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Cases Studies in Public Health Available Online

First study of mers animal host in saudi arabia.

Case studies aren’t just for business schools anymore. Columbia University’s Mailman School of Public Health has been using the case method to teach MPH students as part of the new Columbia Public Health Curriculum. Now, six of the School’s public health cases have been published online, making them available to classrooms anywhere.

“The case method can be a powerful tool for learning public health. It gives students the opportunity to gain experience making decisions in the face of uncertainty, much as they will have to do every day when they graduate and leave us to work in their chosen field,” says Melissa Begg, ScD , Vice Dean for Education at the Mailman School, who is leading the implementation of the new MPH curriculum.

Each case study tells a detailed story which stops mid-action, asking students to imagine themselves into the shoes of a decision-maker facing a tough call. One case developed with the help of David Abramson, PhD , assistant professor of Sociomedical Sciences, looks at the decision of whether to evacuate two hospitals during Superstorm Sandy. Another looks at how to win a community’s trust, as told through the experience of Mailman scientists conducting a federally-funded study of arsenic-tainted water in Bangladesh.

Classroom discussions are lively, and most important, there isn’t a single right answer. “Students practice taking positions and defending them based on the available evidence, while developing communication and critical thinking skills,” explains Dr. Begg. “They learn to argue persuasively for their points of view.

The Mailman School case studies are available through Columbia University’s Case Consortium website, which also features cases by Columbia’s Journalism School and the School for International and Public Affairs (SIPA). They are available free (after registration) to educators and at a nominal cost to students, professionals, and other interested parties. 

“While most existing case curriculum remains paper-based, the Mailman School cases are online and multimedia, meeting students where they live in the digital media world,” says Kirsten Lundberg, MPA, director of the Case Consortium @ Columbia.

The “discussion-based” case study approach has historic roots reaching back to Socrates, and was popularized in the 20th century by business schools. To see the cases, please visit  Case Consortium  and click on Cases.

Public Health Case Studies

Voluntary or Regulated? The Trans Fat Campaign in New York City

This case takes students behind the scenes in the world of public health policymaking.  Students follow the New York City Department of Health and Mental Hygiene, and the process it went through to craft a policy to reduce public consumption of trans fats in restaurants. In 2005, after considerable internal negotiations, the department’s Bureau of Chronic Disease Prevention and Control elected to launch a public awareness campaign aimed equally at consumers, restaurants and their suppliers. But after a year, the awareness campaign had not budged the rate of trans fat use in restaurants. In 2006, the department decided to resort to regulation, despite the risks of triggering protests of a “nanny state,” not to mention pushback from industry.

When BEST Intentions Go Awry: Arsenic Mitigation in Bangladesh

This case is about a public health response to the widespread arsenic contamination of groundwater in Bangladesh. It examines the lead-up to a 2008 media crisis that confronted a Columbia University clinical trial of a potential treatment for arsenic poisoning. The case raises for discussion the challenges of conducting research in rural, less developed and culturally insular communities. It also asks how to help communities while studying them—complicated by funding restrictions and a possible skewing of results. 

Community Savings, or Community Threat? California Policy for Ill and Elderly Inmates

This case looks at the challenges that confront public health professionals who work in a corrections environment. By 2011, a court-appointed Receiver had made progress in fixing a broken system of medical care for prisoners in California. But costs spiraled ever higher for elderly and ailing inmates. Public health officials had to balance competing public priorities: save taxpayer dollars while treating patients. A new law allowed the sickest prisoners to move to community-based care—but now public health doctors had to decide: who qualified for medical parole?

Credible Voice: WHO-Beijing and the SARS Crisis

This case study takes students into the Beijing office of the World Health Organization as it dealt with the SARS crisis in early 2003. The WHO serves as the world’s monitor of disease outbreak and control. It is able to mobilize legions of the world’s best scientists to analyze, diagnose, prescribe treatments for and contain diseases. However, it depends on the cooperation of the countries experiencing an epidemic. What happens when that cooperation is limited or nonexistent?

The Elusive Tuberculosis Case: The CDC and Andrew Speaker

This case explores the ethical and logistical challenges that doctors face when an infectious disease patient does not cooperate with advice to stay out of public spaces in order to protect the general welfare. In April 2007, a young Atlanta lawyer, Andrew Speaker, was diagnosed with active tuberculosis. Initially cooperative, Speaker departs without notice for Greece and his scheduled wedding even though it is clear that his strain of TB is more lethal and difficult-to-treat than anticipated. 

Evacuate or Stay? Northshore LIJ and Hurricane Sandy

This case examines the pros and cons of evacuating medical facilities in the face of a looming natural disaster. In October 2012, the North Shore-Long Island Jewish Hospitals (North Shore-LIJ) network braced—together with rest of the East coast—for the advent of Hurricane Sandy. Weather forecasters painted a grim picture, and North Shore-LIJ had three hospitals in low-lying areas. Vice President of Protective Services James Romagnoli and COO Mark Solazzo had seen this scenario only a year earlier, when in August 2011 they evacuated hospitals in advance of Hurricane Irene. But Irene had, at the last moment, spared New York City. With that unnecessary evacuation fresh in their minds, the two officials had to decide what to do as Sandy approached.

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Oomph library resources: phw 250/250b epidemiologic methods: epidemiologic case study resources.

