven, bringing with them a range of life experiences, and have often had significant careers before enrolment [ 1 , 2 ]. Previous research has identified that teaching and learning methods must be carefully planned and innovative [ 1 ].

Pre-registration nursing education programmes prepare nursing students to provide safe nursing care with crucial skills expected of nursing graduates, including critical thinking and clinical reasoning. Clinical reasoning enables students to approach clinical issues with a problem-solving lens that relies on gathering assessment data and intervening and evaluating the patient’s response to the intervention [ 3 ].

Problem-Based Learning (PBL) aligns with the fundamental elements of authentic learning approaches [ 4 ], where learning is situated in real-world contexts [ 5 ]. Problem-based learning is considered to be an experiential teaching and learning approach that helps students develop a critical lens and clinical reasoning skills [ 6 , 7 ]. The use of PBL in nursing education is well established with previous research focused on students’ experiences and satisfaction [ 8 ]; factors that facilitate or hinder students' learning [ 9 ]; and the development of critical thinking skills [ 10 ].

Graduate entry nursing students report enjoyment of the active learning sets that enabled discussion surrounding case studies, scenarios, and practice issues [ 11 ]. Cangelosi’s [ 12 ] phenomenological study found that although time-poor, GEN students welcomed learning opportunities that were not traditional and facilitated their development and growth.

However, there is conflicting evidence regarding the effectiveness of PBL in nursing. For example, McCormick et al. [ 13 ] compared undergraduate student performance using differing teaching approaches, such as unfolding simulation scenarios versus recorded lectures and found these to be of benefit to students. Carter and Welch [ 14 ] compared the results of associate degree nursing students who attended lectures to those whose learning was informed by an unfolding case study. In contrast to McCormick’s et al.’s [ 13 ] earlier positive results, these authors found both groups of students performed worse in the post-test.

As previous research has identified that new graduate nurses do not always have critical thinking skills, using an unfolding case study approach can reflect the reality of clinical practice where not all the relevant information is known at the first encounter with the patient [ 14 , 15 , 16 ].

Nonetheless, while several studies have investigated the use of unfolding case studies in undergraduate preregistration programmes there is little evidence that supports the use of these with more academically capable GEN students. This article reports on a qualitative interpretivist study that used an educational design methodology to explore the experiences of GEN students who participated in the programme of learning and the experiences of the academics who designed it.

Educational Design Research (EDR) is an iterative, pragmatic, and reflective methodology well suited to small projects [ 17 ]. It has arisen from design-based research and can include both quantitative and qualitative data collection methods. EDR was selected as it fitted with our desire to develop new ways of teaching alongside gaining feedback from both academic staff and students. In the first phase of this research, we redesigned the teaching and learning strategies for a component of the GEN programme [ 18 ].

EDR has four phases (Table  1 ) [ 17 ]:

Aims and objectives

The study aimed to explore and evaluate the design and delivery of course material delivered to GEN students embedded in authentic learning pedagogy from the perspectives of both GEN students and academic staff using an unfolding case study approach.

Theoretical framework

To enable the development of clinical reasoning skills a scaffolded learning approach was implemented that involved unfolding case studies designed to represent the health needs of the New Zealand population, thus, encouraging critical thinking. Unfolding case studies reflective of situations that students might face in the future were used to encourage students to consider and analyse information, provoke further questioning and identify the information required to narrow their inquiries [ 14 , 15 ]. Supported by this evidence the academic staff built a learning environment where a regular teaching schedule (two days of lectures and one day of clinical labs per week), was complemented with online resources. Initial questions about the case study were provided on the learning management system. Students attended simulations where they responded to the case and answered questions critical to unpacking the ‘patients’ reality. Alongside the unfolding case studies were podcasts where experts were interviewed on topics related to the case. Tutorials enabled students to collaboratively construct answers and share their perspectives; at the end of each week students shared their answers in an online discussion forum.

Methods and setting

This study was conducted at an education facility in New Zealand offering undergraduate and GEN programmes. The participants are academics involved in the design and delivery of the course and one cohort of students of the GEN programme. This article reports on Phase 2 and 3 of the EDR approach, the academic staff’s reflective diary during course delivery, and students' feedback after the course was completed the first time. The methods were reported using the Consolidated Criteria for Reporting Qualitative Studies (COREQ) [ 19 ].

Participants

Purposeful sampling was used as the researchers were keen to explore the experiences of a specific GEN cohort [ 20 ]. Academic staff involved in the weekly reflective diaries are also the research team ( n  = 3). All students in the identified cohort ( n  = 7) were invited to participate, totalling ten possible participants. Student participants were approached via an advertisement on the university’s learning management system. Students were asked to contact the research assistant, who was separate from the academic staff and was not involved in the delivery of the GEN programme; five students agreed to participate. A $20 petrol voucher was offered to those who participated.

Data collection and analysis

In keeping with education design methodology, the authors met weekly to reflect on their experiences of delivering the content and guiding students. The weekly reflective conversations, between 60–90 min in length, followed a simple format of ‘what worked, what didn’t work, and what would we (as academic staff) change?’ Face to face student interviews were conducted by the research assistant at a time and place convenient to the students using semi-structured questions that were developed by the research team (see Additional file 1 ).

The semi-structured interviews ( n  = 5) and reflective meetings ( n  = 9) were recorded and transcribed verbatim by a research assistant who had signed a confidentiality agreement. All identifying information was deleted from the transcripts by the research assistant before the research team reviewed the data; each recording and transcript was allocated a unique identifier, for example ‘participant one’.

Thematic analysis [ 21 , 22 ] was used to analyse the data. First, the research team independently read the transcribed interviews to familiarise themselves with the data and identified initial codes. Second, the researchers met and reviewed all transcripts to identify themes and reached consensus on the themes emerging from the data. Themes were established once more than 50% of the participants stated the same issue/thought/perception. A matrix was developed whereby common themes were identified, with quotes demonstrating the themes collated to establish an audit trail.

Reflexivity

Central to this study given the proximity of staff to this student cohort, a reflexive stance was essential. Reflexivity is an engendered practice and was used in this instance not to influence the direction and outcome of the research but to allow the researchers to engage in the data to produce viable and valuable outcomes for future staff and students. Specifically, this reflexive practice provided a means for the research to be rigorous through the consideration of the vulnerability of the participating student cohort, thus inciting reflection-before-action [ 23 ].

Ethical considerations

Ethical approval for this study was obtained from the Auckland University of Technology Ethics Committee (AUTEC) (19/233). Given the potential power differential in the student/staff relationship present, participants were approached via an online advertisement and followed up by an independent research assistant. This is key to the success of the project, as such research undertakings have the potential for conflict of interest to exist [ 24 ]. The academic staff recordings were also undertaken with the knowledge that these would remain confidential to the participants and transcriber only, with a memorandum of understanding completed to this effect. Participant information sheets were given to students interested in joining the study to ensure they knew what it entailed and how their safety and identity would be managed. Written consent was obtained before the interviews were undertaken, with oral consent obtained at the beginning of each interview.

Three dominant themes emerged, which focused on the experiences of both GEN students and teaching staff. These were:

Reflective learning: Students and staff ability to clarify what worked and what did not work

Evaluation of learning: Students and staff being insightful about their ways of learning and needs

Challenges: Planning and delivering appropriate content for GEN students is challenging for teaching staff.

Within these overarching themes, subthemes were developed and will be presented in the following data results (Table 2 ).

Reflective learning

The exploration of student and staff experiences and responses to the unfolding case studies unearths what worked and what was problematic for both parties.

Unfolding case study as problem-based approach

The student experiences of using an unfolding case study approach were divided. Some students enjoyed the case scenarios but did not necessarily find them beneficial in terms of knowledge advancement as.

“ I personally, like the case studies but personally I didn’t really find that they enhanced my learning in like the clinical setting ” (P1)

or that they were relevant to clinical practice in that.

“… some of it was definitely relatable but I just found it was very different in the clinical setting compared with doing this theoretical case setting ” (P1).

A second student supported this idea that the case studies did not add practical clinical knowledge value as.

“ I mean for me the case studies weren’t challenging…I didn’t think the case studies added anything extra into my practice, they didn’t challenge my clinical reasoning or anything like that ” (P2).

Of note was that those students with previous professional healthcare backgrounds found the use of an unfolding case study approach problematic in that.

“ I found that quite a challenge. I think because with my clinical background I was sort of going straight into, yeah like I wanted more information so you know I probably would have preferred…to have a different case study every week or have all the information…and I’d be like well what about this, what about that? ” (P5).

Participant One, however, noted that while the case studies may not have added knowledge value, they were helpful at times as.

“ …one example is we learnt about arterial blood gases and then I was on placement I came across that literally [on] day one, so was really nice to be able to put something that I’d learnt in class into practice ” (P1).

While some students were less keen on the case study approach and found them hard work, others thought they provided opportunities to encourage discussion, clinical reasoning, and autonomous thinking as.

“ there was no right or wrong answer, you just had to prove your point to say I think it is this because of this, and someone else can say something else and just kind of still prove it because it was a quite grey [area] but I actually found that it really got us thinking ” (P3).

Moreover, the same participant acknowledged that.

“…I think that’s the whole idea of the course [GEN Programme] because at this level they shouldn’t be spoon-feeding you…you should be able to think for yourself and reason things out ” (P3).

Although some discord was present with regard to the case study approach, one participant did acknowledge the value of being able to break down a huge scenario into manageable sections to enhance understanding and clinical decision-making, as.

“ when you break it down it makes it easier to kind of work out what you’re going to do and what steps you’re going to do ” (P4), and that “ because you start looking at the smaller things that you need to do rather than just the big bits ” (P4).

It appears, however, that staff involved in the programme of learning were pleased with the overall notion that problem-based learning approach offered a ‘practical’ means through which to discuss what is the hands-on job of nursing. Specifically,

“ the second session around child abuse and recognising child abuse…took me a bit by surprise as I wasn’t expecting that to go very well and it went extraordinarily well, mostly because it was case based again and story based ” (L1).

Moreover, with regard to encouraging discussion and clinical reasoning at a postgraduate level,

“ I think we’ve really pulled out the difference [of] what we’re expecting of them [GEN students] as opposed to what they may have been used to” (L1).

Use of podcasts

While the use of technology is not necessarily a completely new strategy in tertiary education, here we have linked podcasts recorded with experts in their fields which related to the unfolding case studies, Again, however, there was division in the value of podcast recordings, with some students really enjoying them, saying.

“ I liked the podcasts yeah, I found the podcasts really good especially when there was [sic] different people talking about it, yeah...podcasts are good, like to just chuck on in the car or at the gym ” (P2).

Moreover, some found them easy to listen to because.

“… it’s a different way to learn because like you’ve got YouTube videos and you’ve got books and stuff but podcasts are kind of like easy ” (P2).

Some students found the podcasts particularly engaging saying.

…I just remember listening to it and I think I was in the car and I had stopped because I was on my way home…and I was still listening to it in the garage like when I was home and I was like oh this is a really interesting podcast ” (P2).

