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Case Study – Methods, Examples and Guide

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

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

Types of Case Study

Types and Methods of Case Study are as follows:

Single-Case Study

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

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

Multiple-Case Study

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

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

Exploratory Case Study

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

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

Descriptive Case Study

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

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

Instrumental Case Study

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

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

Case Study Data Collection Methods

Here are some common data collection methods for case studies:

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

Observations

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

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

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

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

How to conduct Case Study Research

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

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

Examples of Case Study

Here are some examples of case study research:

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

Application of Case Study

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

Business and Management

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

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

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

Social Sciences

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

Law and Ethics

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

Purpose of Case Study

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

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

Case studies can also serve other purposes, including:

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

Advantages of Case Study Research

There are several advantages of case study research, including:

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

Limitations of Case Study Research

There are several limitations of case study research, including:

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

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

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

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

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

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

Table of contents

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Research bias

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

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Qualitative case study data analysis: an example from practice

Affiliation.

• 1 School of Nursing and Midwifery, National University of Ireland, Galway, Republic of Ireland.
• PMID: 25976531
• DOI: 10.7748/nr.22.5.8.e1307

Aim: To illustrate an approach to data analysis in qualitative case study methodology.

Background: There is often little detail in case study research about how data were analysed. However, it is important that comprehensive analysis procedures are used because there are often large sets of data from multiple sources of evidence. Furthermore, the ability to describe in detail how the analysis was conducted ensures rigour in reporting qualitative research.

Data sources: The research example used is a multiple case study that explored the role of the clinical skills laboratory in preparing students for the real world of practice. Data analysis was conducted using a framework guided by the four stages of analysis outlined by Morse ( 1994 ): comprehending, synthesising, theorising and recontextualising. The specific strategies for analysis in these stages centred on the work of Miles and Huberman ( 1994 ), which has been successfully used in case study research. The data were managed using NVivo software.

Review methods: Literature examining qualitative data analysis was reviewed and strategies illustrated by the case study example provided. Discussion Each stage of the analysis framework is described with illustration from the research example for the purpose of highlighting the benefits of a systematic approach to handling large data sets from multiple sources.

Conclusion: By providing an example of how each stage of the analysis was conducted, it is hoped that researchers will be able to consider the benefits of such an approach to their own case study analysis.

Implications for research/practice: This paper illustrates specific strategies that can be employed when conducting data analysis in case study research and other qualitative research designs.

Keywords: Case study data analysis; case study research methodology; clinical skills research; qualitative case study methodology; qualitative data analysis; qualitative research.

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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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22 Case Study Research: In-Depth Understanding in Context

Helen Simons, School of Education, University of Southampton

• Published: 01 July 2014
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This chapter explores case study as a major approach to research and evaluation. After first noting various contexts in which case studies are commonly used, the chapter focuses on case study research directly Strengths and potential problematic issues are outlined and then key phases of the process. The chapter emphasizes how important it is to design the case, to collect and interpret data in ways that highlight the qualitative, to have an ethical practice that values multiple perspectives and political interests, and to report creatively to facilitate use in policy making and practice. Finally, it explores how to generalize from the single case. Concluding questions center on the need to think more imaginatively about design and the range of methods and forms of reporting requiredto persuade audiences to value qualitative ways of knowing in case study research.

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Investigating the effectiveness of endogenous and exogenous drivers of the sustainability (re)orientation of family smes in slovenia: qualitative content analysis approach.

1. Introduction

2. literature review, 2.1. legal framework on sustainable corporate governance (with a focus on smes), 2.1.1. corporate sustainability reporting directive, 2.1.2. corporate sustainability due diligence directive, 2.1.3. scope of the csddd for smes, 2.2. drivers of the family businesses’ (re)orientation towards sustainability, 2.3. endogenous drivers, 2.3.1. the protection of sew, 2.3.2. ownership and management composition, 2.3.3. values, beliefs and attitudes of family owner-managers, 2.3.4. transgenerational continuity and long-term orientation, 2.3.5. knowledge of sustainability, 2.4. exogenous drivers, 2.4.1. stakeholders pressure, 2.4.2. the impact of institutional environment and local communities, 3. empirical research, 3.1. institutional context of slovenia, 3.2. research method, 3.3. sampling and data collection, 3.4. data analysis, 4.1. results of the final coding of the family businesses’ sustainability (re)orientation, 4.2. references to responsibility, preserving (natural) environment and sustainability/sustainable development in the analysed statements, 4.3. family businesses with a higher level of sustainability awareness and orientation, 5. discussion, 5.1. sustainability awareness and readiness of investigated family smes to comply with the new eu legal framework, 5.2. the effectiveness of endogenous and exogenous drivers of family businesses’ sustainability (re)orientation, 6. conclusions, author contributions, institutional review board statement, informed consent statement, data availability statement, conflicts of interest.

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Share and Cite

Duh, M.; Primec, A. Investigating the Effectiveness of Endogenous and Exogenous Drivers of the Sustainability (Re)Orientation of Family SMEs in Slovenia: Qualitative Content Analysis Approach. Sustainability 2024 , 16 , 7285. https://doi.org/10.3390/su16177285

Duh M, Primec A. Investigating the Effectiveness of Endogenous and Exogenous Drivers of the Sustainability (Re)Orientation of Family SMEs in Slovenia: Qualitative Content Analysis Approach. Sustainability . 2024; 16(17):7285. https://doi.org/10.3390/su16177285

Duh, Mojca, and Andreja Primec. 2024. "Investigating the Effectiveness of Endogenous and Exogenous Drivers of the Sustainability (Re)Orientation of Family SMEs in Slovenia: Qualitative Content Analysis Approach" Sustainability 16, no. 17: 7285. https://doi.org/10.3390/su16177285

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Qualitative Secondary Analysis: A Case Exemplar

Judith ann tate.

The Ohio State University, College of Nursing

Mary Beth Happ

Qualitative secondary analysis (QSA) is the use of qualitative data collected by someone else or to answer a different research question. Secondary analysis of qualitative data provides an opportunity to maximize data utility particularly with difficult to reach patient populations. However, QSA methods require careful consideration and explicit description to best understand, contextualize, and evaluate the research results. In this paper, we describe methodologic considerations using a case exemplar to illustrate challenges specific to QSA and strategies to overcome them.

Health care research requires significant time and resources. Secondary analysis of existing data provides an efficient alternative to collecting data from new groups or the same subjects. Secondary analysis, defined as the reuse of existing data to investigate a different research question ( Heaton, 2004 ), has a similar purpose whether the data are quantitative or qualitative. Common goals include to (1) perform additional analyses on the original dataset, (2) analyze a subset of the original data, (3) apply a new perspective or focus to the original data, or (4) validate or expand findings from the original analysis ( Hinds, Vogel, & Clarke-Steffen, 1997 ). Synthesis of knowledge from meta-analysis or aggregation may be viewed as an additional purpose of secondary analysis ( Heaton, 2004 ).

Qualitative studies utilize several different data sources, such as interviews, observations, field notes, archival meeting minutes or clinical record notes, to produce rich descriptions of human experiences within a social context. The work typically requires significant resources (e.g., personnel effort/time) for data collection and analysis. When feasible, qualitative secondary analysis (QSA) can be a useful and cost-effective alternative to designing and conducting redundant primary studies. With advances in computerized data storage and analysis programs, sharing qualitative datasets has become easier. However, little guidance is available for conducting, structuring procedures, or evaluating QSA ( Szabo & Strang, 1997 ).