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Epidemiologic Case Studies

  • Epidemiologic Case Studies (US CDC) These case studies are interactive exercises developed to teach epidemiologic principles and practices. They are based on real-life outbreaks and public health problems and were developed in collaboration with the original investigators and experts from the Centers for Disease Control and Prevention (CDC). The case studies require students to apply their epidemiologic knowledge and skills to problems confronted by public health practitioners at the local, state, and national level every day.
  • Case Studies (WHO) From "Strengthening health security by implementing the International Health Regulations," each case has learning objectives and documentation.
  • Case Studies in Social Medicine A series of Perspective articles from the New England Journal of Medicine that highlight the importance of social concepts and social context in clinical medicine. The series uses discussions of real clinical cases to translate theories and methods for understanding social processes into terms that can readily be used in medical education, clinical practice, and health system planning.
  • African Case Studies in Public Heath Case study exercises based on real events in African contexts and written by experienced Africa-based public health trainers and practitioners. These case studies represent the most up-to-date and context-appropriate case study exercises for African public health training programs. These exercises are designed to reinforce and instill competencies for addressing health threats in the future leaders of public health in Africa.
  • Case Consortium @ Columbia University: Public Health Cases The case collection includes "teaching" cases. Nearly all the cases are multimedia and based on original research; a few are written from secondary sources. All cases are offered free of charge.
  • Epi Teams Training: Case Studies From the North Carolina Institute for Public Health, this curriculum includes several interactive case studies designed be used by the Epi Team as a group. These case studies are based on actual outbreaks that have occurred in North Carolina and elsewhere.
  • National Center for Case Study Teaching in Science The mission of the NCCSTS at the University at Buffalo is to promote the development and dissemination of materials and practices for case teaching in the sciences. Our website provides access to an award-winning collection of peer-reviewed case studies. We offer a five-day summer workshop and a two-day fall conference to train faculty in the case method of teaching science. In addition, we are actively engaged in educational research to assess the impact of the case method on student learning. "Case Collection" includes over 100 public health cases.

Books of Case Studies

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  • URL: https://guides.lib.berkeley.edu/publichealth/PHW250
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  • Published: 10 November 2020

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

  • Sara Paparini   ORCID: orcid.org/0000-0002-1909-2481 1 ,
  • Judith Green 2 ,
  • Chrysanthi Papoutsi 1 ,
  • Jamie Murdoch 3 ,
  • Mark Petticrew 4 ,
  • Trish Greenhalgh 1 ,
  • Benjamin Hanckel 5 &
  • Sara Shaw 1  

BMC Medicine volume  18 , Article number:  301 ( 2020 ) Cite this article

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

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

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

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The need for methodological development to address the most urgent challenges in health research has been well-documented. Many of the most pressing questions for public health research, where the focus is on system-level determinants [ 1 , 2 ], and for health services research, where provisions typically vary across sites and are provided through interlocking networks of services [ 3 ], require methodological approaches that can attend to complexity. The need for methodological advance has arisen, in part, as a result of the diminishing returns from randomised controlled trials (RCTs) where they have been used to answer questions about the effects of interventions in complex systems [ 4 , 5 , 6 ]. In conditions of complexity, there is limited value in maintaining the current orientation to experimental trial designs in the health sciences as providing ‘gold standard’ evidence of effect.

There are increasing calls for methodological pluralism [ 7 , 8 ], with the recognition that complex intervention and context are not easily or usefully separated (as is often the situation when using trial design), and that system interruptions may have effects that are not reducible to linear causal pathways between intervention and outcome. These calls are reflected in a shifting and contested discourse of trial design, seen with the emergence of realist [ 9 ], adaptive and hybrid (types 1, 2 and 3) [ 10 , 11 ] trials that blend studies of effectiveness with a close consideration of the contexts of implementation. Similarly, process evaluation has now become a core component of complex healthcare intervention trials, reflected in MRC guidance on how to explore implementation, causal mechanisms and context [ 12 ].

Evidence about the context of an intervention is crucial for questions of external validity. As Woolcock [ 4 ] notes, even if RCT designs are accepted as robust for maximising internal validity, questions of transferability (how well the intervention works in different contexts) and generalisability (how well the intervention can be scaled up) remain unanswered [ 5 , 13 ]. For research evidence to have impact on policy and systems organisation, and thus to improve population and patient health, there is an urgent need for better methods for strengthening external validity, including a better understanding of the relationship between intervention and context [ 14 ].

Policymakers, healthcare commissioners and other research users require credible evidence of relevance to their settings and populations [ 15 ], to perform what Rosengarten and Savransky [ 16 ] call ‘careful abstraction’ to the locales that matter for them. They also require robust evidence for understanding complex causal pathways. Case study research, currently under-utilised in public health and health services evaluation, can offer considerable potential for strengthening faith in both external and internal validity. For example, in an empirical case study of how the policy of free bus travel had specific health effects in London, UK, a quasi-experimental evaluation (led by JG) identified how important aspects of context (a good public transport system) and intervention (that it was universal) were necessary conditions for the observed effects, thus providing useful, actionable evidence for decision-makers in other contexts [ 17 ].