Participant three also thought podcasts a positive addition to the resources saying.

“ yeah they were helpful…there was one I listened to…they were talking about dying…I know that [one of the lecturers’] kind of research is kind of talking about death, euthanasia and all this kind of thing, and for some reasons, I don’t know why, maybe that’s why I still remember, I can say it’s the only podcast I really listened to and it was really good because it gave me a good insight as to what is happening… ” (P3)

This positive response was also noted in face-to-face class time as one staff member reported that.

“ they [the students] loved the person who was interviewed, and the feedback was it was really nice to hear a conversation about different perspectives ” (L1).

Yet, not all students were of this opinion, with some advising the podcasts were too long (approximately 60 min each), that they can be distracting, that they preferred videos and images or an in-person discussion, saying.

“ I find podcasts…I tend to switch off a bit, a bit quicker than if I was watching something, I would probably prefer, rather than watching a podcast [sic] I’d rather have an in-class discussion with the person” (P4).

Participant one said that they too struggled with podcasts because.

“ I’m more visual so I like to look at things and see like a slide I guess or what they’re talking about or, so I sort of zone out when it’s just talking and nothing to look at, so that’s what I personally struggle with, they [podcasts] are helpful it’s just I’m more a visual learner ” (P1).

While there were some negative responses to the podcasts, another participant acknowledged their value but offered their own solutions to learning, saying that.

“ I listened to a few podcasts that were put up, because they’re just easy to listen to ” (P2).

but felt that overall there were insufficient resources made available to students and therefore.

“ just went to YouTube and just, any concepts that I was unfamiliar with or stuff in class that we went over and when I went home I was like [I have] no idea what they talked about, I just found my own videos on YouTube… ” (P2).

Evaluation of learning

Learning experiences are unique to each GEN student, as are those experienced by the teaching staff. The data collected highlighted this clearly from both perspectives, offering a particularly strong insight into how this cohort of students’ function.

Approaches to learning

It was evident that these GEN students were aware of their approach to learning and that perhaps the structure of the teaching module did not align with their needs as.

“ I’m not really the best at utilising online things I’m a really hands on learner and things like a lecture…but you know if it’s yeah, more like class time, it’s sort of more my, my learning style [I] guess ” (P5).

A number of students were able to identify that they were visual learners as.

“ I use videos more because I guess I’m more of a visual learner as well and I learn better by seeing things instead of reading a huge article, I think that [videos] it helps me a bit more” (P4).

Another student, however, preferred a discussion based approach as opposed to either videos or podcasts saying that.

“ if it’s interesting, if it’s a topic that you can like relate to [through a podcast] or something it’s fine, but for me I just switch off not really taking a lot of the information [in] whereas in a discussion setting you can ask questions and you can interact with the person, yeah I find that would be a bit more helpful ” (P4).

This approach to learning through discussion was also noted when the teaching staff reflected on their experiences in that in one teaching session the GEN students.

“ were engaged, they were round a table with the second speaker talking and what I think enabled the discussion was that she [the speaker] was using her data as stories and so she was reading them, actually she got them [the students] to read them out” (L3).

The notion of learning styles, however, was not as linear as being visual or auditory or practical, as one student noted that a combination of styles was preferable to enhance learning, saying that.

“ if we weren’t able to have lectures like a recorded lecture so that there was a PowerPoint and just someone actually talking you through it, like I know there’s the YouTube videos…some of them were a little bit helpful, but like I just felt that sometimes we missed the teaching aspect of it. There’s a lot of self-directed stuff but definitely like a recorded lecture every week to go along with the readings and extra videos to watch ” (P5).

Students as insightful and engaged

While GEN students are known for their tenacity and ability to cope with the pressure and fast paced delivery, some students discovered that this did not necessarily equate with their preferred approach to learning. This cohort of GEN students were insightful in terms of their strengths and weaknesses in relation to knowledge acquisition. The use of the unfolding case studies, however, caused some frustrations as.

“ for me it was challenging in the fact that I felt I actually got frustrated because I’m thinking well I want to know this, I want to know that and yeah not getting all the information that I wanted at the time ” (P5).

This participant went further, saying that.

“ I definitely found that difficult [lack of information] I felt like [I] wasn’t getting as much information as I wanted to be able to make my clinical decisions ” (P5),

however this may have been due to the student’s background as their.

“my background is in paramedicine ” where “ we get a lot of information in a very short amount of time ” (P5).

Some fundamental issues were raised by the participants in terms of how much study is required for them to acquire the new knowledge. As one student highlighted,

“ I have a really terrible memory, so I kind of need to listen to things a few times or write it down and then watch a video and do some more reading and then like it’s good having another element to get into your brain you know ” (P2).

For one student, a solution to this was to ensure they did their preparation before attending class as.

“ you’re supposed to have read these things before coming to class, some people don’t but my kind of person, I’d read before coming to class and I tended to answer those questions so the critical, analytical part of me would be trying to find out and come up with a reasonable answer…” (P3).

For another participant, they took an alternative pathway to learning as they.

“ I just watch it and I don’t take [it in], it just sits in the back of my head because sometimes it’s building on top of previous knowledge so just, I just watch it to see if I can gain anything from that, I don’t necessarily take down notes or anything, but I just watch it so that it’s there you know ” (P4).

The pace of content delivery appeared problematic for some students, especially in relation to the practical sessions, with one student highlighting that.

“ personally I didn’t’ really like it and most of the time they were rushing, I was always like can I write this down to go back home to like really make sense of it and then sometimes obviously, sometimes I would have to say can I stay back and practice this thing again [as] I didn’t grab it as quickly as others did and the essence of the labs is that it’s grab all of these things ” (P3).

Challenges: Teaching staff experiences of GEN student learning

While on the whole the teaching staff were able to gauge the learning needs of this GEN cohort, the expectations of both parties did not always align, with one staff member reporting that.

“ the two biggest challenges was [sic] getting them [the students] to unpack already learned behaviour and [to] acknowledge their own limitations or bias ” (L1),

however by the end of the semester the same staff member reported that.

“ I think we made a lot of progress in getting them to acknowledge how they learn ” (L1).

Moreover, the challenges anticipated in teaching GEN students were not those that transpired in that.

“ I actually thought going into the first paper I was pretty excited as to how it was going to roll out, the problems I encountered were not the problems I anticipated ” (L3).

The vocality of this cohort was tangible, however, when content did not meet their needs, interest or expectations with the students saying,

“ that they didn’t do the materials because it wasn’t of interest to them and requested other teaching very much related to the assignment as opposed to anything else …” (L1).

It was expected that the GEN students would be participatory both in class and online irrespective of their ways of learning, but there was a difference in both responses and comfort with this form of engagement. One student that talked about the unfolding case study and the online component of assessment as being problematic said that.

“.. we had to put up about 250 words of something related to the case study every week and then we spoke to someone else, [I] didn’t really like the responses…I didn’t really like having to respond to someone else ” (P3).

Yet in contrast to this statement, the teaching staff were delighted that.

“…actually I got some fantastic questions from one of the students…emailed to me on Monday night about the case that was online for them, questions that I didn’t talk about in [the] lecture, I didn’t introduce the concept…they’re talking about concepts that are currently undergoing international clinical trials” (L1).

This study explored the experiences of both GEN students and academics using unfolding case studies situated in experiential learning pedagogy. The use of unfolding case studies supported with podcasts embraced our idea of developing content situated in real-life contexts. Learning was scaffolded using different teaching approaches such as podcasts, and experiential simulated learning, to offer learners multiple ways of engaging with content. Scaffolding is recognised as learning material being broken into smaller chunks of learning and in this way aligns with case-based learning [ 25 ]. In this way, we hoped that not only would students engage in problem-solving, and develop clinical decision-making skills [ 26 , 27 ], but that they would also achieve deep and lifelong learning and ultimately have an ‘aha’ moment when it all made sense.

Reflections on using an unfolding case study approach

Findings were divided, with some students enjoying the unfolding case studies and others describing them as not sufficiently challenging. The scaffolded learning approach that we developed incorporated a range of teaching approaches that enabled them to engage with the content in a way that fitted in with their lifestyle, even if the teaching method did not align with their individual learning preferences. Students reported differing views about the case studies; some enjoyed the unfolding nature while others wanted more context and direction to feel that they could make an informed clinical decision. Nonetheless, even though they did not like information being presented in smaller chunks one student recognised it meant they analysed the information they received more deeply.

Other learning tools such as podcasts were not always valued by participants and yet, the fact that students were able to provide feedback on their use does indicate that they at least attempted to engage with them.

Student reflections indicate that perhaps the use of unfolding case studies as a learning approach is not the solution to engagement, and that often more traditional teaching methods were preferred Indeed, Hobbs and Robinson’s [ 28 ] study of undergraduate nursing students in the US supported Carter and Welch’s [ 14 ] findings that the use of unfolding case studies were of no direct benefit, whilst Ellis et al.’s., [ 29 ] study confirmed that for final year nurse practitioner students unfolding case studies were beneficial in developing critical thinking and stimulating clinical reasoning. Considering these two conflicting findings, further consideration is needed of how to engage highly motivated GEN students.

As such, our results suggest it can be difficult to predict the needs of the GEN students given the diversity of their previous academic qualifications, career, and often significant life experience they bring to the programme [ 30 , 31 ]. Interestingly students in this study simultaneously demonstrated insight into their needs supporting their previous academic study experience and felt sufficiently secure to voice them, which supports evidence found in D’Antonio et al.’s [ 32 ] study. This suggests that GEN students’ capabilities need to be embraced and incorporated when planning curriculum and scaffolding learning. Anecdotally, we have found that students embrace experiential learning such as that offered in simulation labs whether this involves the use of simulated manikins or not, it seems the hands-on learning offers not only the opportunity to experience simulated reality but also fosters collaboration and problem solving with peers that enables them to dwell in learning of what it is to be a nurse.

Graduate entry students recognised as experienced learners

Our students were not overwhelmingly supportive of the pedagogical approach of unfolding case studies we adopted. As previously recognised GEN students are experienced learners and whilst having differing educational backgrounds bring individual experience and knowledge of their own approach to their learning. Nonetheless, the value of their previous learning experience appears problematic in that those learned behaviours and attitudes need to be refocused to engage with learning how to become a nurse, as demonstrated in the academic staff reflections. Despite this background experience and perceived confidence, some students reflected that online engagement that involved exploring the case studies in discussion forums with colleagues was uncomfortable. This was surprising to the academic staff and contrasted sharply with their reflections on the activity but has been previously noted by Boling et al., [ 33 ].

Implications

Given the disparity that exists between student and academic staff experiences, as demonstrated in our study, co-designing content delivery may offer a progressive solution. By engaging ‘students as partners’ it offers them a much deeper level of involvement in future teaching delivery through collaboration and reciprocation of ideas, thus culminating in appropriate curriculum design [ 34 ]. Collaborating with students in course design might facilitate students learning as they become cognisant of the active engagement of academic staff [ 9 , 10 , 35 ]. In the future, we aim to involve students in any curriculum review and course development to ensure their perspectives influence curriculum design and content delivery.