QSA has been described as “an almost invisible enterprise in social research” ( Fielding, 2004 ). Primary data is often re-used; however, descriptions of this practice are embedded within the methods section of qualitative research reports rather than explicitly identified as QSA. Moreover, searching or classifying reports as QSA is difficult because many researchers refrain from identifying their work as secondary analyses ( Hinds et al., 1997 ; Thorne, 1998a ). In this paper, we provide an overview of QSA, the purposes, and modes of data sharing and approaches. A unique, expanded QSA approach is presented as a methodological exemplar to illustrate considerations.

QSA Typology

Heaton (2004) classified QSA studies based on the relationship between the secondary and primary questions and the scope of data analyzed. Types of QSA included studies that (1) investigated questions different from the primary study, (2) applied a unique theoretical perspective, or (3) extended the primary work. Heaton’s literature review (2004) showed that studies varied in the choice of data used, from selected portions to entire or combined datasets.

Modes of Data Sharing

Heaton (2004) identified three modes of data sharing: formal, informal and auto-data. Formal data sharing involves accessing and analyzing deposited or archived qualitative data by an independent group of researchers. Historical research often uses formal data sharing. Informal data sharing refers to requests for direct access to an investigator’s data for use alone or to pool with other data, usually as a result of informal networking. In some instances, the primary researchers may be invited to collaborate. The most common mode of data sharing is auto-data, defined as further exploration of a qualitative data set by the primary research team. Due to the iterative nature of qualitative research, when using auto-data, it may be difficult to determine where the original study questions end and discrete, distinct analysis begins ( Heaton, 1998 ).

An Exemplar QSA

Below we describe a QSA exemplar conducted by the primary author of this paper (JT), a member of the original research team, who used a supplementary approach to examine concepts revealed but not fully investigated in the primary study. First, we describe an overview of the original study on which the QSA was based. Then, the exemplar QSA is presented to illustrate: (1) the use of auto-data when the new research questions are closely related to or extend the original study aims ( Table 1 ), (2) the collection of additional clinical record data to supplement the original dataset and (3) the performance of separate member checking in the form of expert review and opinion. Considerations and recommendations for use of QSA are reviewed with illustrations taken from the exemplar study ( Table 2 ). Finally, discussion of conclusions and implications is included to assist with planning and implementation of QSA studies.

Research question comparison

Application of the Exemplar Qualitative Secondary Analysis (QSA)

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Weinert, C. R., & Calvin, A. D. (2007). Epidemiology of sedation and sedation adequacy for mechanically ventilated patients in a medical and surgical intensive care unit. Critical Care Medicine , 35(2), 393–401.

The Primary Study

Briefly, the original study was a micro-level ethnography designed to describe the processes of care and communication with patients weaning from prolonged mechanical ventilation (PMV) in a 28-bed Medical Intensive Care Unit ( Broyles, Colbert, Tate, & Happ, 2008 ; Happ, Swigart, Tate, Arnold, Sereika, & Hoffman, 2007 ; Happ et al, 2007 , 2010 ). Both the primary study and the QSA were approved by the Institutional Review Board at the University of Pittsburgh. Data were collected by two experienced investigators and a PhD student-research project coordinator. Data sources consisted of sustained field observations, interviews with patients, family members and clinicians, and clinical record review, including all narrative clinical documentation recorded by direct caregivers.

During iterative data collection and analysis in the original study, it became apparent that anxiety and agitation had an effect on the duration of ventilator weaning episodes, an observation that helped to formulate the questions for the QSA ( Tate, Dabbs, Hoffman, Milbrandt & Happ, 2012 ). Thus, the secondary topic was closely aligned as an important facet of the primary phenomenon. The close, natural relationship between the primary and QSA research questions is demonstrated in the side-by-side comparison in Table 1 . This QSA focused on new questions which extended the original study to recognition and management of anxiety or agitation, behaviors that often accompany mechanical ventilation and weaning but occur throughout the trajectory of critical illness and recovery.

Considerations when Undertaking QSA ( Table 2 )

Practical advantages.

A key practical advantage of QSA is maximizing use of existing data. Data collection efforts represent a significant percentage of the research budget in terms of cost and labor ( Coyer & Gallo, 2005 ). This is particularly important in view of the competition for research funding. Planning and implementing a qualitative study involves considerable time and expertise not only for data collecting (e.g., interviews, participant observation or focus group), but in establishing access, credibility and relationships ( Thorne, 1994 ) and in conducting the analysis. The cost of QSA is often seen as negligible since the outlay of resources for data collection is assumed by the original study. However, QSA incurs costs related to storage, researcher’s effort for review of existing data, analysis, and any further data collection that may be necessary.

Another advantage of QSA is access to data from an assembled cohort. In conducting original primary research, practical concerns arise when participants are difficult to locate or reluctant to divulge sensitive details to a researcher. In the case of vulnerable critically ill patients, participation in research may seem an unnecessary burden to family members who may be unwilling to provide proxy consent ( Fielding, 2004 ). QSA permits new questions to be asked of data collected previously from these vulnerable groups ( Rew, Koniak-Griffin, Lewis, Miles, & O'Sullivan, 2000 ), or from groups or events that occur with scarcity ( Thorne, 1994 ). Participants’ time and effort in the primary study therefore becomes more worthwhile. In fact, it is recommended that data already collected from existing studies of vulnerable populations or about sensitive topics be analyzed prior to engaging new participants. In this way, QSA becomes a cumulative rather than a repetitive process ( Fielding, 2004 ).

Data Adequacy and Congruency

Secondary researchers must determine that the primary data set meets the needs of the QSA. Data may be insufficient to answer a new question or the focus of the QSA may be so different as to render the pursuit of a QSA impossible ( Heaton, 1998 ). The underlying assumptions, sampling plan, research questions, and conceptual framework selected to answer the original study question may not fit the question posed during QSA ( Coyer & Gallo, 2005 ). The researchers of the primary study may have selectively sampled participants and analyzed the resulting data in a manner that produced a narrow or uneven scope of data ( Hinds et al., 1997 ). Thus, the data needed to fully answer questions posed by the QSA may be inadequately addressed in the primary study. A critical review of the existing dataset is an important first step in determining whether the primary data fits the secondary questions ( Hinds et al., 1997 ).

Passage of Time

The timing of the QSA is another important consideration. If the primary study and secondary study are performed sequentially, findings of the original study may influence the secondary study. On the other hand, studies performed concurrently offer the benefit of access to both the primary research team and participants member checking ( Hinds et al., 1997 ).

The passage of time since the primary study was conducted can also have a distinct effect on the usefulness of the primary dataset. Data may be outdated or contain a historical bias ( Coyer & Gallo, 2005 ). Since context changes over time, characteristics of the phenomena of interest may have changed. Analysis of older datasets may not illuminate the phenomena as they exist today.( Hinds et al., 1997 ) Even if participants could be re-contacted, their perspectives, memories and experiences change. The passage of time also has an affect on the relationship of the primary researchers to the data – so auto-data may be interpreted differently by the same researcher with the passage of time. Data are bound by time and history, therefore, may be a threat to internal validity unless a new investigator is able to account for these effects when interpreting data ( Rew et al., 2000 ).

Researcher stance/Context involvement

Issues related to context are a major source of criticism of QSA ( Gladstone, Volpe, & Boydell, 2007 ). One of the hallmarks of qualitative research is the relationship of the researcher to the participants. It can be argued that removing active contact with participants violates this premise. Tacit understandings developed in the field may be difficult or impossible to reconstruct ( Thorne, 1994 ). Qualitative fieldworkers often react and redirect the data collection based on a growing knowledge of the setting. The setting may change as a result of external or internal factors. Interpretation of researchers as participants in a unique time and social context may be impossible to re-construct even if the secondary researchers were members of the primary team ( Mauthner, Parry, & Milburn, 1998 ). Because the context in which the data were originally produced cannot be recovered, the ability of the researcher to react to the lived experience may be curtailed in QSA ( Gladstone et al., 2007 ). Researchers utilize a number of tactics to filter and prioritize what to include as data that may not be apparent in either the written or spoken records of those events ( Thorne, 1994 ). Reflexivity between the researcher, participants and setting is impossible to recreate when examining pre-existing data.