The overall approach of case study research is based on the in-depth exploration of complex phenomena in their natural, or ‘real-life’, settings. Empirical case studies typically enable dynamic understanding of complex challenges rather than restricting the focus on narrow problem delineations and simple fixes. Case study research is a diverse and somewhat contested field, with multiple definitions and perspectives grounded in different ways of viewing the world, and involving different combinations of methods. In this paper, we raise awareness of such plurality and highlight the contribution that case study research can make to the evaluation of complex system-level interventions. We review some of the challenges in exploiting the current evidence base from empirical case studies and conclude by recommending that further guidance and minimum reporting criteria for evaluation using case studies, appropriate for audiences in the health sciences, can enhance the take-up of evidence from case study research.

Case study research offers evidence about context, causal inference in complex systems and implementation

Well-conducted and described empirical case studies provide evidence on context, complexity and mechanisms for understanding how, where and why interventions have their observed effects. Recognition of the importance of context for understanding the relationships between interventions and outcomes is hardly new. In 1943, Canguilhem berated an over-reliance on experimental designs for determining universal physiological laws: ‘As if one could determine a phenomenon’s essence apart from its conditions! As if conditions were a mask or frame which changed neither the face nor the picture!’ ([ 18 ] p126). More recently, a concern with context has been expressed in health systems and public health research as part of what has been called the ‘complexity turn’ [ 1 ]: a recognition that many of the most enduring challenges for developing an evidence base require a consideration of system-level effects [ 1 ] and the conceptualisation of interventions as interruptions in systems [ 19 ].

The case study approach is widely recognised as offering an invaluable resource for understanding the dynamic and evolving influence of context on complex, system-level interventions [ 20 , 21 , 22 , 23 ]. Empirically, case studies can directly inform assessments of where, when, how and for whom interventions might be successfully implemented, by helping to specify the necessary and sufficient conditions under which interventions might have effects and to consolidate learning on how interdependencies, emergence and unpredictability can be managed to achieve and sustain desired effects. Case study research has the potential to address four objectives for improving research and reporting of context recently set out by guidance on taking account of context in population health research [ 24 ], that is to (1) improve the appropriateness of intervention development for specific contexts, (2) improve understanding of ‘how’ interventions work, (3) better understand how and why impacts vary across contexts and (4) ensure reports of intervention studies are most useful for decision-makers and researchers.

However, evaluations of complex healthcare interventions have arguably not exploited the full potential of case study research and can learn much from other disciplines. For evaluative research, exploratory case studies have had a traditional role of providing data on ‘process’, or initial ‘hypothesis-generating’ scoping, but might also have an increasing salience for explanatory aims. Across the social and political sciences, different kinds of case studies are undertaken to meet diverse aims (description, exploration or explanation) and across different scales (from small N qualitative studies that aim to elucidate processes, or provide thick description, to more systematic techniques designed for medium-to-large N cases).

Case studies with explanatory aims vary in terms of their positioning within mixed-methods projects, with designs including (but not restricted to) (1) single N of 1 studies of interventions in specific contexts, where the overall design is a case study that may incorporate one or more (randomised or not) comparisons over time and between variables within the case; (2) a series of cases conducted or synthesised to provide explanation from variations between cases; and (3) case studies of particular settings within RCT or quasi-experimental designs to explore variation in effects or implementation.

Detailed qualitative research (typically done as ‘case studies’ within process evaluations) provides evidence for the plausibility of mechanisms [ 25 ], offering theoretical generalisations for how interventions may function under different conditions. Although RCT designs reduce many threats to internal validity, the mechanisms of effect remain opaque, particularly when the causal pathways between ‘intervention’ and ‘effect’ are long and potentially non-linear: case study research has a more fundamental role here, in providing detailed observational evidence for causal claims [ 26 ] as well as producing a rich, nuanced picture of tensions and multiple perspectives [ 8 ].

Longitudinal or cross-case analysis may be best suited for evidence generation in system-level evaluative research. Turner [ 27 ], for instance, reflecting on the complex processes in major system change, has argued for the need for methods that integrate learning across cases, to develop theoretical knowledge that would enable inferences beyond the single case, and to develop generalisable theory about organisational and structural change in health systems. Qualitative Comparative Analysis (QCA) [ 28 ] is one such formal method for deriving causal claims, using set theory mathematics to integrate data from empirical case studies to answer questions about the configurations of causal pathways linking conditions to outcomes [ 29 , 30 ].

Nonetheless, the single N case study, too, provides opportunities for theoretical development [ 31 ], and theoretical generalisation or analytical refinement [ 32 ]. How ‘the case’ and ‘context’ are conceptualised is crucial here. Findings from the single case may seem to be confined to its intrinsic particularities in a specific and distinct context [ 33 ]. However, if such context is viewed as exemplifying wider social and political forces, the single case can be ‘telling’, rather than ‘typical’, and offer insight into a wider issue [ 34 ]. Internal comparisons within the case can offer rich possibilities for logical inferences about causation [ 17 ]. Further, case studies of any size can be used for theory testing through refutation [ 22 ]. The potential lies, then, in utilising the strengths and plurality of case study to support theory-driven research within different methodological paradigms.