Even so, our initial intention of scaffolding learning by offering different ways for students to engage with content is supported by recent research by Dong et al. [ 36 ] who found that students performed better academically in a flipped classroom. This point, in association with our findings, suggests that the best approach to content delivery for graduate entry nursing students is to ensure students are involved in curriculum and course design alongside the delivery of learning experiences that are well facilitated and supported by faculty so that students are aware of the expectations, required of them, and importantly how they will be assessed.

Limitations

We acknowledge that the sample size in this study is small in terms of generalisability. However, our findings offer interesting, detailed and in-depth insights into the experiences and needs of both GEN students and the academic staff involved in the development and delivery of educational material. Further work needs to be undertaken to evaluate the experiences of GEN students from a range of educational providers. A longitudinal study has been undertaken to explore the motivations and experiences of GEN students in Australasia [ 37 ], which will also support these findings regarding the learning needs of GEN students.

This study has provided a platform through which academics and GEN students can share their insights of teaching and learning experiences. The results offer a clear insight into what these students expect and need to expedite their learning and how teaching staff must respond. While participants' views were somewhat mixed in relation to the use of unfolding case studies and scaffolded learning these results demonstrate how GEN students are aware of their personal ways of learning and how this translates in terms of education needs. The sharing of these experiences provides an insightful lens through which to re-evaluate pedagogical approaches for GEN students. As such, we suggest that to meet the needs of GEN student’s not only is a blended pedagogical approach appropriate but expanding education design boundaries further through a co-design focused approach to GEN programme design.

Availability for data and materials

The datasets generated and analysed during the current study are not publicly available due privacy and ethical restrictions of the participants, but are available from the corresponding author on reasonable request.

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Macdiarmid, R., Merrick, E. & Winnington, R. Using unfolding case studies to develop critical thinking for Graduate Entry Nursing students: an educational design research study. BMC Nurs 23 , 399 (2024). https://doi.org/10.1186/s12912-024-02076-8

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Integration of Acute Malnutrition Treatment Into Integrated Community Case Management in Three Districts in Southern Mali: An Economic Evaluation

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Key Findings

This study analyzed the costs associated with 3 levels (basic, medium, and high) of support to and supervision of acute malnutrition treatment at community health worker (CHW) sites and community health centers.

The medium and high level of supervision significantly increased total program costs and cost per child treated compared to the basic level of supervision.

However, as cure rates were significantly higher in the districts with medium or high levels of supervision, differences in cost per child cured were small with overlapping uncertainty ranges.

Results suggest that, despite the higher costs, additional supervision is needed to achieve better treatment outcomes and that additional supervision has the potential to be a cost-effective strategy if efficiencies are made in its delivery.

Key Implication

Acute malnutrition treatment access, coverage, and health outcomes could be improved if adequate training, supervision, and technical support are in place and the best and most efficient way to deliver the additional supervision is carefully considered and is context specific to ensure cost-effectiveness and sustainability.

Background:

Enabling community health workers (CHWs) to treat acute malnutrition improves treatment access and coverage. However, data on the cost and cost-effectiveness of this approach is limited. We aimed to cost the treatment at scale and determine the cost-effectiveness of different levels of supervision and technical support.

This economic evaluation was part of a prospective nonrandomized community intervention study in 3 districts in Mali examining the impact of different levels of CHW and health center supervision and support on treatment outcomes for children with severe acute malnutrition. Treatment admission and outcome data were extracted from the records of 120 participating health centers and 169 CHW sites. Cost data were collected from accountancy records and through key informant interviews. Results were presented as cost per child treated and cured. Modeled scenario sensitivity analyses were conducted to determine how cost-efficiency and cost-effectiveness estimates change in an equal scale scenario and/or if the supervision had been done by government staff.

In the observed scenario, with an unequal number of children, the average cost per child treated was US$203.40 in Bafoulabé where a basic level of supervision and support was provided, US$279.90 in Kayes with a medium level of supervision, and US$253.9 in Kita with the highest level of supervision. Costs per child cured were US$303.90 in Bafoulabé, US$324.90 in Kayes, and US$311.80 in Kita, with overlapping uncertainty ranges.

Conclusion:

Additional supervision has the potential to be a cost-effective strategy if supervision costs are reduced without compromising the quality of supervision. Further research should aim to better adapt the supervision model and associated tools to the context and investigate where efficiencies can be made in its delivery.

• Introduction

An estimated 45 million children worldwide are affected by wasting. It is linked to significant morbidity and mortality, 2 , 3 and prevalence estimates of acute malnutrition have barely shifted over the last decade. The exact prevalence of acute malnutrition—a term that, in addition to children with a low weight-for-height z-score includes children with a mid-upper arm circumference (MUAC) of less than 125 mm and/or nutritional edema—is unknown but likely higher.

In the past, severe acute malnutrition (SAM), defined as a weight-for-height z-score less than −3 and a MUAC of less than 115 mm, required inpatient treatment solely at hospitals. This approach restricted the number of children that could receive treatment due to a limited number of hospital beds and required caregivers to spend a significant amount of time at the hospitals. 4 In the early 2000s, the advent of ready-to-use therapeutic foods (RUTFs) and the introduction of community-based management of acute malnutrition enabled children to be treated at home as outpatients, requiring only weekly visits to health facilities. This approach has reduced treatment costs, increased coverage of treatment, and reduced mortality rates from SAM. 5 – 7 Yet, it is estimated that less than 20% of children with acute malnutrition worldwide receive treatment as a result of unavailability of services, difficulty accessing services as a result of long distances to health centers, high opportunity costs to caregivers, and limited funds for acute malnutrition treatment services globally. 8 , 9 Recently, there has been an increasing interest in approaches that reduce the cost, simplify treatment, and bring treatment closer to communities to increase the coverage of acute malnutrition treatment. One such approach is the integration of acute malnutrition treatment into the package of services provided by community health workers (CHWs) as part of the integrated community case management (iCCM) approach, which has shown promising results. 10 The most recent revision of the World Health Organization guideline for the prevention and treatment of wasting and nutritional edema (acute malnutrition) stated that the identification and management of wasting can be carried out by CHWs if adequate training and supervision are provided. 11 However, the certainty of evidence for this conditional recommendation was judged as very low, 11 and more evidence is needed on the cost-effectiveness of this approach. 12

Interest has increased in approaches that reduce the cost of acute malnutrition treatment, simplify treatment , and bring treatment closer to communities to increase coverage.

In Mali, one of the countries affected the worst by acute malnutrition, the treatment of SAM is already considered to be an important part of the package of activities to be provided by CHWs, 13 and studies have shown the effectiveness of this approach both at small 14 and large scale. 15 , 16 An observational cohort study conducted in 7 health facilities and 19 CHW sites in Kita district, Kayes region in southwest Mali found that CHWs could effectively treat acute malnutrition in the community 14 and that this approach was cost effective. 17 Following the promising results of this pilot study, a second study was carried out from 2017 to 2018 at 120 health facilities and 169 CHW sites in 3 districts in the same region, where the 3 different districts received different levels of supervision as well as technical and financial support. 15 The objective was to determine whether the results of the pilot study could be maintained at scale as well as what level of supervision support was needed to maintain a good quality of care and maximize cost-effectiveness. Results showed that district-level recovery rates ranged from 66.9% to 86.2%, where districts that received an increased amount of technical and financial support at both health centers and CHW sites and a greater level of supportive supervision of CHWs had better outcomes. 15 We present the results of the economic evaluation linked to the aforementioned study.

Study Context

This economic evaluation was linked to a prospective nonrandomized community intervention study in 3 districts in Mali, namely Bafoulabé, Kayes, and Kita in the region of Kayes, taking place between July 2017 and October 2018. The methods and outcomes of the parent study are described in more detail elsewhere. 15

From 2016 to 2017, in Kayes, the prevalence of global acute malnutrition increased from 8.4% (95% confidence interval [CI]=6.3, 11.1) to 14.2% (95% CI=12.3, 16.4), and the prevalence of SAM increased from 0.9% (95% CI=0.5, 1.8) to 2.6% (95% CI=1.8, 3.6). 18 A socioeconomic survey conducted as part of the study showed that there were no differences between the 3 districts in terms of the proportion of children aged younger than 5 years in the family, the proportion of children with a MUAC of less than 125 mm, and access to health care. 15 However, in Bafoulabé, more households had access to clean water, a better food consumption score, and dietary diversity than households in the other 2 locations. Furthermore, the 3 districts differed in population size, density, and number of health facilities included ( Table 1 ). In Bafoulabé, the educational level of CHWs was lower, but a greater proportion of CHWs had more than 2 years of experience there than in the other 2 locations (91.2% in Bafoulabé, 82.2% in Kayes, and 77.8% in Kita). 15

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Characteristics of the Three Study Districts, Southwest Mali

Intervention and Study Participants

In October 2017, the treatment of malnutrition was integrated into the iCCM model in 3 districts in Kayes, meaning that CHWs were able to detect and treat uncomplicated cases of SAM while health facilities also continued to provide treatment. All children aged 6–59 months with SAM defined as a MUAC less than 115 mm and/or a weight-for-height z-score (WHZ) less than −3 and/or edema admitted for treatment at 1 of the 120 health centers or 169 CHW sites were included in the study and received treatment according to the Malian nutrition protocol. Decentralizing treatment to CHW sites brings the treatment closer to the village level, thereby facilitating accessibility, as health centers are often difficult to reach. A CHW site typically is a room in the village given to the CHW by the community where they see patients and keep supplies. CHWs report to, are supervised by, and receive supplies, such as RUTF, from their affiliated health centers. They also refer complex cases beyond their capacity to the health centers. CHWs in the 3 districts received the same training, which consisted of a 3-week practical training and a 6-week supervised internship at the health facility, but different levels of supervision. Access to treatment in the project area before the intervention was low, with coverage surveys indicating a treatment coverage of 20.4% (12.9%–30.8%) in Bafoulabé, 28.7% (20.6%–38.6%) in Kayes, and 28.4% (19.9%–39.2%) in Kita. 19 Low coverage was partly due to long distances to health facilities. In Mali, an estimated 42% of the population lives more than 5 km away from a health center. 20 A year after the integration of acute malnutrition treatment into the package of care provided by CHWs, treatment coverage increased to 61.1% in Bafoulabé and increase to 57.1% in Kayes but did not change in Kita. 19

Supervision and Support

Intervention support and supervision differed across the 3 districts. In Bafoulabé, the basic level of supervision was implemented, which consisted of biannual supervision of the health centers and CHW sites by individuals from the national and regional Ministry of Health, quarterly supervision of the CHW sites by the district health management team of the Ministry of Health, and monthly supervision of the CHW sites by health center staff.

Intervention technical and financial support and biannual, quarterly, and monthly supervision visits differed across the 3 districts.