Relationship of QSA Researcher to Primary Study

The relationship of the QSA researcher to the primary study is an important consideration. When the QSA researcher is not part of the original study team, contractual arrangements detailing access to data, its format, access to the original team, and authorship are required ( Hinds et al., 1997 ). The QSA researcher should assess the condition of the data, documents including transcripts, memos and notes, and clarity and flow of interactions ( Hinds et al., 1997 ). An outline of the original study and data collection procedures should be critically reviewed ( Heaton, 1998 ). If the secondary researcher was not a member of the original study team, access to the original investigative team for the purpose of ongoing clarification is essential ( Hinds et al., 1997 ).

Membership on the original study team may, however, offer the secondary researcher little advantage depending on their role in the primary study. Some research team members may have had responsibility for only one type of data collection or data source. There may be differences in involvement with analysis of the primary data.

Informed Consent of Participants

Thorne (1998) questioned whether data collected for one study purpose can ethically be re-examined to answer another question without participants’ consent. Many institutional review boards permit consent forms to include language about the possibility of future use of existing data. While this mechanism is becoming routine and welcomed by researchers, concerns have been raised that a generic consent cannot possibly address all future secondary questions and may violate the principle of full informed consent ( Gladstone et al., 2007 ). Local variations in study approval practices by institutional review boards may influence the ability of researchers to conduct a QSA.

Rigor of QSA

The primary standards for evaluating rigor of qualitative studies are trustworthiness (logical relationship between the data and the analytic claims), fit (the context within which the findings are applicable), transferability (the overall generalizability of the claims) and auditabilty (the transparency of the procedural steps and the analytic moves processes) ( Lincoln & Guba, 1991 ). Thorne suggests that standard procedures for assuring rigor can be modified for QSA ( Thorne, 1994 ). For instance, the original researchers may be viewed as sources of confirmation while new informants, other related datasets and validation by clinical experts are sources of triangulation that may overcome the lack of access to primary subjects ( Heaton, 2004 ; Thorne, 1994 ).

Our observations, derived from the experience of posing a new question of existing qualitative data serves as a template for researchers considering QSA. Considerations regarding quality, availability and appropriateness of existing data are of primary importance. A realistic plan for collecting additional data to answer questions posed in QSA should consider burden and resources for data collection, analysis, storage and maintenance. Researchers should consider context as a potential limitation to new analyses. Finally, the cost of QSA should be fully evaluated prior to making a decision to pursue QSA.

Acknowledgments

This work was funded by the National Institute of Nursing Research (RO1-NR07973, M Happ PI) and a Clinical Practice Grant from the American Association of Critical Care Nurses (JA Tate, PI).

Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

Disclosure statement: Drs. Tate and Happ have no potential conflicts of interest to disclose that relate to the content of this manuscript and do not anticipate conflicts in the foreseeable future.

Contributor Information

Judith Ann Tate, The Ohio State University, College of Nursing.

Mary Beth Happ, The Ohio State University, College of Nursing.

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• Open access
• Published: 26 August 2024

Health worker perspectives on barriers and facilitators of tuberculosis investigation coverage among index case contacts in rural Southwestern Uganda: a qualitative study

• Paddy Mutungi Tukamuhebwa 1 ,
• Pascalia Munyewende 1 ,
• Nazarius Mbona Tumwesigye 2 ,
• Juliet Nabirye 3 &
• Ntombizodwa Ndlovu 1  

BMC Infectious Diseases volume  24 , Article number:  867 ( 2024 ) Cite this article

Metrics details

In 2012, the World Health Organization recommended screening and investigation of contacts of index tuberculosis patients as a strategy to accelerate detection of tuberculosis (TB) cases. Nine years after the adoption of this recommendation, coverage of TB contact investigations in Uganda remains low. The objective of this study was to examine health care providers’ perceptions of factors influencing coverage of TB contact investigations in three selected rural health facilities in Mbarara district, southwestern Uganda.

This study identified provider opinions on the barriers and facilitators to implementation of TB contact investigation using the Consolidated Framework for Implementation Research. Using an exploratory qualitative study design, semi-structured interviews with 19 health workers involved in the TB program at district, health facility and community levels were conducted from April 2020 and July 2020. Analysis was conducted inductively using reflexive thematic analysis in six iterative steps: familiarizing with the data, creating initial codes, searching for themes, reviewing themes, developing theme definitions, and writing the report.

Nineteen health care workers participated in this study which translates to a 100% response rate. These included two district TB and leprosy supervisors, five nurses, five clinical officers, six village health team members and one laboratory technician. The three themes that emerged from the analysis were intervention-related, health system and contextual factors. Health system-related barriers included inadequate or delayed government funding for the TB program, shortage of human resources, insufficient personal protective equipment, and a stock-out of supplies such as Xpert MTB cartridges. Contextual barriers included steep terrain, poverty or low income, and the stigma associated with TB and COVID-19. Facilitators comprised increased knowledge and understanding of the intervention, performance review and on-the-job training of health workers.

Conclusions

This study found that most of the factors affecting TB contact investigations in this rural community were related to health system constraints such as inadequate or delayed funding and human resource shortages. This can be addressed by strengthening the foundational elements of the health system - health financing and human resources - to establish a comprehensive TB control program that will enable the efficient identification of missing TB patients.

Peer Review reports

Introduction

An estimated 10 million people suffer from active tuberculosis (TB) every year [ 1 ]. The disease continues to be the leading infectious cause of death globally, causing about 1.5 million deaths—95% of which occurred in low- and middle-income countries [ 2 , 3 ]. Although the African region has 9% of the world population, the region contributed 25% of all new TB cases in 2019, becoming the continent with the second-highest TB cases after South-East Asia. In Africa TB is mainly driven by the HIV pandemic, with about 50% of TB cases co-infected with HIV, and is the top cause of death among patients with HIV, causing more than 30% of all AIDS-related deaths [ 4 , 5 ].

In 2012, the WHO recommended the screening and evaluation of contacts of persons with infectious TB as an intervention for increasing TB case detection [ 6 ]. The intervention also provides an opportunity to diagnose latent TB and to scale-up TB preventive therapy among the eligible contacts, such as, children below five years, HIV positive patients, and other high-risk groups [ 7 , 8 ]. Five years later, in 2017, the Uganda Ministry of Health (MoH) adopted these WHO recommendations as high-level policy, and integrated them into the Manual for Management and Control of TB and Leprosy in Uganda [ 9 ]. Furthermore, in 2019, detailed operational guidelines were developed by the Uganda National Tuberculosis and Leprosy Program (NTLP) to guide and standardize TB contact investigation processes at health facility and community levels [ 8 ].

Despite the WHO policy guidance, coverage of TB contact investigation in many TB high burden countries such as Uganda, Kenya, Lao Republic, Pakistan and Yemen is still low [ 10 ]. A meta-analysis conducted in 2015 by Block et al., showed low TB contact investigation coverage in five countries (2.8% in the Lao Republic, 4.8% in Kenya, 14.9% in Pakistan and 15.1% in Uganda) and high coverage in one country (91.7% in the Democratic Republic of Congo) [ 10 ]. Armstrong et al. (2017), in a prospective multi-center observational study conducted in Kampala, Uganda, reported significant drop-out rates across the steps in the contact investigation cascade [ 11 ]. Among the 338 clients eligible for TB contact investigation, only 61% were scheduled for home visits, and only 50% of them were visited [ 11 ]. Furthermore, among the 131 people who were screened for TB and required definitive evaluation, only 20% were evaluated [ 11 ].