Evaluation research in health has much to learn from a range of social sciences where case study methodology has been used to develop various kinds of causal inference. For instance, Gerring [ 35 ] expands on the within-case variations utilised to make causal claims. For Gerring [ 35 ], case studies come into their own with regard to invariant or strong causal claims (such as X is a necessary and/or sufficient condition for Y) rather than for probabilistic causal claims. For the latter (where experimental methods might have an advantage in estimating effect sizes), case studies offer evidence on mechanisms: from observations of X affecting Y, from process tracing or from pattern matching. Case studies also support the study of emergent causation, that is, the multiple interacting properties that account for particular and unexpected outcomes in complex systems, such as in healthcare [ 8 ].

Finally, efficacy (or beliefs about efficacy) is not the only contributor to intervention uptake, with a range of organisational and policy contingencies affecting whether an intervention is likely to be rolled out in practice. Case study research is, therefore, invaluable for learning about contextual contingencies and identifying the conditions necessary for interventions to become normalised (i.e. implemented routinely) in practice [ 36 ].

The challenges in exploiting evidence from case study research

At present, there are significant challenges in exploiting the benefits of case study research in evaluative health research, which relate to status, definition and reporting. Case study research has been marginalised at the bottom of an evidence hierarchy, seen to offer little by way of explanatory power, if nonetheless useful for adding descriptive data on process or providing useful illustrations for policymakers [ 37 ]. This is an opportune moment to revisit this low status. As health researchers are increasingly charged with evaluating ‘natural experiments’—the use of face masks in the response to the COVID-19 pandemic being a recent example [ 38 ]—rather than interventions that take place in settings that can be controlled, research approaches using methods to strengthen causal inference that does not require randomisation become more relevant.

A second challenge for improving the use of case study evidence in evaluative health research is that, as we have seen, what is meant by ‘case study’ varies widely, not only across but also within disciplines. There is indeed little consensus amongst methodologists as to how to define ‘a case study’. Definitions focus, variously, on small sample size or lack of control over the intervention (e.g. [ 39 ] p194), on in-depth study and context [ 40 , 41 ], on the logic of inference used [ 35 ] or on distinct research strategies which incorporate a number of methods to address questions of ‘how’ and ‘why’ [ 42 ]. Moreover, definitions developed for specific disciplines do not capture the range of ways in which case study research is carried out across disciplines. Multiple definitions of case study reflect the richness and diversity of the approach. However, evidence suggests that a lack of consensus across methodologists results in some of the limitations of published reports of empirical case studies [ 43 , 44 ]. Hyett and colleagues [ 43 ], for instance, reviewing reports in qualitative journals, found little match between methodological definitions of case study research and how authors used the term.

This raises the third challenge we identify that case study reports are typically not written in ways that are accessible or useful for the evaluation research community and policymakers. Case studies may not appear in journals widely read by those in the health sciences, either because space constraints preclude the reporting of rich, thick descriptions, or because of the reported lack of willingness of some biomedical journals to publish research that uses qualitative methods [ 45 ], signalling the persistence of the aforementioned evidence hierarchy. Where they do, however, the term ‘case study’ is used to indicate, interchangeably, a qualitative study, an N of 1 sample, or a multi-method, in-depth analysis of one example from a population of phenomena. Definitions of what constitutes the ‘case’ are frequently lacking and appear to be used as a synonym for the settings in which the research is conducted. Despite offering insights for evaluation, the primary aims may not have been evaluative, so the implications may not be explicitly drawn out. Indeed, some case study reports might properly be aiming for thick description without necessarily seeking to inform about context or causality.

Acknowledging plurality and developing guidance

We recognise that definitional and methodological plurality is not only inevitable, but also a necessary and creative reflection of the very different epistemological and disciplinary origins of health researchers, and the aims they have in doing and reporting case study research. Indeed, to provide some clarity, Thomas [ 46 ] has suggested a typology of subject/purpose/approach/process for classifying aims (e.g. evaluative or exploratory), sample rationale and selection and methods for data generation of case studies. We also recognise that the diversity of methods used in case study research, and the necessary focus on narrative reporting, does not lend itself to straightforward development of formal quality or reporting criteria.

Existing checklists for reporting case study research from the social sciences—for example Lincoln and Guba’s [ 47 ] and Stake’s [ 33 ]—are primarily orientated to the quality of narrative produced, and the extent to which they encapsulate thick description, rather than the more pragmatic issues of implications for intervention effects. Those designed for clinical settings, such as the CARE (CAse REports) guidelines, provide specific reporting guidelines for medical case reports about single, or small groups of patients [ 48 ], not for case study research.

The Design of Case Study Research in Health Care (DESCARTE) model [ 44 ] suggests a series of questions to be asked of a case study researcher (including clarity about the philosophy underpinning their research), study design (with a focus on case definition) and analysis (to improve process). The model resembles toolkits for enhancing the quality and robustness of qualitative and mixed-methods research reporting, and it is usefully open-ended and non-prescriptive. However, even if it does include some reflections on context, the model does not fully address aspects of context, logic and causal inference that are perhaps most relevant for evaluative research in health.

Hence, for evaluative research where the aim is to report empirical findings in ways that are intended to be pragmatically useful for health policy and practice, this may be an opportune time to consider how to best navigate plurality around what is (minimally) important to report when publishing empirical case studies, especially with regards to the complex relationships between context and interventions, information that case study research is well placed to provide.