In Kita and Kayes, Action Against Hunger provided financial, logistic, and human resource support. This included financially supporting staff from the Ministry of Health and health centers to conduct biannual and quarterly supervision by covering per diems, transport, and accommodation costs. Furthermore, in these 2 districts, the quarterly supervision was expanded to also include supervision of health centers. Monthly supervision was also intensified in Kayes and Kita. In Kayes, the monthly supervision of CHW sites was done by 4 supervisors and 2 medical doctors employed by Action Against Hunger Mali, together with the health center technical directors using the supervision checklist from the iCCM policy in Mali. 13 In Kita, CHW sites were subject to a particularly rigorous level of supervision, which, in addition to the same supervision received by CHW sites in Kayes, also included monthly nutrition-specific supervision visits by 6 supervisors and 3 medical doctors from Action Against Hunger using the checklist outlined in the Mali community-based management of acute malnutrition policy. 21 The ratio of Action Against Hunger supervisors was 1 supervisor for 15 CHW sites in Kita and 1 for 11.2 CHW sites in Kayes. Action Against Hunger staff spent approximately half their time supervising CHW sites and half their time supporting the health centers. Table 2 provides an overview of the different levels of supervision in the 3 districts.

Supervision Models Used at Health Centers and CHW Sites, Southwest Mali

Design of the Economic Evaluation

Time horizons for the costing study are within the study period from July 2017 to October 2018. Training of CHWs took place between July and October 2017, and treatment from November 2017 to the end of October 2018. Financial and economic costs only for outpatient treatment incurred by project partners, health centers, and CHW sites were collected as part of this study. We did not include costs to families, as these were previously collected as part of the pilot study 14 and were not expected to differ between the 3 supervision models.

Cost Data Collection

Costs were estimated using an activity-based and ingredients approach. As an initial step, a focus group discussion with key project staff was conducted to determine project partners, timelines, project activities, and ingredients ( Table 3 ).

Overview of Cost Data Collected at CHW Sites and Health Centers, Southwest Mali

Project proposals and documents were reviewed to understand which activities and ingredient costs would likely be found in the Action Against Hunger accountancy data and which additional costs needed to be determined through key informant interviews with project partners. The project was a collaboration between the Direction Nationale de la Santé (National Health Directorate) and the Direction Régionale de la Santé (Regional Health Directorate) of the Ministry of Health as well as the Institut National de Recherche en Santé Publique (National Public Health Research Institute) and Action Against Hunger, with essential supplies (e.g., RUTFs) provided by UNICEF. The CHW salaries were paid for by Save the Children with funding from the U.S. Agency for International Development. In addition, Population Services International played a role in equipping CHWs with essential tools, such as registers, support documents, and monthly reporting sheets. Finally, the Associations de Santé Communautaires (community health associations) manage the community health centers. Health center staff salaries are paid for either by the community health associations or the government.

Between September 24, 2018, and October 31, 2018, a total of 120 people were interviewed as part of this study. More specifically, at the national level, 20 people were interviewed from Action Against Hunger, Save the Children, Population Services International, the National Health Directorate, and the National Public Health Research Institute. At the regional level, 4 key informants from the Regional Health Directorate were interviewed. At the district level, 30 key informants (e.g., Action Against Hunger staff, district-level Ministry of Health staff, health center staff, and CHWs) were interviewed in Bafoulabé, 30 in Kayes, and 48 in Kita. Purposive sampling was used. Individuals were asked about costs, including supervision, staff, materials, supplies, transport, health center costs (including salaries, upkeep, equipment, and supplies), CHW site costs, and time spent on project activities, as well as time allocation to different project activities. To estimate the cost of the space used for the nutrition treatment program at the health centers and the CHW sites, respondents were asked what the monthly rent for such a space would be.

Data from a CHW time use study conducted as part of the main study were also used. This study was conducted among 140 CHWs (30 in Bafoulabé, 68 in Kita, and 42 in Kayes) to determine the total number of hours a CHW worked and the time spent on malnutrition treatment. 22 CHWs were asked to note how much time they spent on iCCM activities for 1 month (September 1–30, 2018) using a self-administered questionnaire. Data showed that CHWs in Bafoulabé, Kayes, and Kita worked an average of 5 hours 10 minutes, 2 hours 40 minutes, and 2 hours 10 minutes per day, respectively. Of this, CHWs in Bafoulabé spent 13% of working hours on the treatment of SAM, CHWs in Kayes 12.3%, and CHWs in Kita 16.9%. Data from the time use study were triangulated with data from interviews with CHWs.

UNICEF provided costs per carton for RUTF supplies and associated transport costs. Total RUTF costs were estimated based on the cost per carton provided by UNICEF (US$45), the number of children admitted for treatment, and, due to the absence of RUTF consumption data, the assumption that 1 carton (150 sachets) per child was necessary for treatment.

Accountancy data from Action Against Hunger’s accounting system was reviewed at the end of the project. Any costs not directly linked to implementation, such as research costs, were excluded.

Treatment Outcomes Data

Data on treatment outcomes were obtained from the main study. 15 Outcomes included the number of children who recovered, defaulted, and died, as well as the number of children transferred to another health facility for inpatient care because they did not respond to treatment or developed another medical condition that prevented them from being treated as outpatients. Data were collected at CHW sites and health facilities. CHWs sent monthly activity reports to the health centers, which were reviewed by the health center technical directors and then sent to the district. At the district level, Action Against Hunger staff entered the data. Data from coverage surveys conducted at the start and the end of the study period, as well as data from socioeconomic surveys, were considered in the interpretation. 19

Data Management

Data from all sources (accountancy data, key informant interviews, time use study) were aggregated into a Microsoft Excel spreadsheet and adjusted.

Salary costs were obtained from Action Against Hunger accounting records for Action Against Hunger staff and from government salary scales for government and health center staff. Salary costs were then adjusted for time spent on the project, in the case of Action Against Hunger staff, or, in the case of health center staff, the proportion of time spent on malnutrition treatment. The proportion was determined during the key informant interviews or, in the case of CHWs, the time use study.

Building, facilities, and transport costs that were not supported by Action Against Hunger, such as CHW sites and health centers, were estimated based on interviews and adjusted according to the proportion of time spent on nutrition activities, as determined during key informant interviews and the CHW time use study conducted as part of the parent study.

Support costs from the Action Against Hunger accountancy were allocated to the 3 districts in several ways. First, costs that were independent of the number of staff or size of operation in the district were allocated as one-third to each district. Any support costs that were shared among multiple projects were allocated to each project based on a percentage of total projects. Costs that were expected to be dependent on the number of Action Against Hunger staff at the district level (e.g., support costs at the country office level) or number of CHWs (e.g., training) were allocated based on the percentage of personnel at Action Against Hunger district offices or CHWs in the districts, respectively.

Costs were adjusted for inflation and capital cost depreciation. Adjusting for inflation was done using the Consumer Price Index. 23 Capital costs, defined as any item that can be used for more than 1 year and costs more than US$100, 24 were adjusted to only reflect the costs of life of the item that was used by the program. Capital items, such as computers and cars, were amortized using standard tables and discounted at a rate of 3%. The lifespan of items was assigned as suggested by WHO-CHOICE. 25 For office supplies not found in the WHO-CHOICE table, such as mobile phones and telephones, a life span of 3 years was assumed. As costs came from various sources and were expressed in different currencies, all costs were converted to US$ using average yearly exchange rates. 26 All costs are expressed in 2018 US$.

Data Analysis

Aggregated costs were organized into main cost centers according to activity and ingredients. Cost per child treated and cost per child cured were calculated by dividing the total cost per district by the number of children fully treated and cured, respectively. As the supervision of CHW sites was a key component of this study, we also presented CHW supervision and direct treatment costs (CHW time, CHW site costs, and supplies) separately ( Supplemental Tables S1 and S2 ). However, it is important to note that the CHW sites do not function as an independent program and require a link to a functioning health center.

Accounting for Uncertainty

Given the amount of assumptions regarding the inclusion and adjustment of costs, as well as estimations done when assigning economic costs, there is a lot of uncertainty in economic evaluations. In our analysis, we treated per diems and transport costs paid for by Action Against Hunger as fixed costs and RUTF, staff, support, and building and facilities costs as uncertain. Staff costs were treated as uncertain because of the difficulty in accurately estimating the amount of time spent on project activities in the absence of detailed time sheets. We assumed a 10% margin of error for costs collected during interviews, 27 such as staff, support, building, and facilities costs. We assumed a −50% and +25% margin of error for RUTF based on data in the literature that showed a range of RUTF consumption between 70 and 193 sachets per patient, 15 , 28 , 29 as well as the number of boxes sent to the study areas as provided by UNICEF, which is in line with the high estimate of 193 sachets per child.

We used an approach based on triangular fuzzy numbers and fuzzy arithmetic described by Myatt et al. to account for uncertainty and calculate 95% CI around cost-efficiency and cost-effectiveness estimates. 27 Using triangular numbers to account for uncertainty is similar to a sampling based approach but is based on a triangular distribution instead of binomial or probability distributions. 27 In this approach, triangular fuzzy numbers are expressed as a minimum, maximum, and most likely value, where the most likely value is the one estimated by the data collection in the base case, and the minimum and maximum were calculated as the base case +/− the assumed margin of error. For cure rates, the minimum and maximum were calculated as the proportion cured +/− 2 standard errors of the proportion.

Operations between fuzzy numbers (e.g., a combination of multiple cost categories and cost per child recovered as well as 95% CI) were calculated using a fuzzy arithmetic calculator. 30

Modeled Scenario Sensitivity Analyses

Three modeled scenario sensitivity analyses were conducted to determine how cost-efficiency and cost-effectiveness estimates change if the number of children treated and sites had been the same across locations and/or the supervision had been done by government staff. First, in the equal scale scenario sensitivity analysis, the number of sites and number of children treated per site from Kita was applied to the other 2 districts. RUTF costs and personnel time were adjusted to reflect the higher number of sites and children treated in Bafoulabé and Kayes. Cure rates from the main study were then applied to determine the cost per child cured. As there was a significant difference in the number of children treated at health facilities versus CHW sites, 15 we recalculated the number of cured children separately for CHW sites and health facilities. In a second model, we reduced the Action Against Hunger supervision staff costs to one-third, a number that was deemed to be achievable by replacing supervision staff with government staff at the level of a nurse. The third model is a combination of the first 2 scenarios (i.e., equal scale and government staff costs).

Ethical Approval

The study is registered under ISRCTN14990746 . Ethical approval was obtained from the Ethics board in Mali (No. 17/2017/CE-INRSP).

Cohort Treatment Outcomes

During the study duration, a total of 862, 1,930, and 3,320 children were treated in Bafoulabé, Kayes, and Kita, respectively. The treatment outcomes are described in detail by Charle et al. 15 Nevertheless, the main results are reproduced here to facilitate an understanding of the economic evaluation results. The number of children by district and average number of children treated by health facility and CHW is shown in Table 4 , and the treatment outcomes are shown in Table 5 .