In rural Uganda, the coverage of TB contact investigation is much lower (15.1%) than that in urban areas such as Kampala (20%), and yet many of the missing TB cases are in such hard to reach and underserved rural areas [ 10 , 11 ]. This low coverage increases undiagnosed and untreated TB patients, thus perpetuating the TB pandemic. Furthermore, without TB contact investigation, many TB patients might infect other people in the household and the community, or die from TB related complications [ 12 ]. The low contact investigation coverage contributes to a high numbers of missed diagnoses in Uganda (400,000 in 2014), and high TB transmission rates, which hamper progress towards achievement of the third United Nations Sustainable Development Goal of ending the TB epidemic by 2030 [ 13 ].

Implementation research helps to connect research and practice by speeding-up the development and provision of public health interventions [ 14 ]. Given that urban settings have been the primary focus of the majority of implementation research studies in Africa and that the burden of TB differs between urban and rural areas [ 7 , 15 , 16 ], this study used implementation research tools to investigate the barriers to and enablers of TB contact investigation coverage in rural southwestern Uganda [ 3 ]. Although 82% of the Ugandan population lives in rural areas, there is inadequate information about TB contact investigation coverage, and its barriers and facilitators in rural settings [ 17 ]. The purpose of this study was to investigate the barriers and facilitators of investigation coverage among contacts of TB patients in rural Uganda.

The Consolidated Framework for Implementation Research (CFIR) by Damschroder et al. was used to explore barriers and facilitators of implementation in this study [ 18 ]. The framework consists of 39 constructs and five domains: characteristics of the intervention, inner setting, outer setting, individuals involved and implementation process [ 18 ]. The framework has been widely used across the globe to identify the barriers and facilitators of implementation outcomes in various healthcare settings, for example, evaluation of the online frailty tool in primary health care in Canada, integration of hypertension-HIV management in three Ugandan HIV clinics, examining the task shifting strategy for hypertension control at 32 hospitals and community health centers in Ghana and evaluating the implementation context of a quality improvement program for increasing vaccination coverage in Nigeria [ 19 , 20 , 21 , 22 ].

Study setting

This study was conducted in the rural district of Mbarara, located in the southwestern region of Uganda, about 270 km southwest of the capital city, Kampala. According to the 2014 population and housing census, the district had a population of 472,629 (Land area 1785.6 km 2 ), of which 59% resided in rural areas [ 23 ]. In total the district had 87 health facilities including 48 government owned, 26 private clinics and 13 nonprofit health facilities [ 24 ]. There were no data on TB contact investigation available at district level. Health Centres (HC) in Uganda are ranked II, III or IV based on the administrative zone served by the health facility with level II serving a parish, level III serving a sub-county and level IV serving a county [ 25 ]. A HC IV is expected to serve a population of at least 100,000 people. The services offered included general outpatient clinic (including TB and HIV care), immunization, antenatal care, maternity services, inpatient, laboratory, emergency surgery and blood transfusion [ 25 ].

The Ugandan health system operates on a referral basis, with the lowest level of health care provided by community health workers called Village Health Teams (VHTs) and the highest level of care offered at highly specialized hospitals called National Referral Hospitals. Levels of health care increase with complexity in terms of the packages of services offered, staffing levels, and the size of the population served. Three health facilities where the study was conducted were purposively selected due to their rural location, level of care (IV), and significant volume of patients compared to lower levels (II and III).

Coordination of TB services in the district was done by the District TB and Leprosy Supervisor (DTLS), who is responsible for 26 TB diagnostic and treatment centers. Regional coordination of TB activities is done by the Zonal TB and Leprosy Supervisor (ZTLS), while national level coordination and policy formulation is done by the National TB and Leprosy Program (NTLP) [ 15 ].

Study design and study population

A qualitative, exploratory study design was conducted to identify barriers and facilitators to implementing TB contact investigations between April and July 2020. Semi-structured interviews were conducted with all 19 health workers who were purposively selected based on their direct participation in the implementation of TB interventions since they were likely to have the most knowledge and experience with TB contact investigations. These included TB focal persons at the health facilities, clinical officers, nurses, laboratory staff, VHTs, and District TB and Leprosy Supervisors. Health workers who were not in the health facility during the data collection period were excluded from the study. The Consolidated criteria for reporting qualitative studies (COREQ) were applied to comply with the reporting standards (Table S2 ) [ 26 ].

Data collection

Semi-structured interview guides were developed and included background information about study participants and questions developed according to the five domains of the CFIR. The VHT interview guides were translated into the regional dialect and put through a pilot test to ensure that the questions were understood and to gauge how long the interviews would take. Two health facilities that provided comparable research sites in terms of staffing levels and services were used for the pilot testing.

Physical interviews for the study participants were conducted by the lead researcher (PT) in either English or Runyankore and each interview was tape recorded while a trained research assistant took field notes. Data collection for each category of study participants was continued until saturation was reached [ 27 ]. Since data collection took place during the first wave of the COVID-19 pandemic, precautions were taken to prevent COVID-19 cross-infection on both the researcher and the participants. Interviews were conducted at the selected health facilities in well-ventilated spaces, with both the interviewer and the participant wearing N-95 respirators, and surgical masks, respectively. Each interview lasted between 30 and 45 min and no repeat interviews were conducted.

Data management and analysis

Data were transcribed verbatim by the research team and the lead researcher listened to each audio recording while reading through the transcripts to correct errors in transcription and familiarize himself with the data. Transcripts were not given back to the participants for review or comments because evidence suggests that interviewee transcript review does not add value to the quality and rigor of qualitative research [ 28 ]. PT and JN reviewed the transcripts and made initial notes of interesting features or potential codes and themes in the data. The transcripts were then uploaded into MAXQDA 2020, and analyzed using reflexive thematic analysis in six iterative and recursive steps as described by Braun and Clarke [ 29 ]. The six steps included (1) familiarization with the data, (2) coding, (3) searching for themes, (4) reviewing the themes, (5) naming and defining the themes, and (6) writing the report [ 29 ]. The first step of the analysis was to look at the participants’ own words and expressions, without preconceived notions or classifications. The researchers then examined the language used by each participant in relation to the five domains of the CFIR. To ensure the reliability and credibility of the research analysis, both researchers PT and JN developed the themes by reading the transcripts independently to establish inter-coder agreement [ 30 ]. After the initial coding, the two-member team met to discuss the independently developed codes and themes and to reach an agreement on the themes. The transcribed texts and quotes were then grouped into themes, and the lead researcher used a reflexive approach to identify similarities or differences among CFIR domains and constructs. This iterative and recursive process provided space for reflexivity and ensured the credibility of the research findings. Themes were then defined and further refined to reflect the challenges and enablers of contact investigation coverage.

The research team and reflexivity

The field research team consisted of the principal investigator (PT), a male master’s student at the University of the Witwatersrand, and a female research assistant (GA), who is trained in population studies and monitoring and evaluation, and she was not employed at the time of this study. The principal investigator is a medical doctor who has training and experience in TB care and is familiar with WHO TB guidelines for contact investigations. He was not affiliated with the District Health Department or the Ministry of Health NTLP and is therefore unlikely to have influenced participant responses. Prior to the study, the principal investigator received training in qualitative research methods at the University of the Witwatersrand, so he was aware of how a researcher’s background, location, and assumptions can influence a qualitative study. The research team did not know the participants beforehand, and they were not directly involved in patient care in a way that would have influenced their responses.