The conventional scientific quest for certainty, predictability and linear causality (maximised in RCT designs) has to be augmented by the study of uncertainty, unpredictability and emergent causality [ 8 ] in complex systems. This will require methodological pluralism, and openness to broadening the evidence base to better understand both causality in and the transferability of system change intervention [ 14 , 20 , 23 , 25 ]. Case study research evidence is essential, yet is currently under exploited in the health sciences. If evaluative health research is to move beyond the current impasse on methods for understanding interventions as interruptions in complex systems, we need to consider in more detail how researchers can conduct and report empirical case studies which do aim to elucidate the contextual factors which interact with interventions to produce particular effects. To this end, supported by the UK’s Medical Research Council, we are embracing the challenge to develop guidance for case study researchers studying complex interventions. Following a meta-narrative review of the literature, we are planning a Delphi study to inform guidance that will, at minimum, cover the value of case study research for evaluating the interrelationship between context and complex system-level interventions; for situating and defining ‘the case’, and generalising from case studies; as well as provide specific guidance on conducting, analysing and reporting case study research. Our hope is that such guidance can support researchers evaluating interventions in complex systems to better exploit the diversity and richness of case study research.

Availability of data and materials

Not applicable (article based on existing available academic publications)

Abbreviations

Qualitative comparative analysis

Quasi-experimental design

Randomised controlled trial

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This work was funded by the Medical Research Council - MRC Award MR/S014632/1 HCS: Case study, Context and Complex interventions (TRIPLE C). SP was additionally funded by the University of Oxford's Higher Education Innovation Fund (HEIF).

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Paparini, S., Green, J., Papoutsi, C. et al. Case study research for better evaluations of complex interventions: rationale and challenges. BMC Med 18 , 301 (2020). https://doi.org/10.1186/s12916-020-01777-6

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

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What is it?

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

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

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

Benefits and limitations of case studies

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

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

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

Examples of case studies

Example 1: nurses’ paediatric pain management practices.

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

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

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

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

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

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

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

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

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

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

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

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

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The case study approach

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

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Introduction

The case study approach is particularly useful to employ when there is a need to obtain an in-depth appreciation of an issue, event or phenomenon of interest, in its natural real-life context. Our aim in writing this piece is to provide insights into when to consider employing this approach and an overview of key methodological considerations in relation to the design, planning, analysis, interpretation and reporting of case studies.

The illustrative 'grand round', 'case report' and 'case series' have a long tradition in clinical practice and research. Presenting detailed critiques, typically of one or more patients, aims to provide insights into aspects of the clinical case and, in doing so, illustrate broader lessons that may be learnt. In research, the conceptually-related case study approach can be used, for example, to describe in detail a patient's episode of care, explore professional attitudes to and experiences of a new policy initiative or service development or more generally to 'investigate contemporary phenomena within its real-life context' [ 1 ]. Based on our experiences of conducting a range of case studies, we reflect on when to consider using this approach, discuss the key steps involved and illustrate, with examples, some of the practical challenges of attaining an in-depth understanding of a 'case' as an integrated whole. In keeping with previously published work, we acknowledge the importance of theory to underpin the design, selection, conduct and interpretation of case studies[ 2 ]. In so doing, we make passing reference to the different epistemological approaches used in case study research by key theoreticians and methodologists in this field of enquiry.

This paper is structured around the following main questions: What is a case study? What are case studies used for? How are case studies conducted? What are the potential pitfalls and how can these be avoided? We draw in particular on four of our own recently published examples of case studies (see Tables 1 , 2 , 3 and 4 ) and those of others to illustrate our discussion[ 3 – 7 ].

What is a case study?

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

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

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

What are case studies used for?

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

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

How are case studies conducted?

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

Defining the case

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

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

Selecting the case(s)

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

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

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

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

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

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

Collecting the data

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

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

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

Analysing, interpreting and reporting case studies

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

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

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

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

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

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

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

Conclusions

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

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Acknowledgements

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

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Crowe, S., Cresswell, K., Robertson, A. et al. The case study approach. BMC Med Res Methodol 11 , 100 (2011). https://doi.org/10.1186/1471-2288-11-100

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case study definition public health

OPINION article

Community case study article type: criteria for submission and peer review.

\r\n      \r\nMatthew Lee Smith,*

  • 1 Department of Health Promotion and Behavior, College of Public Health, The University of Georgia, Athens, GA, USA
  • 2 Department of Health Promotion and Community Health Sciences, Texas A&M Health Science Center School of Public Health, College Station, TX, USA
  • 3 College of Social Work, University of South Carolina, Columbia, SC, USA

The Importance of Case Studies in Public Health Education and Promotion

Health programs and practices are often conceived and delivered by community-based practitioners to address specific community health education and promotion needs ( 1 ). Although, initially untested, such programs can provide important lessons for researchers and practitioners, alike. Given the growing emphasis on community-based participatory research (CBPR) approaches ( 2 ), it is especially important for researchers to build upon findings from CBPR studies, which can contribute to the development of evidence-based programs and practices for widespread dissemination ( 3 ).

While a community case study can take many forms ( 4 , 5 ), we are defining it as a description of, and reflection upon, a program or practice geared toward improving the health and functioning of a targeted population. We utilize the term “community” in contrast to “clinical” studies, but it is important to note that a community can be defined in terms of geographic boundaries as well as demographic characteristics, common settings, and/or affiliations.