Number of Children Treated for Acute Malnutrition at Health Centers and by CHWs, Southwest Mali

Outcomes for Children Treated for Acute Malnutrition, Southwest Mali

Total Intervention Costs

In the observed scenario, the total cost of the intervention in Bafoulabé was US$175373.8 (95% CI=US$159839.9, US$191948.4); in Kayes, US$540270.6 (95% CI=US$476549, US$588147.6); and in Kita, US$843084.6 (95% CI=US$734885.4, US$912231.8), with treatment and supervision being the most expensive activities ( Table 6 ). In terms of ingredients, personnel costs make up the highest proportion of total costs in the 3 intervention areas. Treatment supplies (RUTFs and medicines) make up 23.5%, 17.2%, and 18.4% of total costs in Bafoulabé, Kayes, and Kita, respectively. The costs of CHW salaries make up only 2.1% of total project costs in Bafoulabé, 0.7% in Kayes, and 1.7 % in Kita ( Table 6 and Figure ). Direct treatment costs accounted for 51.1% in Bafoulabé, 34.0% in Kayes, and 38.7% in Kita ( Table 6 ).

Project Costs by Activity for Each Study Location in the Base Case, Southwest Mali

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Costs Associated With Integrating Treatment of Acute Malnutrition Into Integrated Community Case Management, by Ingredient, in Three Districts, Southwest Mali

Abbreviations: AAH, Action Against Hunger; CHW, community health worker; RUTF, ready-to-use therapeutic food.

Supervision Costs

Supervision costs amounted to US$27819 (15.9%), US$174551.1 (32.3%), and US$232047.8 (27.7%) in Bafoulabé, Kayes, and Kita, respectively ( Table 6 ). Of the total supervision costs, US$10939.4 (41.6%), US$60919.2 (34.6%), and US$123897.5 (52.2%) were spent on supervision of CHWs in Bafoulabé, Kayes, and Kita; the rest was supervision to the health centers. This equates to a monthly supervision cost per CHW of US$27 in Bafoulabé, US$113 in Kayes, and US$115 in Kita. A breakdown of CHW supervision costs, as well as supervision costs per child treated and recovered at CHW sites, is presented in Supplemental Table S1 .

Cost per Child Treated and Recovered

In the base case, the average cost per child treated was US$203.4 (95% CI=US$185.4, US$222.7) in Bafoulabé; US$279.9 (95% CI=US$246.9, US$304.7) in Kayes; and US$253.9 (US$221.4, US$274.8) in Kita. A total of US$48 (95% CI=US$28, US$57) of this were RUTF and medicine costs. There was no difference between the 3 locations as the estimates of RUTF data were based on the literature rather than consumption during the study. Lack of available data on RUTF consumption led to a large amount of uncertainty in RUTF cost estimates; therefore, the cost per child treated and cured are presented both with and without RUTF costs ( Table 7 ). In the base case, the cost per child treated in Bafoulabé was notably lower than in the other 2 districts, the difference in cost per child recovered was less pronounced, and uncertainty ranges overlapped ( Table 7 .). Direct treatment costs per child treated and cured disaggregated by treatment site are shown in Supplemental Table S2 .

Cost per Child Treated and Cured in the Observed Base Case Analysis, Southwest Mali

Modeled Scenarios

The equal scale modeled scenario sensitivity analysis showed that, where all costs not related to the additional supervision were equal, such as the number of health centers, the cost per child treated and cured in Bafoulabé was significantly lower than in the other 2 areas. In contrast, where Action Against Hunger supervision staff costs are replaced by government staff costs, the additional supervision and support provided in Kita and Kayes becomes a cost-effective strategy ( Supplemental Table S3 ).

In this study, we have assessed the cost of the treatment of acute malnutrition in 3 districts in southern Mali and aimed to determine the impact of additional supervision and technical support at CHW sites and health centers on the cost per child treated and cost per child cured.

Overall, our treatment cost estimates, ranging from US$203 to US$280, were comparable to estimates in previous studies, ranging from US$135–US$802 in Zambia, 31 Malawi, 6 Ethiopia, 7 Niger, 32 , 33 Ghana, 34 Bangladesh, 5 Mali, 17 and Pakistan. 35 An earlier smaller study in Kita, Mali, covering some of the same sites as this study, found a similar cost per child treated and cured of US$244 and US$259, respectively. 17 Similar to other studies involving international nongovernmental organizations (NGOs), 5 , 17 , 31 , 35 we found that institutional support, coordination, and supervision costs together accounted for a large proportion of overall costs, in this case, more than 50% in Kayes and Kita. In Bafoulabé, without the additional technical and supervision support, these costs were lower at 25.5%, and the proportion of direct treatment costs was higher (51.1% Bafoulabé, compared to 34% in Kayes and 39% in Kita). In terms of ingredients, the largest proportion of costs were personnel costs in all 3 areas (42%–61%), followed by RUTF costs, which is consistent with prior research. 5 – 7 , 17 , 31 , 32 In the present study, the overall proportion of costs for CHW salaries was small at 1%–2% of the intervention costs. Yet, CHWs commented that sometimes, there are gaps in their payment. Given that their participation is essential to the success of this approach, future interventions of this type should ensure that sufficient funding is allocated to their salaries.

We found that institutional support, coordination, and supervision costs together accounted for a large proportion of overall costs, in this case, more than 50% in Kayes and Kita.

Our results suggest that additional supervision and support are needed to achieve acceptable health outcomes despite the high additional cost. Although the cost per child treated was significantly higher in Kayes and Kita, the cure rate in Bafoulabé was significantly lower than in the other 2 districts and did not meet Sphere Standards of at least 75% recovery. 15 This is also reflected in the fact that while the cost per child treated in the base case was US$50–US$77 higher in the areas with additional supervision, the difference in cost per child cured in the base case estimate was lower at US$8–US$21 and uncertainty ranges overlapped. Interestingly, there was no discernible benefit of adding the nutrition-specific monthly supervision in Kita compared to Kayes. Charle et al. have previously suggested this lack of impact may indicate the need for better adaptation of the evaluation grids to the context and CHW sites. 15 Furthermore, some of the items on the community-based management of acute nutrition checklist were already covered by iCCM supervision and may, therefore, not have led to additional impact on outcomes.

Results from our modeled sensitivity analysis indicate that the additional supervision has the potential to be a cost-effective strategy if efficiencies are made in its delivery. Replacing Action Against Hunger staff with government staff is an option. Other options include better integration of the nutrition-specific supervision into iCCM supervision activities and better adaptation of the said supervision to the CHW level, as also recommended by the technical committee of the project led by the Directorate of Nutrition of the Ministry of Health following the publication of the effectiveness results. 36 Another alternative may be to start with high-intensity supervision when new CHWs are starting and then to reduce the supervision as they become more experienced.

This study had several strengths. It is one of few economic evaluations costing treatment of acute malnutrition integrated into the iCCM approach at scale. We conducted modeled scenario sensitivity analyses to understand the impact of scale and higher staff costs resulting from the involvement of NGO staff. The fact that it was not a randomized study but included all children in a relatively large area enabled us to cost the treatment more realistically outside of a trial context.

In line with our findings, since this study was conducted, the Malian government has put a new strategy of CHW supervision in place, which recommends employing and training 1 supervisor per 10–15 CHWs undertaking monthly supervision visits, where supervision is supported by a digital application which guides the workflow. The rollout of this strategy has started.

Limitations

This study had several limitations. First, a number of assumptions/estimations had to be made regarding cost data that led to significant uncertainty around the cost estimates (as described in detail in the methods section), and data on RUTF consumption, length of stay, and baseline anthropometry were not available. It is possible that higher levels of supervision and technical support, which also included support to active case finding, in Kita and Kayes would have enabled earlier detection, which, in turn, could have led to quicker recovery, lower staff costs, and lower quantities of RUTF. The difference in cost per child treated and cured between Bafoulabé and 2 intervention areas, both in the base case and in the modeled equal scale scenario sensitivity analysis, may, therefore, be slightly overestimated. RUTF costs could also have been affected by different levels of defaulting and potentially more difficulties in assigning the correct weight-based dose in Bafoulabé, where CHWs had lower levels of education and less supportive supervision. Lack of availability of baseline anthropometric status and socioeconomic data for each participant also meant that the comparison of cure rates was not adjusted for baseline and other characteristics, which makes it difficult to completely disentangle the effect of the added supervision on effectiveness. Second, the treatment at CHWs was not rolled out simultaneously at all sites from the start of the project. It was not possible to obtain exact dates for all the sites. Therefore, the CHW-related costs, which were calculated based on similar start dates in the 3 districts, may have been slightly overestimated. However, the overall cost contribution of CHW salaries was small (less than 2%); therefore, more exact dates are unlikely to impact the overall result. Third, because of the different supervision levels in the districts, there was more quality control of the treatment outcome data in the intervention areas than in the control area. A further limitation is that we did not include inpatient treatment in total costs. Lastly, this study was not a randomized controlled trial, so the higher cure rates in Kita and Kayes cannot be solely attributed to the different levels of supervision and could have been influenced by other factors, such as the education level of CHWs, dietary factors, and prior knowledge of the approach in Kita.

In conclusion, in this study, the additional supervision in Kita and Kayes significantly increased treatment costs. Although additional supervision came at a significant cost, results indicate that the additional supervision is needed to achieve satisfactory cure rates above Sphere Standards. Finally, the results of the sensitivity analysis indicate that the additional supervision has the potential to be a cost-effective strategy if supervision costs are reduced without compromising the quality of supervision, for example, by replacing INGO supervision staff with government staff. Further research should aim at better adapting the supervision model and associated tools to the context and investigate whether efficiencies can be made in its delivery.

• Acknowledgments

We would like to thank the patients and their parents, the community health workers and health staff, and community leaders, as well as all partners who contributed to this study, namely the Nutrition Division of Mali, the Institut National de Recherche en Santé Publique, and all of the organizations of the Technical Advisory Group for their support and involvement of the study. We would also like to thank Abdoul Salam Savadogo for his support in facilitating the data collection part of the cost-effectiveness study.

This work was funded by the Innocent Foundation, The European Civil Protection and Humanitarian Aid Operation (ECHO), the Post Code Lottery Foundation, and UNICEF.

• Author contributions

PC-H, NLE, and BC conceived the study. PCH, NLE, and MB oversaw the data collection of the effectiveness study. BC collected and analyzed cost data and wrote the first draft of the article. PCH, NLE, MBM, AB, and MS reviewed and shaped the submitted version of the article. All authors approved the final version of the article.

• Competing interests

None declared.

Peer Reviewed

First published online: June 20, 2024

Cite this article as : Cichon B, López-Ejeda N, Mampindu MB, Bagayoko A, Samake M, Cuellar PC. Integration of acute malnutrition treatment into integrated community case management in three districts in southern Mali: an economic evaluation. Glob Health Sci Pract . 2024;12(3):e2300431. https://doi.org/10.9745/GHSP-D-23-00431

• Received: October 12, 2023.
• Accepted: May 14, 2024.
• © Cichon et al.