Ethical considerations

This study was cleared by the Human Research Ethics Committees (Medical) at the University of the Witwatersrand (M200101), and Mbarara University of Science and Technology (MUREC 1/7). The Uganda National Council for Science and Technology granted permission to conduct the study in Uganda (HS569ES). Administrative approval was obtained from the District Health Officer, and the health facility managers of the respective study sites. Information about the study was shared with the participants before the interviews and written informed consent for participation and audio recording was obtained from each participant. To preserve participant privacy, interviews were conducted in a private space within the outpatient units, with only the researchers and the participants present.

Characteristics of study participants

Nineteen participants took part in semi-structured interviews with a response rate of 100% and 21.1% ( n  = 4) of them were male (Table  1 ). The sample comprised five clinical officers (26.3%), five nurses (26.3%), six VHT members (31.6%), one laboratory technician (5.2%), and two DTLs (10.5%). Eight of the participants (42.1%) had over three years’ experience in offering TB care. Clinical officers were paramedics with a diploma in clinical medicine, as opposed to nurses who had a bachelor’s degree in nursing, a diploma, or a nursing certificate. VHTs were lay health workers based in the community to aid with TB interventions in the local population. Laboratory technicians had a diploma in laboratory sciences, whereas DTLSs had one in nursing or clinical medicine.

Barriers and facilitators of TB contact investigation coverage

A reflective thematic analysis of the data gave rise to three themes: health system, contextual and intervention-related factors. The barriers and facilitators identified under each of the three themes (Table S3 ). Based on the WHO’s health system building blocks, the factors affecting the health system emerged under six sub-themes: human resources, commodities, service delivery, leadership and coordination, funding, and health information systems. Contextual factors were further categorized into geographic, social, and cultural, economic, and policy-related factors. Issues affecting TB contact investigations linked to the intervention itself were covered by the final theme (intervention-associated factors).

Barriers and facilitators

Domain 1: characteristics of the intervention.

The intervention related factors reported by the participants fell under three constructs, that is: evidence-base, intervention complexity and implementation cost.

Evidence-base

Out of the 19 healthcare workers involved in this research, 16 were aware of the intervention and its effectiveness in detecting, treating, and stopping the spread of tuberculosis in the community. Some of them had even engaged in relevant programs at the district, health facility, and community levels to improve uptake, such as support supervision, enlisting household contacts, home visits, health education, screening, and sputum sample collection. The DTLSs reported that training and regular orientation on several aspects of TB management, including TB contact investigation, provided easy access to knowledge and information. The district provided training on TB contact investigation to health workers in different platforms, including quarterly performance review meetings. As a result, they had the necessary information, abilities, or confidence to carry out contact investigation tasks.

“Even in meetings , we talk about contact tracing and investigation. Because for us we do meetings quarterly , all those meetings we…include a training in contact tracing and investigation” (Respondent 1—Nurse).

Intervention complexity

Three VHTs reported that TB contact investigations had multiple processes and therefore required a team to go for community visits, which interfered with other ongoing interventions at the health facility, such as TB screening at outpatient clinics, linking positive patients to treatment, providing community-based DOTs for patients on treatment, and following up with clients who defaulted on treatment. They also assisted with other medical services, such as immunizations, prenatal care, and providing ART refills to stable HIV patients. Therefore, during contact investigations, VHTs were mostly involved in community activities, leaving some of the basic facility-based interventions unattended.

“…it interferes with other programs… Now I am here working at the health facility , collecting sputum , screening and… I have many patients attending immunization , antenatal , ART (HIV clinic) , and I am the one who works on them too. And after that , I want to go and do contact tracing… Sometimes I ignore some of the facility activities so that I spare some time to go and do contact tracing in the community” (Respondent 4—VHT) .

Cost of the intervention

During TB contact investigations, it may be required to phone many patients or contacts. It is frequently necessary to call people who have appointments but do not show up at the health facility. Healthcare workers find it challenging to make these calls due to the high airtime requirements of this intervention and the associated cost.

“…some of these contacts need to be contacted on the phone several times because someone tells you he is coming tomorrow; and he doesn’t come. And the person keeps giving appointments without coming. And we do not have all that airtime…” (Respondent 5—Clinical Officer) .

Domain 2: outer setting

Funding from external entities: inadequate funding.

Multiple funding related challenges were reported at national, district and health facility levels. Funding for TB contact investigation was provided, through the Primary Health Care grants released from the Ministry of Health to public health facilities. Additional funds for contact investigation came from USAID through the Regional Health Integration to Enhance Services in Southwestern Uganda; a program for scaling up access to comprehensive HIV, TB and reproductive health services in the region.

Health workers believed that TB was not considered a priority by the Ministry of Health, which led to underfunding of the NTLP, and eventually underfunded TB work at district, health facility and community levels. TB interventions were not integrated into the annual budgeting processes like other interventions. For example, Malaria and sanitation interventions received funds, while TB remained unfunded, since 2014. The DTLS reported that the sanitation program was prioritized and funded better than the TB program, because of the advocacy by the sanitation program.

“…I think if the government says , ‘let us fight this disease’ , they need to put in (funds). Let them consider TB across the board. Let them budget for it like the way they budget for other conditions. Malaria is budgeted for , sanitation…receives money every quarter. But it is like six years (since 2014) when there was money for TB…and it was for only one quarter” (Respondent 1—Nurse).

The DTLSs reported insufficient funds for TB support supervision at the district level, which limited the amount of time the district TB supervisor spends in each health facility for supervision visits. Eventually, the quality of the supervision was compromised because teams did not have sufficient resources to train, mentor and supervise health facility teams.

“Because of the funds being little , we are forced , like in a day , to move to about four facilities. Remember , in TB , there are six indicators that you need to focus on and get to understand what the problem is. So , you find we do not have sufficient time to spend in the facility and support it.” (Respondent 2—Clinical Officer).

Health facility level funding challenges included delayed reimbursement of funds, and inadequate funds for home visits. In some cases, health facilities rely on NGOs for extra funds to conduct contact investigations, because of insufficient funds from the Primary Health Care (PHC) fund.

“…but when you do not have that NGO , things are challenging because you know that PHC money cannot be enough. You find that the PHC money is for only two patients , yet you have like six of them (to follow-up). So , when you do not have that money from NGOs , you cannot do it smoothly.” (Respondent 2—Clinical Officer) .

Some participants reported that they used their own money to trace index TB contacts; however, this money takes a long time to be refunded. Some participants even had a pay gap of about five months, which lowered their morale to continue with community visits.

“Most of the cases , we use our own money… you want to do your job , but transport facilitation (is missing)! Even…when they decide to refund it (money) , it takes so long…for example , since January we have never got that transport (money). We did contact tracing in January , February , March , April and May; we gave them reports , and they see that we are working , but we do not see our transport (refund)” (Respondent 16—VHT).

Critical incidents: COVID-19 pandemic related factors

This study was conducted during the first wave of the COVID-19 pandemic a lockdown policy was implemented by the government. This was characterized by suspension of public and private transportation, some health workers, TB patients and their contacts were unable to access health facilities. These restrictions affected the mobility of the health workers and patients to the health facility, and undermined TB contact investigation efforts. Besides lockdown measures, the COVID-19 pandemic was also associated with stigma among patients and health workers. Some TB contacts were afraid to report cough, in fear of being suspected of having COVID-19 and having to be quarantined for 14 days as per the MOH recommendations at the time. COVID-19 heightened the stigma associated with TB, because the two conditions have similar symptoms. Health workers could not tell who had COVID-19 or TB and, therefore, avoided anyone presenting with cough, because they feared it might be COVID-19. Some laboratory personnel declined to examine sputum samples because they were concerned that the samples might contain COVID-19 and increase their risk of getting the virus.