Typically, a community case study documents a local experience about delivering services to meet an identified need. Community-based studies often rely on community engagement principles, which are not typically incorporated in the more traditional science-based approach to evidence-based program development (e.g., CBPR, action research, and community-engaged research). The community case study that documents early experiences can contribute to programmatic development as well as to the future development of evidence-based practice. This has been referred to as the “practice to science” approach to the development of evidence-based practices ( 6 ). The community case study can also represent activities at later development stages, for example, documenting the experience of implementing an evidence-based program or practice in a different context (e.g., different culture, different population, and different setting) from that in which it was first developed [“from science to practice” ( 6 )]. The lessons learned from such community case studies are essential for adaptation, replication, and eventual widespread dissemination and sustainability of innovations across a wide range of settings and populations.

Although case studies are a recognized form of research ( 5 ), the criteria for evaluating the quality of such efforts necessarily differs from empirical research articles where there is less attention to the local experience and context in which the intervention occurs, and more emphasis is given to the use of standardized research designs, measures, and analyses.

Key Components of a Community Case Study

Under this article type, Frontiers in Public Health Education and Promotion will accept a broad spectrum of manuscripts that describe interventions, including programs and services, which promote public health education, practice, research, and/or policy. Such public health interventions can be implemented at the behavioral, organizational, community, environmental, and/or policy level(s). Articles require a description of the nature of the problem being addressed and rationale for the proposed intervention, the context (setting and population) in which the intervention is being implemented, and sufficient detail to allow replication of key programmatic elements. Reflections about public health impact as well as what works and what does not work should be highlighted. Additionally, submissions will require a discussion section that shares practical implications, lessons learned for future applications, and acknowledgment of any conceptual or methodological constraints. Articles should not exceed 5,000 words and include a maximum of five tables/graphs. Evaluation criteria for this article type are outlined below:

We recommend that community case study article submissions address the following issues (if relevant).

□ What is the problem? Whom does it affect?

□ What are the gaps about what is known or done currently?

□ What is the setting? Who are the key stakeholders? Who is the target population or participants?

□ With whom did you work or collaborate? Are there any unique characteristics of the team who worked to implement the solution?

□ What is the solution described by this community case study?

□ Is this solution innovative/novel in terms of content, format, and/or delivery? If yes, why?

□ What are the essential elements of the solution? Could this community case study be replicated? Include sufficient detail that the reader would know if replication would be feasible in his/her own context.

□ What are the barriers and facilitators to the development, implementation, and/or dissemination of the intervention?

□ What are the major successes of the solution? What are the promising results to date? Include data and/or evaluation results, if available.

□ How does this improve public health education, practice, research, and/or policy? What are the broader implications of this work?

□ Recommendations for those who want to replicate this in other settings, populations, or over time.

Criteria for Review (Template for Review Editors to Complete for Each Manuscript)

Indicate what the community case study describes (check all that apply)

__an education effort

__a health promotion program

__a health promotion service

__an environmental change taking place in the community

__a technological change taking place in the community

__a policy change taking place in the community

__a community partnership

__others. Please specify: _____________________

__none of the above (i.e., inappropriately categorized for submission as a community case study article).

Indicate the target audience for the case study (check all that apply)

__educators

__community professionals

__health-care professionals

__lay public

__policy makers

__other. Please specify: _____________________

Mandatory Sections and Associated Criteria

A community case study article has the following mandatory sections: abstract, introduction, background and rationale, description of the case, methodological aspects (including targeted population and setting), discussion, and lessons learned/recommendations. Are all sections present?

• Is the abstract written in a clear and comprehensive way?

• Does the abstract reflect major conclusions articulated in the case study?

Introduction

• Does the introduction present the problem in an appropriate context?

• Other comments on introduction.

Background and Rationale

• Is the intent of the case study adequately described?

• Is a justification made for the innovation/novelty of proposed case in content, format, and/or delivery?

• Are the questions asked by the case study most essential to the success of the initiative?

• Other comments on background and rationale.

Essential Elements of the Intervention

• Is the intervention adequately described (e.g., development, previous findings if any, components, and format/design)?

• Is the intervention described in sufficient detail to understand the essential elements?

• Are the implementation procedures adequately described (e.g., how is the intervention being implemented in a particular setting, population, and/or partnerships; are any adaptations needed from prior work)?

• Are the target setting(s) and population(s) adequately described so that context for the case study is clearly understood?

• Is this a single community or multiple community study?

• Is there an overall conceptual model or framework for understanding the importance of the problem and selection of intervention elements?

• Is it clear whether the emphasis is on furthering knowledge about the process and/or outcome of the case study? If focus is on process, is there attention to key elements of implementation such as reach, reproducibility, scalability, or sustainability? If on outcomes, are the metrics of success (outcome indicators) clearly articulated?

• Is the generalizability of findings/lessons learned addressed?

• Other comments on methods.

• Are findings/lessons learned accurately reported from data presented?

• Is the level of detail of the results appropriate (too much, too little, or about right)?

• Is any essential information missing?

• Other comments on results.

• Are the reported findings/lessons learned summarized briefly and described within the context of what is currently known about the public health issue(s) or problem(s) being addressed?