This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. To view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/ . When linking to this article, please use the following permanent link: https://doi.org/10.9745/GHSP-D-23-00431

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• Published: 18 June 2024

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• Laura A. Huppert   ORCID: orcid.org/0000-0002-8512-5608 1 ,
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Leptomeningeal disease (LMD) is a devastating complication of metastatic breast cancer (MBC). It is critical to better understand the risk factors, natural history, and treatment outcomes, including patients in a modern cohort.

In this single center retrospective cohort study, we identified patients with MBC and LMD who received care from 2000 to 2024 and abstracted key clinical, treatment, and survival data.

We identified 111 patients with MBC and LMD, including patients with the following subtypes: HR+/HER2− ( n  = 53, 47.7%), HER2+ ( n  = 30, 27.0%), and triple negative breast cancer (TNBC; n  = 28, 25.2%). Median time from the diagnosis of MBC to LMD was 16.4 months (range 0–101.3 months). After the diagnosis of LMD, most patients received systemic therapy ( n  = 66, 59.5%) and/or central nervous system (CNS)-directed therapy ( n  = 94, 84.7%) including intrathecal therapy ( n  = 42, 37.8%) and/or CNS-directed radiation therapy ( n  = 70, 63.1%). In all patients, median overall survival (OS) from the diagnosis of LMD to death was 4.1 months (range 0.1–78.1 months) and varied by subtype, with HR+/HER2− or HER2+ MBC patients living longer than those with TNBC (4.2 and 6.8 months respectively vs. 2.0 months, p  < 0.01, HR 2.15, 95% CI 1.36–3.39). Patients who received CNS-directed therapy lived longer than those who did not (4.2 vs. 1.3, p  = 0.02 HR 0.54, 0.32–0.91). Patients diagnosed with LMD from 2015 to 2024 lived longer than those diagnosed from 2000 to 2014 (6.4 vs. 2.9 months, p  = 0.04, HR 0.67, 95% CI 0.46–0.99). On multivariable analysis, having TNBC was associated with shorter OS from time of LMD to death ( p  = 0.004, HR 2.03, 95% CI 1.25–3.30).

This is one of the largest case series of patients with MBC and LMD. Patients diagnosed with LMD from 2015 to 2024 lived longer than those diagnosed from 2000 to 2014, although median OS was short overall. Patients with TNBC and LMD had particularly short OS. Novel therapeutic strategies for LMD remain an area of unmet clinical need.

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Introduction

One of the most devastating complications of metastatic breast cancer (MBC) is the development of leptomeningeal disease (LMD), also called leptomeningeal carcinomatosis. LMD is defined as cancer cell infiltration into the leptomeninges, including the pia mater, arachnoid, and subarachnoid space from a primary tumor. LMD can be diagnosed based on positive cerebrospinal fluid (CSF) cytology and/or convincing radiographic findings on MRI brain or spinal canal [ 1 ]. LMD was once thought to be a rare complication of MBC. However, newer studies show that LMD compromises up to 11–20% of the burden of central nervous system (CNS) disease [ 2 ]. With increasing survival after the diagnosis of metastatic disease, as well as improvement in diagnostic imaging and CSF detection techniques, more patients are being diagnosed with LMD over the last 20 years [ 3 ]. LMD can cause symptoms including headaches, confusion, word finding difficulties, difficulty with ambulation, incontinence, and other neurologic deficits, which can lead to significant morbidity and very negatively impact quality of life. Prognosis is poor, with a median overall survival of 3–4 months even with aggressive multimodal therapies [ 4 , 5 ].

Unfortunately, at present there are few effective treatment options for patients with LMD and there is no generally accepted standard of care for patients with LMD. Surgery for placement of a ventriculo-peritoneal shunt (if hydrocephalus is present), radiation therapy, chemotherapy (intravenous or intrathecal) and/or other systemic therapies, and best supportive care can all be considered, and selection of treatment depends upon the patient’s performance status and goals of care. Radiation therapy as a palliative or adjunctive therapy with other systemic therapies may include whole brain radiation therapy (WBRT), craniospinal irradiation, or focal radiation to sites of symptomatic LMD [ 1 ]. Intrathecal (IT) therapy including chemotherapies such as IT methotrexate, depot cytarabine, thiotepa or topotecan have been utilized over the past 20 years, although several agents are no longer commercially available and responses are generally limited [ 6 , 7 , 8 , 9 , 10 , 11 , 12 , 13 ]. IT trastuzumab has been studied in patients with human epidermal growth factor receptor 2 (HER2) positive LMD [ 14 , 15 , 16 , 17 , 18 ], including in a recent prospective study in 34 patients with HER2 + MBC and MBC, demonstrating a median overall survival of 10.5 months [ 19 ]. In the last decade, several intravenous (IV) or oral agents have been approved for MBC that have superior central nervous system (CNS) penetration. Patients with HER2-overexpressing breast cancers have had more effective systemic therapy for CNS disease since the introduction of lapatinib in 2007 and specifically since the LANDSCAPE trial in 2013, which demonstrated that patients with parenchymal brain metastases could delay radiation and a substantial percentage of intracranial responses were observed [ 20 , 21 , 22 ]. Improvements and advances in HER2 targeted TKIs including neratinib, tucatinib, and pyrotinib have improved outcomes for patients with HER2 + MBC with CNS disease [ 23 , 24 , 25 ]. Tucatinib in combination with capecitabine and trastuzumab was studied specifically in the treatment of patients with HER2 + LMD in the TBCRC 49 study; in the 17 patients treated, the median time to CNS progression was 6.9 months and median overall survival was 10 months [ 26 ]. Most recently, there is some data that the antibody–drug conjugate (ADC) trastuzumab deruxtecan (T-DXd) also has CNS activity [ 27 , 28 ], and multicenter retrospective data demonstrated responses in patients with MBC and LMD [ 29 ]. Therapy advances for patients with LMD and hormone receptor positive (HR+)/HER2− or triple negative breast cancer (TNBC) have been more limited. The CDK4/6 inhibitor abemaciclib was studied in a small cohort of patients ( n  = 10) with HR+/HER2− LMD and no LMD responses were observed [ 30 ]. For patients with all breast cancer subtypes, a multicenter phase II study evaluated the use of ANG1005, a brain-penetrating peptide-drug conjugate and showed some activity in patients with breast cancer and LMD and/or recurrent brain metastases [ 31 ]. There have also been clinical trials evaluating the safety and efficacy of IV immunotherapy for patients with LMD, although response rates are limited [ 32 , 33 ]. Unfortunately, patients with LMD after often excluded from clinical trials [ 34 ] which has impeded progress, and novel therapies are desperately needed.

Prior retrospective cohort studies have described the diagnosis, treatment, and survival of patients with MBC and LMD, although many of these case series are older and pre-date the introduction of some CNS-penetrant therapies described above. In one of the largest case series to date, Morikawa et al identified 318 patients treated from 1998 to 2013 with LMD and MBC at a single center. In this cohort, 44% of patients had HR+/HER2− MBC, 26% had HER2 + MBC, and 26% had TNBC. Most patients underwent a combination of radiation (64%), IT therapy (46%), and systemic therapy (20%) with an overall median survival of 3.5 months from date of LMD diagnosis [ 3 ]. Median overall survival varied across case series, ranging from 2 to 4.5 months, which was typically shorter in patients with TNBC (2–2.5 months) and longer in patients with HER2 + disease (5.2–8.4 months) [ 3 , 35 , 36 ]. There was significant variation among factors that improved overall survival in these case series. Some studies found that receipt of any therapy or a combination of systemic or CNS directed therapy was beneficial to overall survival [ 37 , 38 , 39 ]. Other studies specifically found no benefit of radiation without IT or systemic therapy [ 36 , 40 ]. A few groups collected data on only IT therapy [ 41 ] or systemic therapy [ 35 , 42 , 43 ] and demonstrated an improvement in survival compared to no treatment. Finally, one study by Azevedo et al. found no significant impact on survival with any form of treatment studied [ 44 ]. However, almost all studies agree that functional status and subtype of disease had a significant association with overall survival after LMD diagnosis [ 37 , 41 , 44 ]. While these data provide important information about the natural history and treatment of LMD, the majority of these retrospective cohort studies, including the larger study done by Morikawa et. al., are based on data primarily gathered from the 1990s and 2000s, and therefore look at outcomes prior to the availability of newer HER2-directed therapies and systemic therapies like antibody–drug conjugates. To our knowledge, the study by Wallace et al. is one of the only more recent studies that evaluated patients with MBC and LMD from 2011 to 2020 and interestingly found similar numbers in median overall survival (4.5 months) compared to older cohort studies [ 36 ]. In this study, the authors found that systemic therapy, IT therapy, and WBRT prolonged survival for all patients, and showed that lapatinib and trastuzumab improved overall survival (OS) in patients with HER2 + MBC and LMD [ 36 ].

It is critical to better understand the risk factors and natural history of LMD, including patients in a modern cohort after the introduction of additional therapies with improved CNS penetration. In this retrospective cohort study, we identified patients with MBC and LMD at a single center. Using detailed chart extraction, we evaluated demographic and clinical characteristics, treatment history, time to the development of LMD, management strategies, and overall survival.

Study design and objectives

This is a retrospective study of patients with MBC and LMD treated at the University of California San Francisco (UCSF) between 1/2000 and 1/2024. The primary objective of this study is to characterize the clinical characteristics and outcomes of patients with MBC and LMD. Secondary objectives include identifying risk factors associated with poor prognosis.

Participant identification

Patients were identified in three ways: (1) Via a search of the UCSF pathology database for patients with breast cancer and positive cerebrospinal fluid cytology; (2) Via a search of the UCSF radiation oncology database for patients with MBC and LMD receiving radiation at UCSF; and (3) Via a search of the deidentified form of the UCSF medical record using the Electronic Medical Record Search Engine (EMERSE) platform [ 45 ], a search engine that enables investigators to search a complete deidentified copy of the UCSF medical record, using the search terms “breast cancer” and “leptomeningeal disease” or “LMD” or “leptomeningeal carcinomatosis”. Patients were 18 years of age or older. Patients were excluded during initial screening if they were duplicated or if they did not have a primary diagnosis of breast cancer. After chart abstraction, additional patients were excluded if there were insufficient clinical records, insufficient radiology records, and/or if the diagnosis of LMD could not be confirmed.

Chart abstraction

Detailed information including patient demographics and tumor characteristics, treatment history, lab values, clinical outcomes, and survival dates were obtained via manual chart abstraction. Survival data was updated on 1/15/24.

Data were analyzed using Prism Software (GraphPad; San Diego, CA) and R version 4.2.2 ( www.r-project.org ). Descriptive statistics were used to summarize numeric responses as rate of events (%) and median (range) as appropriate. Comparisons between groups were made using the unpaired t -test, two-sided Fisher’s exact test, or log-rank (Mantel-Cox) test as appropriate. Survival distributions were estimated by the Kaplan–Meier non-parametric method. Univariable and multivariable analyses of factors associated with OS after diagnosis of LMD were evaluated using the Cox proportional-hazards model. All variables with p value < 0.1 on univariable analysis were included in the final multivariable model. p values of < 0.05 was considered statistically significant.