“Now with corona (COVID-19) , we would come here and not find any patient or health worker because they did not have transport means during the lockdown. Most of our people stayed at home. Even if you had your own motorcycle , they would not allow you to ride it…” (Respondent 13—Clinical officer).

Partnerships and connections: collaboration with NGOs and community-based organizations

Health workers and VHTs reported that the district and health facilities are networked with NGOs and community-based organizations which support the implementation of TB contact investigation and other health interventions. The primary implementing partner was Regional Health Integration to Enhance Services in Southwestern (RHITES-SW) Uganda, which supports the district with transportation and materials, while doing household visits.

Along with funding TB contact investigation, district-based NGOs also sponsored radio airtime to increase awareness and create demand for TB services.

“…RHITES-SW provides us with materials to use , like carrier bags. They provide us with transport to do contact tracing and the information. They normally update us on each and everything that is current in contact tracing and investigation” (Respondent 5—Clinical officer) . “Other stakeholders are working hand in hand with the government and our implementing partners. I see them working as a team to sponsor airtime on radios to create awareness and give some financial assistance.” (Respondent 12 , Clinical Officer).

Policies and laws: availability of updated operational guidelines

The district established favorable communication networks at district and health facility levels, facilitating efficient communication of guidelines, reference materials, and patients’ results. For example, the district had a WhatsApp group, specifically for the district TB team, to share information and monitor district activities.

“…we have a WhatsApp group of all the in charges and TB focal persons , where we discuss TB management and…share guidelines , so whoever needs guideline in TB management , he just goes there” (Respondent 1—Nurse).

Domain 3: inner setting

Available resources.

The barriers that emerged under available resources included, lack of personal protective equipment (PPE), stock-outs of Xpert MTB cartridges and shortage of human resources. Commodities that frequently went out of stock included toolkits for TB contact investigations and Xpert MTB cartridges for conducting Xpert MTB and RIF tests. At times health facilities spend about two months without cartridges, and health workers were notified by the laboratory team not to send sputum samples for analysis, which weighs down contact investigation efforts. Additionally, VHTs reported the lack of essential tools for community visits, especially during extreme weather. Health facilities also frequently ran short of PPE for home-based contact screening, such as masks and gloves, which discouraged them from doing community contact tracing out of fear of acquiring TB.

“…sometimes , there are no GeneXpert (Xpert MTB) cartridges; you find that we are not doing GeneXpert (tests) because cartridges are finished… , at times we take like a month or two without cartridges and…that is not good… , the lab people tell us , ‘do not send samples this month , we do not have (cartridges)’ , which means we are missing people (patients).” (Respondent 12—Clinical Officer). “At times you go to a difficult place…in a rainy season… , you climb a hill while it is raining on you. You do not have an umbrella; you do not have boots or a bag to carry the stuff (materials)…” (Respondent 4—VHT).

Human resource shortage was also reported as barrier. Sometimes, only one health worker was available to go for community visits, yet there are multiple tasks to do, including health education, screening, and sample collection. Therefore, this scarcity of human resources affects the quality of implementation since some of the tasks are left incomplete.

“…sometimes there is a lack of manpower because…the health workers are not enough at the facility , so you find that only one person is going for contact tracing , and the work there is huge , and that person cannot do all the work alone. So , most of the things are not done. They do part of the work and leave out some” (Respondent 15—Nurse).

Two facilitators were discussed under the construct of available resources: presence of a landline telephones to aid communication and a motorcycle to support transportation during community visits. The telephones were loaded with airtime for scheduling household visits and communicating Xpert MTB/RIF results from the hub laboratory while the motorcycle helped to reduce the cost of transportation since community visits only required fuel for the motorcycle.

“We have a health facility motorcycle , which does not force us to put in a lot of money… We just consider the distance we are covering and then put in fuel and move , which is easier than getting a boda-boda (motorcycle taxi).” (Respondent 16—VHT).

Structural characteristics: rugged terrain and poor road network, paper-based reporting systems, and hub and spoke laboratory system

All six VHTs reported that some patients came from hard-to-reach areas, characterized by rugged terrain, where vehicles or motorcycles cannot reach. This makes it hard for health workers to visit such communities for contact investigations. Additionally, some places have poor roads that are impassable during the rainy season, thus affecting service delivery. In such circumstances, health workers use boda-bodas (motorcycle taxis) to a certain point, and then walk the remaining distance. Sometimes the terrain is hilly and exhausting, which discourages teams from doing community visits. Large health facility catchment areas also made it more difficult for field teams to deliver contact investigation services to distant households. As a result, contacts of index TB cases from remote places were instead asked to come to the health facility for further evaluation, however, some of them did not come.

“…for those people who come from hard-to-reach areas , going to those homes is quite challenging. Sometimes we reach a point of walking on foot because we cannot reach there using a car or a motorcycle. So , we must climb a steep hill to look for those patients” (Respondent 4—VHT). “This is a big sub-county; people come from distant areas , even neighboring districts. And of course , as a health worker , you cannot reach every homestead. So , some (contacts) are called to come to the health facility. But because of the long distances , some fail to come.” (Respondent 4—VHT).

Another barrier was the use of the paper-based reporting system. One of the TB focal persons reported that TB contact investigation reports were submitted manually using a paper-based system which affects timeliness of reporting. Submission of reports had to wait for an opportunity when someone was going to the district headquarters, which causes a delay and eventually affects re-imbursement of the payments for activities.

“Sometimes , since we are sending the reports to Mbarara , they reach late because of transport issues. It becomes hard for someone to send the report since you cannot get any transport , so you get someone going to Mbarara , give them the reports , and tell that person where they should be delivering the reports. So , it also takes a bit of time” (Respondent 8—Nurse).

The laboratory system in the district used a “hub and spoke” system, where laboratory samples are collected in peripheral laboratories and transported by motorcycle riders to the central laboratory for analysis. However, participants reported that this system was dysfunctional because of the long results turn-around time, compromised early TB diagnosis and treatment and affected TB contact investigation coverage. In some cases, health workers spent up to two months, waiting for Xpert MTB results.

“And we have a challenge with hub riders… Sometimes , the hub riders take sputum samples to Mbarara , and if they do not go back to pick the results , you will never see them. And you end up spending around two months without results” (Respondent 12—Clinical Officer).

Domain 4: individuals involved

Under characteristics of the individuals involved, participants reported the presence of internal implementation leads called TB focal persons at health facility and DTLS at district level. These were responsible for coordinating the provision of TB services and technical leadership and supervision of the TB program and different levels of care. Additionally, health workers received adequate training on various aspects of TB management including TB contact investigation. Such training sessions supported them with the adequate knowledge and skills to confidently conduct contact investigation activities.

Domain 5: implementation process

The three constructs that emerged under implementation process were planning, engaging and reflection and evaluation.

The DTLSs reported that leaders at the Ministry of Health had transferred the planning, coordination, and funding of TB interventions, including TB contact investigation. Instead, this role was left to implementing partners, usually local and international Non-Governmental Organizations (NGOs), which negatively impacted the TB program at district level. Also, participants reported that implementing partners tend to have different priorities. For example, these organizations mainly focus on HIV interventions, and less on TB. Therefore, it is challenging to divert them from their preferences and focus them on district priorities, since their priorities are often guided by donor funding.