• Does the article conclude with practical recommendations for others who might replicate this intervention/program (or similar interventions/programs)?

• Does the article conclude with applied recommendations for those in the field who might deliver this intervention/program (or similar interventions/programs) in their communities/settings?

• Does the case study contribute concrete recommendations for delivering and/or improving the intervention for future applications (directed toward educators, researchers, or practitioners, as appropriate)?

• Does the article address any conceptual or methodological limitations for future implementation, dissemination, and sustainability?

• Other comments on discussion.

• Are the conclusions justified?

• Overall, does the article contribute to building evidence-based practice and/or policy?

• Is prior work, if any, properly and fully cited?

Article Length

• A case study article should not exceed 5,000 words. Should any part of the article be shortened? If yes, please specify which part should be shortened.

• A case study article should not include more than five tables/figures. If there are more tables/figures included, please specify if you believe tables can be combined, condensed, or eliminated.

Language and Grammar

• Are the language and grammar correct?

• Should the paper be sent to an expert in English language and scientific writing?

Other Comments

• Please add any further comments you have regarding this manuscript.

Reviewer Ratings

• Significance of issue being addressed by the case study: scored out of a maximum of 10 points

• Description of essential elements of the case study: scored out of a maximum of 10 points

• Appropriateness of the context (population and setting) in addressing the public health issue/problem described in the case study: scored out of a maximum of 10 points

• Sufficient conceptual and methodological detail describing why and how the intervention was implemented: scored out of a maximum of 10 points

• Reflections on what worked and did not work in the design, implementation, and/or dissemination of the program: scored out of a maximum of 10 points

• Quality of the writing: scored out of a maximum of 10 points

• Quality of the figure(s) and table(s): scored out of a maximum of 10 points

• Significance of the findings/lessons learned: scored out of a maximum of 10 points

• Could this intervention be replicated by other educators, researchers, or practitioners?

Author Contributions

All authors were integral in formulating and drafting the manuscript and associated criteria.

Conflict of Interest Statement

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

1. Ory MG, Smith MLS, Howell D, Zollinger A, Quinn C, Swierc S, et al. The conversion of a practice-based lifestyle enhancement program into a formalized, testable program: from texercise classic to texercise select. Front Public Health (2015) 2 :291. doi: 10.3389/fpubh.2014.00291

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Keywords: case study, review criteria, article type, intervention, evaluation criteria

Citation: Smith ML, Levkoff SE and Ory MG (2016) Community Case Study Article Type: Criteria for Submission and Peer Review. Front. Public Health 4:56. doi: 10.3389/fpubh.2016.00056

Received: 06 November 2015; Accepted: 14 March 2016; Published: 14 April 2016

Reviewed by:

Copyright: © 2016 Smith, Levkoff and Ory. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) or licensor are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Matthew Lee Smith, health@uga.edu

Disclaimer: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.

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Health Case Studies

(29 reviews)

case study definition public health

Glynda Rees, British Columbia Institute of Technology

Rob Kruger, British Columbia Institute of Technology

Janet Morrison, British Columbia Institute of Technology

Copyright Year: 2017

Publisher: BCcampus

Language: English

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Reviewed by Jessica Sellars, Medical assistant office instructor, Blue Mountain Community College on 10/11/23

This is a book of compiled and very well organized patient case studies. The author has broken it up by disease patient was experiencing and even the healthcare roles that took place in this patients care. There is a well thought out direction and... read more

Comprehensiveness rating: 5 see less

This is a book of compiled and very well organized patient case studies. The author has broken it up by disease patient was experiencing and even the healthcare roles that took place in this patients care. There is a well thought out direction and plan. There is an appendix to refer to as well if you are needing to find something specific quickly. I have been looking for something like this to help my students have a base to do their project on. This is the most comprehensive version I have found on the subject.

Content Accuracy rating: 5

This is a book compiled of medical case studies. It is very accurate and can be used to learn from great care and mistakes.

Relevance/Longevity rating: 5

This material is very relevant in this context. It also has plenty of individual case studies to utilize in many ways in all sorts of medical courses. This is a very useful textbook and it will continue to be useful for a very long time as you can still learn from each study even if medicine changes through out the years.

Clarity rating: 5

The author put a lot of thought into the ease of accessibility and reading level of the target audience. There is even a "how to use this resource" section which could be extremely useful to students.

Consistency rating: 5

The text follows a very consistent format throughout the book.

Modularity rating: 5

Each case study is individual broken up and in a group of similar case studies. This makes it extremely easy to utilize.

Organization/Structure/Flow rating: 5

The book is very organized and the appendix is through. It flows seamlessly through each case study.

Interface rating: 5

I had no issues navigating this book, It was clearly labeled and very easy to move around in.

Grammatical Errors rating: 5

I did not catch any grammar errors as I was going through the book

Cultural Relevance rating: 5

This is a challenging question for any medical textbook. It is very culturally relevant to those in medical or medical office degrees.

I have been looking for something like this for years. I am so happy to have finally found it.