Institutional review board statement

This research was approved by the UCSF Institutional Review Board.

Patient demographic characteristics and tumor characteristics at MBC diagnosis

111 patients with MBC and LMD were identified at our institution and included in this analysis. Patient demographic and disease characteristics are shown in Table  1 . Most patients were female ( n  = 110; 99.1%), non-Hispanic ( n  = 96, 86.5%), and white ( n  = 77, 69.4%). Median age at MBC diagnosis was 51.4 years (range 25.8–80.0 years). Most patients had ductal histology ( n  = 76, 68.5%), but patients with lobular histology or mixed ductal/lobular histology ( n  = 23 and n  = 2 respectively, 22.5% combined) were over-represented compared to the general MBC population. 23 patients (20.7%) had de novo metastatic disease. Patients had the following MBC subtypes: HR+/HER2− ( n  = 53, 47.7%), HR+/HER2+ ( n  = 24, 21.6%), HR−/HER2+ ( n  = 6, 5.4%), and TNBC ( n  = 28, 25.2%). Most patients had parenchymal brain metastases ( n  = 82, 73.9%) in addition to LMD.

Systemic therapy in the metastatic setting prior to the diagnosis of LMD

Systemic therapy in the metastatic setting prior to the diagnosis of LMD is shown in Table  2 . Across all breast cancer subtypes, patients received a median of 3 prior lines of therapy for MBC prior to diagnosis of LMD (range 1–10), including a median of 2 prior lines of chemotherapy (range 0–8) and 1 prior line of endocrine therapy (range 0–5). Lines of therapy by breast cancer subtype is also shown in Table  2 . Of the patients with HER2+ disease, half received a prior HER2-directed TKI (15/30, 50%). A minority of patients received prior ADC therapy (14/111, 12.6%), likely due to the date range of this retrospective registry before ADC approvals. Similarly, only a minority of patients with TNBC received prior checkpoint inhibitor therapy (3/28, 10.7%).

Time from the diagnosis of MBC to the diagnosis of LMD

Time from the diagnosis of MBC to the diagnosis of LMD is shown in Table  3 . The median time from the diagnosis of MBC to LMD was 16.4 months (range 0–101.3 months). Median time from MBC to LMD differed by subtype with longer time to LMD in patients with HR+/HER2− (20.5 months) and HER2+BC (17.5 months) vs. shorter time in patients with TNBC (10.5 months) ( p  < 0.01). There was no statistically significant difference in time from MBC to LMD by histology: ductal vs. lobular or mixed ductal/lobular (16.8 vs. 15.8 months, p  = 0.65) or by year of MBC diagnosis 1999–2014 vs. 2014–2023 (17.0 vs. 15.2, p  = 0.28). Some patients had progression of systemic disease at the time of LMD diagnosis ( n  = 62, 55.9%), while other patients had stable or improved extracranial disease at the time of LMD diagnosis ( n  = 49, 44.1%).

Systemic and CNS-directed therapy in the metastatic setting after the diagnosis of LMD

Systemic and CNS-directed therapy in the metastatic setting after the diagnosis of LMD is shown in Table  4 . After the diagnosis of LMD, most patients received systemic therapy ( n  = 66, 59.5%) with a median of 1 line of systemic therapy (range 0–4). The percentage of patients who received any systemic therapy after the diagnosis of LMD differed by subtype: HR+/HER2− (33/53, 62.3%), HER2+(22/30, 73.3%), TNBC (11/28, 39.3%).

After the diagnosis of LMD, most patients also received CNS-directed therapy ( n  = 94, 84.7%), including intrathecal therapy ( n  = 42, 37.8%) and/or CNS-directed radiation therapy ( n  = 70, 63.1%). Rates of IT therapy use varied by subtype: HR+/HER2− (20/53, 37.7%), HER2+(15/30, 50.0%), TNBC (7/28, 25.0%). Of the 42 patients to have received IT therapy, most received 1 line of IT therapy ( n  = 37, 88.1%) but some received 2 lines of IT therapy ( n  = 5, 11.9%). Types of IT therapies administered included IT methotrexate ( n  = 23, 20.7%), IT topotecan ( n  = 4, 3.6%), IT depot cytarabine ( n  = 9, 8.1%), and/or IT trastuzumab ( n  = 11, 9.9%). Most patients received CNS-directed radiation for LMD ( n  = 70, 63.1%), including many who received WBRT ( n  = 57, 51.4%).

A minority of patients received no therapy after the diagnosis of LMD (neither systemic nor CNS-directed therapy) ( n  = 17, 15.3%).

Overall survival from diagnosis of LMD to death

Kaplan–Meier curves for survival data from the diagnosis of LMD to death are shown in Fig.  1 and favors associated with OS in univariate and multivariate analysis are shown in Table  5 . In all patients, median OS from the diagnosis of LMD to death was 4.1 months (range 0.1–78.1 months) (Fig.  1 A). Forty-three patients were alive at least 6 months (38.7%), 25 patients were alive at least 12 months (22.5%), and 10 patients were alive at least 24 months (9.0%). Median OS from LMD to death varied by subtype, with patients with HR+/HER2− or HER2+MBC and LMD living longer than those with TNBC and LMD (4.2 and 6.8 months respectively vs. 2.0 months, p  < 0.01, HR 2.15, 95% CI 1.36–3.39) (Fig.  1 A). There was no significant difference in median OS by histology: ductal vs. lobular (3.6 vs. 5.0 months, p  = 0.47, HR 0.83, 95% CI 0.50–1.37) (Fig.  1 C) or by presence vs. absence of concurrent brain metastases (4.7 vs. 2.0 months, p  = 0.30, HR 0.79, 95% CI 0.51–1.23) (Fig.  1 D). Patients who received CNS-directed therapy survived longer than those who did not receive CNS-directed therapy (4.2 vs. 1.3 months, p  = 0.02, HR 0.54, 95% CI 0.32–0.91) (Fig.  1 E). Patients who received IT therapy survived longer than those who were not treated with IT therapy (7.1 vs. 2.7, p  = 0.01, HR 0.60, 95% CI 0.40–0.90) (Fig.  1 F), whereas there was no statistically significant difference in survival based on receipt of CNS-directed radiation vs. not (4.2 vs. 2.8, p  = 0.79, HR 0.95, 95% CI 0.63–1.43) (Fig.  1 G). Patients diagnosed with LMD from 2015 to 2024 lived longer than those diagnosed from 2000 to 2014 (6.4 vs. 2.9 months, p  = 0.04, HR 0.67, 95% CI 0.46–0.99) (Fig.  1 H). On multivariable analysis, having TNBC was associated with shorter OS from time of LMD to death ( p  = 0.004, HR 2.03, 95% CI 1.25–3.30).

Overall survival from the diagnosis of LMD to death. Kaplan–Meier curves showing survival data of patients in this cohort from diagnosis of LMD (leptomeningeal disease) to death: A For all patients in this cohort ( n  = 111). B By breast cancer subtype: HR+/HER2− (red, n  = 53), HER2+ (blue, n  = 30), vs. TNBC (green, n  = 28). C By breast cancer histology: invasive ductal carcinoma (IDC) (purple, n  = 76) vs. invasive lobular carcinoma (ILC) (orange, n  = 23). D By presence of concurrent parenchymal brain metastases (yellow, n  = 82) vs. no parenchymal brain metastases (green, n  = 29). E By receipt of CNS-directed therapy (teal, n  = 94) vs. no receipt of CNS-directed therapy (pink, n  = 17). F By receipt of intrathecal (IT) therapy (dark blue, n  = 42) vs. no IT therapy (light blue, n  = 69). G By receipt of central nervous systemic (CNS)-directed radiation for LMD (gray, n  = 70) vs. no CNS-directed therapy for LMD (magenta, n  = 41). H By diagnosis of LMD from 2000 to 2014 (light pink, n  = 57) vs. 2015–2024 (dark pink, n  = 54). (Color figure online)

This study represents one of the largest reported case series of patients with MBC and LMD, including a more modern cohort with most patients diagnosed after 2010. Through detailed chart abstraction, we describe the patient demographic characteristics, disease biology, treatment history before and after the diagnosis of LMD, and overall survival in these patients.

In our cohort, we found that patients with HER2 + (27.0%) and TNBC (25.2%) were over-represented compared to the overall population of patients with MBC (typically 10–15% for each subtype) [ 46 ], which is consistent other published data [ 3 , 37 , 39 , 41 , 42 ]. Multiple mechanisms have been reported to explain the increased incidence of CNS disease in HER2-overexpressing cancers, both in mouse models and in humans [ 47 ]. Biological factors that may predispose patients with TNBC to preferentially developing CNS disease include an increased epithelial-to-mesenchymal transition (EMT) phenotype, “stem cell like” behavior, and upregulation of transcriptions factors such as MYC [ 48 ]. We also observed that patients with invasive lobular histology (22.5%) were overrepresented compared to the general population (10–15%) [ 49 ], which has also been reported in other LMD case series. Biologically, this is consistent with the behavior of lobular cancers which, due to loss of e-cadherin, a transmembrane glycoprotein that mediates a cell–cell adhesion, have a predisposition to spread to mucosal surfaces such as the peritoneum and GI tract [ 50 ]. The relatively young median age of patients and high percentage of patients with de novo metastatic disease may reflect the referral pattern of younger, healthier patients to our academic center. Consistent with prior studies, most patients in our cohort had concurrent brain metastases and LMD [ 3 , 36 , 43 ].

Prior to the diagnosis of LMD, patients in our cohort received a median of three prior lines of systemic therapy. In this more modern cohort of patients, we were specifically interested in whether patients received prior therapies known to have improved CNS penetration. We found that half of patients with HER2 + disease had received prior HER2−targeted TKIs. Fewer patients had received ADCs prior to the diagnosis of LMD, likely due to the more recent approvals of these agents. Across all patients, the median time from the diagnosis to MBC to the diagnosis of LMD was 16.4 months, with a wide range from 0.0 months (LMD at time of MBC diagnosis) up to 101.3 months. This is similar to prior retrospective studies, such as the median time from MBC to LMD of 22.5 months in the study by Morikawa et al. and 22.0 months in the study by Gauthier et al. [ 3 , 40 ]. Of note, there is variation in the frequency of CNS imaging and when radiologists make the diagnosis of LMD, so it is possible that the slightly shorter time from MBC to LMD in our population may have been due to more frequent CNS-imaging in our academic, clinical trial population, although this was not formally evaluated. Time from the diagnosis of MBC to the diagnosis of LMD was longer for patients with HR+/HER2− and HER2 + disease than for TNBC but did not differ by histology. Interestingly, there was no difference in time from MBC to LMD diagnosis by year of MBC diagnosis from 1999 to 2014 vs. 2015–2023. With tremendous advances in general for patients with MBC in the last decade, this may be due to the small sample size and random variance in this cohort, or it could speak to the fact that many agents do not have sufficient CNS penetration, so while patients with MBC in general are living longer, we may not be adequately preventing the development of LMD. Of note, about one half of patients were diagnosed with LMD at the time of systemic disease progression, whereas the other half of patients had stable/responding disease at the time of LMD diagnosis, which underlies the fact that the CNS compartment and in particular the CSF tumor microenvironment may be distinct from the systemic tumor microenvironment [ 51 ].