“Also , The Ministry of Health has deliberately left this work (TB contact investigation) …to implementing partners , and it has killed everything. And in that line , I think we can eradicate TB , but if the government is putting in (effort) , not leaving this disease for the implementing partners.” (Respondent 1—Nurse). “They tell you their priority is HIV , and you cannot shift them. They have their …operational guidelines that you cannot change.” (Respondent 1 , Nurse).

Reflection and evaluation

data use to inform program decisions by the district health team was identified as a facilitator. The district held quarterly performance and reflection meetings with the participation of the district’s NGOs, community-based organizations, district health management team, and healthcare providers from the various health centers. In these meetings, attendees discussed their performance, challenges across the different technical areas, and strategies for bridging the gaps.

the involvement of all stakeholders within the district, including health facility teams, district teams, NGOs, and community-based organizations involved in the TB program, in regular engagements to review implementation progress, performance, and plan improvement strategies was reported as a facilitator. Non-Governmental Organizations are actively involved in discussions regarding potential funding opportunities for specific activities.

“…we normally have the district stakeholders meeting , where they (external stakeholders) normally come here , and we discuss performance in different areas - MCH (maternal and child health) and HIV; TB is also given a platform. We tell them about our challenges.” (Respondent 1—Nurse) .

The stigma associated with TB was reported as a common challenge by all participants in this study. For this reason, index TB patients preferred not to be visited at home by a health worker, out of fear of being stigmatized if neighbors and other community members found out that they had TB. Some index TB patients even tried to avoid being visited by giving health workers incorrect phone numbers and physical addresses. Patients with TB and HIV co-infection have an increased fear of disclosing their status because of the misconception that every TB patient has HIV. Additionally, poverty among index TB patients was also found to be a challenge because contacts of TB patients lacked funds to transport them to the health facility for assessment, diagnosis, and treatment. As a result, it was necessary for health professionals to collect sputum samples from the community and bring them to the health facility for analysis. This, however, was not always feasible, leaving some of the contacts of TB patients unevaluated.

“…some patients give us wrong telephone contacts , we call the number , it is not on , or a different person picks it. So , we fail to trace that person. Some fear health workers going to their homes. Mostly when the index TB patient is also HIV positive , they do not want people in their villages to see any health care worker coming to their home because they may identify them” (Respondent 11—VHT).

This study explored the factors influencing TB contact investigation coverage in three rural, primary health facilities in Southwestern Uganda. The study is unique in its rural focus unlike previous studies in Uganda and Kenya, which were conducted in cities [ 7 , 15 , 31 ]. The barriers and facilitators identified in this study were diverse and covered all the five domains of the CFIR. Although some studies have used other implementation research tools to identify the barriers and facilitators to implementing TB contact investigation, this study used the CFIR to explore the factors influencing TB contact investigation coverage in Africa.

The key challenges that emerged from this study included health system challenges, such as the lack of funding for TB contact investigation, insufficient PPE and inadequate Xpert MTB equipment for diagnostic testing. The rugged terrain and poor road networks in rural communities also made it difficult for health workers to access patients in the community, and vice versa. Poverty, TB- and COVID19-related stigma were also perceived as barriers. On the other hand, the facilitators to TB contact investigation included an increased awareness of TB contact investigation, adequate knowledge of the Ugandan MoH guidelines, confidence in delivering the intervention and on-the-job training of health workers. In addition, the availability of a telephone and transport to schedule and make household visits were reported as facilitators. The support of key district stakeholders involved in TB contact investigations and quarterly performance review meetings also emerged as facilitators.

The health system barriers that emerged from this research were inadequate or irregular funding, human resource shortages, lack of PPE supplies (face masks, gloves, raincoats, and gumboots), out of stock of Xpert MTB cartridges and lack of airtime for communication. In addition, inadequate or inconsistent funding limited the frequency of the DTLS visits to health facilities for supervision and caused a delay in payment of travel and allowances to field teams, causing TB contact investigation operations to be hampered. This finding is in contrast with another study conducted in urban Kenya, which found that the TB program received sustainable funding for infrastructure and health workforce for contact investigation [ 32 ]. Furthermore, this Kenyan study used the WHO health systems framework. It focused on the stakeholder perspectives of the barriers and facilitators to optimizing TB contact investigation in Nairobi, the capital of Kenya. This funding disparity between rural and urban areas could be due to a higher TB prevalence in most urban settings thus attracting the attention of policy makers to allocate more resources there [ 33 ].

Consistent with this study, three studies conducted in Botswana, Ethiopia and Uganda reported human resource shortages as a considerable hindrance to TB contact investigation coverage [ 3 , 15 , 16 ]. In urban Uganda, health workers had other competing duties in the TB clinics, thus, they did not have sufficient time for community-level activities, including household contact tracing [ 15 ]. In this study, sometimes only one health worker was available for community visits, and they could not complete multiple tasks, such as health education, screening, sample collection, HIV testing and documentation in the registers. The staff shortage is partly attributed to a small number of staff trained in TB, and assigning them responsibilities in other units outside the TB unit [ 3 ].

Another challenge identified in this study was a lack of PPE materials such as masks, gloves, raincoats and gumboots for health workers to protect themselves against TB and other infectious diseases (such as COVID-19). Health staff were hesitant to conduct household contact investigations without wearing masks and gloves, to avoid contracting TB and COVID-19. Similarly, protective gear, such as raincoats and gumboots, to be used in harsh weather conditions, were not provided to health workers. There is limited literature on the influence of PPE materials on TB contact investigation coverage and this calls for more research in this area. These findings indicate that the supply chain management system for essential infection control materials is weak. These findings emphasize the need to strengthen mechanisms to guarantee sufficient PPE supplies and sustain the supply chain for these products.

The context within which an intervention is implemented, is recognized as a significant determinant of implementation success [ 18 ]. Contextual factors refer to issues about a person or their environment that can positively or negatively affect the delivery of an intervention [ 18 ]. Socio-economic, policy-related, and geographical barriers emerged as contextual barriers in this research. The socio-economic factors included poverty, lack of phones where patients can be contacted to confirm the appointment of household visits, stigma, and fear of reporting cough in fear of being labelled as having COVID-19.

In Botswana, Kenya, Ethiopia, and Uganda, the stigma associated with Tuberculosis has been reported as a barrier to TB contact investigation. [ 3 , 7 , 15 , 16 ]. Although these studies did not specifically focus on TB contact investigation coverage, stigma hindered household visits, because index TB patients avoided home visits by health workers, out of fear of their status being disclosed to the community and discrimination from them, which could eventually affect demand and coverage of the intervention. An important observation in our study was that stigma was aggravated by the misconception that every TB patient has HIV, and the emergence of the COVID-19 pandemic. Tuberculosis and COVID-19 have common respiratory symptoms (cough, fever, and breathing difficulties), making it difficult to distinguish the two. This causes diagnostic confusion, and the health workers may also avoid such patients, in fear of contracting COVID-19 [ 34 ]. Furthermore, because of the new COVID-19 stigma, patients with a chronic cough might fear coming to the health facilities for diagnosis, thus complicating the two pandemics [ 34 ].

The COVID-19 lockdown policy implemented in 2020 by the Government of Uganda posed significant challenges to TB contact investigation efforts. Both health staff and patients could not access health facilities, due to stringent lockdown measures, including travel restrictions and public and private transportation prohibitions. Additionally, health providers could not conduct home visits to screen the contacts. Similar findings were found in another study on the impact of COVID-19 on TB programs in Western Pacific nations [ 35 ]. Other COVID-19 related problems encountered in the Western Pacific study included a change in priorities towards the COVID-19 response, as demonstrated by the relocation of TB program staff to the COVID-19 response, and a reduced willingness of patients and contacts to visit health facilities [ 35 ]. Therefore, innovative strategies are required to streamline TB contact investigation in the context of the COVID-19 pandemic.

As reported by Cattamanchi et al., geographical challenges contribute to the failure of TB patients and contacts to present at health facilities for TB care [ 36 ]. In their study, health workers reported that the physical remoteness of patients’ homes from the health facility and the rugged terrain encountered during travel, was a challenge [ 36 ]. Likewise, in this study, health workers reported that some index TB patients and contacts came from distant and challenging areas, with steep hills and poor road networks, preventing access to health facilities. This challenge was aggravated by poverty, because patients and contacts from the periphery of the county could not travel to health facilities because of high transport costs.

Facilitators

All health workers interviewed in this study reported awareness of the intervention. They had even engaged in relevant programs to improve its uptake, including enlisting household contacts, home visits, screening, and sputum sample collection. In addition, the clarification of the various steps demonstrated health workers’ adherence to the organizational protocols for TB contact investigations. The increased awareness and fidelity to the guidelines may be attributed to the development and dissemination of local contact investigation guidelines through training and the use of electronic media, such as WhatsApp. Conversely, a similar study conducted in rural Ethiopia found that awareness and adherence to the guidelines were poor because of a lack of refresher training. [ 3 ].

The health system facilitators that emerged from this study include good provider knowledge and access to information, performance review meetings at the district level, and engagement of district stakeholders to obtain their support. In contrast to other studies in Uganda, Ethiopia, and the USA, provider knowledge and confidence (self-efficacy) worked as a facilitator in this study because staff involved in TB contact investigation had received on-the-job training on various aspects of TB management, including contact investigation, diagnosis, and management [ 3 , 15 , 37 ]. In this study, health workers reported that they had the knowledge, skills, and confidence to conduct TB contact investigations successfully. These results are partly attributed to the quarterly district performance review meetings, in which an orientation on TB contact investigation was done and guidelines were shared with health workers.

Reflection and evaluation in TB contact investigation performance were demonstrated by Karamagi et al., in a Quality Improvement study to improve case finding in Northern Uganda [ 38 ]. A review meeting was held to discuss progress on active case finding and develop scale-up plans for the intervention [ 38 ]. Similarly, this study found that quarterly district review meetings were held, to discuss district and health facility performance, challenges, and improvement strategies in various program components, including TB contact investigation. These reflection meetings involved district-based stakeholders such as NGOs, health workers, TB focal persons, and health facility managers, and this promoted ownership of the interventions, and helped in resource mobilization. These meetings were also used to review quarterly TB performance, and develop action plans to improve multiple TB indicators, including TB contact investigation.

Strengths and limitations of the study

This study had the following strengths. First, we included various health provider categories at different levels of the district healthcare system, including community, health facility and district levels, to obtain different perspectives from the participants. Second, this study used implementation science methods such as the CFIR to investigate the rural perceptions of the challenges and enablers of TB contact investigation coverage. The CFIR provided a framework for developing the semi-structured interview guides and interpretation of study findings and this promotes transferability of these results to other settings.

Some weaknesses were also observed. First, index TB patients and their contacts were not interviewed; therefore, some information on the challenges and enablers of contact investigation coverage from the patients’ and caregivers’ perspective may have been missed. Second, data collection was conducted during the COVID-19 lockdown, and some health workers were inaccessible, especially laboratory personnel involved in pandemic control activities at the time. Consequently, the laboratory may have challenges that were not identified in this study. Third, the COVID-19 pandemic may have aggravated some challenges, which were not so pronounced before the pandemic. Finally, the generalizability of our results to other geographical locations may be limited, because this study was conducted in one district in Uganda, which gives it a smaller scope. However, we included three health facilities in different counties, which may improve transferability to other settings.

This study explored health providers perceptions of the barriers and facilitators of TB contact investigation in rural Mbarara district, Southwestern Uganda. This study found that most of the challenges limiting TB contact investigations in rural communities are related to health system; for-example inadequate or delayed funding and human resource shortages. The Ministry of Health in Uganda therefore must strengthen the health system building blocks, particularly health financing and human resources to establish a robust TB control program that will enable the efficient identification of missing TB patients. It also demonstrated the unique challenges affecting the rural settings regarding tuberculosis contact investigation including lack of personal protective equipment, stock-out of Xpert MTB cartridges, shortage of airtime for communication, TB-related stigma, and inconsistent funding for TB contact investigation. Further research is needed to determine the effectiveness of potential implementation strategies for eliminating these barriers in rural communities. Also, having identified the disruptive nature of the COVID-19 pandemic to the achievement of optimal TB contact investigation coverage, there is a need to develop measures for integrating both COVID-19 and TB contact investigation interventions.

Data availability

The dataset used in the current study are available from the corresponding author on reasonable request.

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Acknowledgements

I acknowledge the contribution of Grace Ayebazibwe (GA), who supported me during the data collection and analysis by taking field notes, transcription, and translation of audio recordings.

This research work was supported by TDR, the Special Program for Research and Training in Tropical Diseases, which is hosted at the World Health Organization, and co-sponsored by UNICEF, UNDP, the World Bank and WHO. TDR grant number: B40299, first author ORCID ID: 0000-0001-9722-1202. The content is solely the responsibility of the authors and does not necessarily represent the official views of the funder.

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Paddy Mutungi Tukamuhebwa, Pascalia Munyewende & Ntombizodwa Ndlovu

Department of Epidemiology and Biostatistics, School of Public Health, Makerere University, Kampala, Uganda

Nazarius Mbona Tumwesigye

Department of Health Policy, Planning and Management, School of Public Health, Makerere University, Kampala, Uganda

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Contributions

PT, NN and PM participated in the conceptualization and design of the study, developing interview guides, writing the initial version of the manuscript, and reviewing subsequent versions, with substantial input from NMT. With assistance from NN and PM, PT and JN conducted the data analysis. Each author contributed to the writing of the manuscript, and they all reviewed and gave their approval for publishing of the final draft.

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Correspondence to Paddy Mutungi Tukamuhebwa .

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Tukamuhebwa, P.M., Munyewende, P., Tumwesigye, N.M. et al. Health worker perspectives on barriers and facilitators of tuberculosis investigation coverage among index case contacts in rural Southwestern Uganda: a qualitative study. BMC Infect Dis 24 , 867 (2024). https://doi.org/10.1186/s12879-024-09798-9

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Received : 04 May 2024

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Published : 26 August 2024

DOI : https://doi.org/10.1186/s12879-024-09798-9

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College managerial practices for promoting english language teaching and learning in tanzania: a case study of grade ‘a’ public teachers’ training colleges, deogratius mathew wenga, winfrida saimon malingumu.

This study examined the college management practices for promoting English language teaching and learning in public teachers’  colleges using a case of Grade ‘A’ central zone training institutions. The objective of the study was to identify college management  practices for promoting English language teaching and learning. The qualitative study employed a case study design, and interviews and  focus group discussions to generate data from 20 conveniently and purposively sampled respondents comprising English language  teachers, academic deans, principals and students. The study found out that teachers’ training colleges used performance rewards, close monitoring and evaluation of teachers, debating and other English clubs, staff professional development, and providing supportive  teaching and learning environment to enhance English language teaching and learning. Additionally, the teachers’ college management  need regular monitoring to ensure that English language promotion plans it was are properly executed instead of remaining only good  on paper. 

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