After the diagnosis of LMD, patients received a median of one additional line of systemic therapy, including 25% of patients with HER2 + breast cancer who continued or were treated with a HER2-directed TKI. Most patients also received some form of CNS-directed therapy, including IT therapy and/or CNS-directed radiotherapy. Specifically, 37.8% of patients received IT therapy, most commonly IT methotrexate for patients with HR+/HER2− and TNBC LMD and IT trastuzumab for patients with HER2 + LMD. Most patients also received radiation for LMD, including over half of the patients being treated with WBRT.

Among the patients with MBC and LMD in this cohort, the median OS from the diagnosis of LMD to death was 4.1 months, which varied by subtype: HR+/HER2− 4.2 months, HER2 + 6.8 months, and TNBC 2.0 months. These survival data are consistent with prior studies of MBC and LMD. For example, in a retrospective study of 318 patients with MBC and LMD from 1998 to 2013, the patients in their cohort had a median overall survival of 3.5 months from LMD to death, with subtype variation as follows: HR+/HER2− 3.9 months, HER2 + 5.2 months, and TNBC 2.5 months [ 3 ]. In a more recent study by Wallace et al. which included patients from 2011 to 2000, median overall survival from LMD to death by subtype was: HR+/HER2− 5.3 months, HER2 + 8.4 months, TNBC 2.0 months. We observed no difference in survival by histology (ductal vs. lobular), which is consistent with a prior retrospective analysis by Niwinska et al. [ 38 ]. Interestingly, there was also no difference in survival by the presence or absence of concurrent brain metastases. We found that patients who received CNS-directed therapy lived longer than those who did not receive CNS-specific therapy, and specifically patients who received IT therapy lived longer than those who did not receive IT therapy, as was also seen in the study by Wallace et al. [ 36 ], whereas there was no difference in survival based on receipt of CNS-directed radiation therapy in our cohort. It is possible that IT therapy indeed prolonged OS for these patients, or more likely that patients who had advanced LMD or a poor performance status may not have been offered or chosen to pursue IT therapy. Patients diagnosed with LMD from 2015 to 2024 lived longer than those diagnosed from 2000 to 2014 (6.4 vs. 2.9 months, p  = 0.04, HR 0.67, 95% CI 0.46–0.99) which may suggest some improvement in outcomes with novel CNS-penetrant agents in a more modern cohort, but survival was still short in both groups and this was not significant on multivariate analysis, so clearly better therapeutic strategies are needed. It is interesting to note that there was a small subset of patients who did live longer, with ten patients in our cohort (9.0%) that survived more than 24 months after the diagnosis of LMD. Further work is needed to determine predictors of favorable outcomes and whether there are one or more biomarkers that can predict longer-term survival.

This study has several notable strengths. First, we performed extensive chart abstraction to capture detailed demographic, clinical, and treatment data. This allowed us to provide a thorough description of the clinical and biologic characteristics of patients who developed LMD and their previous and subsequent treatment courses. Second, the patient population included in this investigation spans a long period of time during which several major therapeutic breakthroughs (ADCs and immunotherapy) were introduced into breast cancer care. The outcomes from this dataset provide important prognostic information for clinicians and patients, including analysis by various subgroups of interest.

This study also has several limitations due to its retrospective nature. First, the absence of a control arm that includes patients with MBC who do not develop LMD limits our ability to interpret specific risk factors for LMD. Subsequent studies are needed to better address this question. Second, reflective of current clinical practice, not all patients underwent evaluation of CSF cytology and complete imaging of the neuro-axis, so we were not able to evaluate survival based on presence or absence of specific cytologic features or radiographic findings, as this data was not available for all patients. Third, while this analysis includes a more modern cohort of patients, a relatively small number of patients received HER2-directed TKIs, ADCs, and other novel therapies prior to and after the diagnosis of LMD, even after some of these agents were approved. This is in part explained by the fact that while patients with HER2 + and triple negative disease are over-represented in this sample, most patients with LMD in our series had HR+/HER2− disease and no systemic targeted therapy has demonstrated efficacy in treatment of LMD. Looking ahead, with more evidence for CNS penetration with some ADCs and many TKIs, and with approval of these agents for ER + and HER2 “low” disease, we may observe better outcomes in these subsets of patients. Fourth, while we found that patients who received CNS-directed therapy and specifically IT therapy lived longer, this is likely confounded by the fact that patients with advanced LMD and/or poor performance status may not have been offered or chosen to pursue additional therapies, so these findings should be interpreted with caution. Finally, retrospective chart reviews are limited by written details included in the clinical record, so it is possible that certain demographic features or aspects of treatment history were not captured if they were not well-documented in the UCSF electronic medical record.

In summary, this retrospective case series helps better define the clinical characteristics, treatment history, and overall survival in a more modern cohort of patients with LMD and MBC. Patients diagnosed with LMD from 2015 to 2024 lived longer than those diagnosed from 2000 to 2014, although survival remained short even in this modern cohort. Novel therapeutic strategies for patients with MBC and LMD remains an important area of unmet clinical need.

Data availability

The datasets generated during the current study are not publicly available in order to protect patient privacy.

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Acknowledgements

The EMERSE platform was supported by the National Cancer Institute of the National Institutes of Health under Award Numbers U24CA204863 and P30CA046592, as well as the National Center for Advancing Translational Sciences of the National Institutes of Health under Award Numbers UL1TR000433 and UL1TR002240. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the NIH.

The EMERSE platform was supported by the National Cancer Institute of the National Institutes of Health under Award Numbers U24CA204863 and P30CA046592, as well as the National Center for Advancing Translational Sciences of the National Institutes of Health under Award Numbers UL1TR000433 and UL1TR002240. In addition, research reported in this publication was supported by the National Cancer Institute of the National Institutes of Health under Award Number K12CA260225. The contents of this work are solely the responsibility of the authors and do not necessarily represent the official views of the NIH.

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Laura A. Huppert, Samantha Fisch, Elene Tsopurashvili, Sai Sahitha Somepalle, A. Jo Chien, Melanie Majure, Hope S. Rugo & Michelle E. Melisko

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Laura A. Huppert: Ad board/honoraria from: AstraZeneca, Pfizer. A. Jo Chien: Research funding to institution: Merck, Puma, Amgen, Seagen. Hope S. Rugo: Research support for clinical trials through the University of California: Pfizer, Merck, Novartis, Lilly, Roche, Daiichi, Seattle Genetics, Macrogenics, Sermonix, Boehringer Ingelheim, AstraZeneca, Astellas and Gilead. Honoraria from: Puma, Samsung, Mylan, Chugai, Blueprint, and NAPO. Ronald Balassanian: Consultant—Genentech; Stockholder—Cerus Corp. Michelle E. Melisko: Research funding to institution: AstraZeneca, Novartis, KCRN Research, Puma, Seattle Genetics. For spouse: Speaker bureau/honoraria: Genentech, Gilead, AstraZeneca. Stock Ownership: Merrimack. Samantha Fisch, Elene Tsopurashvili, Sai Sahitha Somepalle, Mia Salans, Harish Vasudevam, Melanie Majure, Laurena Boreta: No financial disclosures.

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Huppert, L.A., Fisch, S., Tsopurashvili, E. et al. Demographic and clinical characteristics of patients with metastatic breast cancer and leptomeningeal disease: a single center retrospective cohort study. Breast Cancer Res Treat (2024). https://doi.org/10.1007/s10549-024-07339-1

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DOI : https://doi.org/10.1007/s10549-024-07339-1

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This laboratory is meant for research and experimentation in farming and plant maintenance. It has the infrastructure required to conduct research related to agricultural activities in the field of physiology, biochemistry and molecular biology of plants, fungus and microorganisms.

The site is part of a bigger area of environmental interest close to the river Tormes. We therefore propose an intervention in which the architecture is not imposed but rather becomes part of the territory. We intend to rethink the existing terrain into a new transformed landscape and discover a hidden morphology in the site through the activation of the current topography. Working on it emerged a series of folds and movements that have defined a landscape in which is recognized the former one.

The new building emerge in the landscape distancing itself from a housing environment without a clear order, with different shapes and indiscriminate occupation. The topographic redevelopment of the site lead to two levels: in the upper, with the entrance from the street, the building is hidden in the landscape, while the lower level opens onto the river, separating from the ground by piles that isolate the construction of possible floods.

The educational program is located in a representative volume that occupies the upper level of the access. The research program and support facilities occupy an elongated half-buried volume that gives access to different nuanced services through an interior street. The laboratories are situated in four cubes on piles, guiding their views to the river and being separated in such a way to allow a sequenced view to the river bank from the common area.

The relationship between the volumes of the laboratories and the one containing the educational program set up a wide compositional sequence allied to the cadence of the vegetation and topography of the bank, which helps the building to integrate itself into the landscape. The highest level of the plot has direct access to the didactic and administrative program, and from the lower it is possible to enter the building through the laboratory areas. Their support zones are virtually buried by ensuring appropriate insulation.

In the closest area to the river there are a number of greenhouses connected by a path outside, inside them is particularly suitable the research related to the agrobiotechnology. The research area is reached after crossing the pronounced cut of the slab that supports the roof garden, a ramp guides you to the hall and the interior street that goes across and articulate the whole.

Through a glass wall protected by the eaves of the roof garden, light flows in this elongated and complex space that, despite undergoing the strictness demanded by the functional program, is energized with ramps and galleries that give way to the platforms of the different laboratory volumes, the exit zone or the teaching building; this varied sequence receives more interest having as a background reference the dense layer of trees and river water.

The most complex operation performed is on the ground, and special attention has been taken in order to ensure that once realized it will barely be perceived. The architecture is clear and easily understandable, seeks a flexible and versatile scheme, able to solve the appearance of new programs that will necessarily be incorporated into the research complex.

One of the aims of the proposal is to get permeability and transparency between building and landscape, in order to obtain this, a light multilayer facade system is used, resulting in a variable density filter that meets both the heat and sunlight needs as well as the necessary privacy.

The construction was entrusted to systems that simplified the complexity of the building and eased the execution phase. The building is separated from the ground and supported on piles, the materiality of the structure is revealed throughout the entire building, establishing a heavy and steady world. On the contrary the facade systems are light, dry mounted to exhibit their temporary and removable character.

A gallery of accessible facilities under the slabs runs the building all the way long. This infrastructure can solve the maintenance and further introduction of new services and technology. This solution avoids ceilings that would hide the structure and blur the proposal.

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