Reviewed by Cindy Sun, Assistant Professor, Marshall University on 1/7/23

Interestingly, this is not a case of ‘you get what you pay for’. Instead, not only are the case studies organized in a fashion for ease of use through a detailed table of contents, the authors have included more support for both faculty and... read more

Interestingly, this is not a case of ‘you get what you pay for’. Instead, not only are the case studies organized in a fashion for ease of use through a detailed table of contents, the authors have included more support for both faculty and students. For faculty, the introduction section titled ‘How to use this resource’ and individual notes to educators before each case study contain application tips. An appendix overview lists key elements as issues / concepts, scenario context, and healthcare roles for each case study. For students, learning objectives are presented at the beginning of each case study to provide a framework of expectations.

The content is presented accurately and realistic.

The case studies read similar to ‘A Day In the Life of…’ with detailed intraprofessional communications similar to what would be overheard in patient care areas. The authors present not only the view of the patient care nurse, but also weave interprofessional vantage points through each case study by including patient interaction with individual professionals such as radiology, physician, etc.

In addition to objective assessment findings, the authors integrate standard orders for each diagnosis including medications, treatments, and tests allowing the student to incorporate pathophysiology components to their assessments.

Each case study is arranged in the same framework for consistency and ease of use.

This compilation of eight healthcare case studies focusing on new onset and exacerbation of prevalent diagnoses, such as heart failure, deep vein thrombosis, cancer, and chronic obstructive pulmonary disease advancing to pneumonia.

Each case study has a photo of the ‘patient’. Simple as this may seem, it gives an immediate mental image for the student to focus.

Interface rating: 4

As noted by previous reviewers, most of the links do not connect active web pages. This may be due to the multiple options for accessing this resource (pdf download, pdf electronic, web view, etc.).

Grammatical Errors rating: 4

A minor weakness that faculty will probably need to address prior to use is regarding specific term usages differences between Commonwealth countries and United States, such as lung sound descriptors as ‘quiet’ in place of ‘diminished’ and ‘puffers’ in place of ‘inhalers’.

The authors have provided a multicultural, multigenerational approach in selection of patient characteristics representing a snapshot of today’s patient population. Additionally, one case study focusing on heart failure is about a middle-aged adult, contrasting to the average aged patient the students would normally see during clinical rotations. This option provides opportunities for students to expand their knowledge on risk factors extending beyond age.

This resource is applicable to nursing students learning to care for patients with the specific disease processes presented in each case study or for the leadership students focusing on intraprofessional communication. Educators can assign as a supplement to clinical experiences or as an in-class application of knowledge.

Reviewed by Stephanie Sideras, Assistant Professor, University of Portland on 8/15/22

The eight case studies included in this text addressed high frequency health alterations that all nurses need to be able to manage competently. While diabetes was not highlighted directly, it was included as a potential comorbidity. The five... read more

The eight case studies included in this text addressed high frequency health alterations that all nurses need to be able to manage competently. While diabetes was not highlighted directly, it was included as a potential comorbidity. The five overarching learning objectives pulled from the Institute of Medicine core competencies will clearly resonate with any faculty familiar with Quality and Safety Education for Nurses curriculum.

The presentation of symptoms, treatments and management of the health alterations was accurate. Dialogue between the the interprofessional team was realistic. At times the formatting of lab results was confusing as they reflected reference ranges specific to the Canadian healthcare system but these occurrences were minimal and could be easily adapted.

The focus for learning from these case studies was communication - patient centered communication and interprofessional team communication. Specific details, such as drug dosing, was minimized, which increases longevity and allows for easy individualization of the case data.

While some vocabulary was specific to the Canadian healthcare system, overall the narrative was extremely engaging and easy to follow. Subjective case data from patient or provider were formatted in italics and identified as 'thoughts'. Objective and behavioral case data were smoothly integrated into the narrative.

The consistency of formatting across the eight cases was remarkable. Specific learning objectives are identified for each case and these remain consistent across the range of cases, varying only in the focus for the goals for each different health alterations. Each case begins with presentation of essential patient background and the progress across the trajectory of illness as the patient moves from location to location encountering different healthcare professionals. Many of the characters (the triage nurse in the Emergency Department, the phlebotomist) are consistent across the case situations. These consistencies facilitate both application of a variety of teaching methods and student engagement with the situated learning approach.

Case data is presented by location and begins with the patient's first encounter with the healthcare system. This allows for an examination of how specific trajectories of illness are manifested and how care management needs to be prioritized at different stages. This approach supports discussions of care transitions and the complexity of the associated interprofessional communication.

The text is well organized. The case that has two levels of complexity is clearly identified

The internal links between the table of contents and case specific locations work consistently. In the EPUB and the Digital PDF the external hyperlinks are inconsistently valid.

The grammatical errors were minimal and did not detract from readability

Cultural diversity is present across the cases in factors including race, ethnicity, socioeconomic status, family dynamics and sexual orientation.

The level of detail included in these cases supports a teaching approach to address all three spectrums of learning - knowledge, skills and attitudes - necessary for the development of competent practice. I also appreciate the inclusion of specific assessment instruments that would facilitate a discussion of evidence based practice. I will enjoy using these case to promote clinical reasoning discussions of data that is noticed and interpreted with the resulting prioritizes that are set followed by reflections that result from learner choices.

Reviewed by Chris Roman, Associate Professor, Butler University on 5/19/22

It would be extremely difficult for a book of clinical cases to comprehensively cover all of medicine, and this text does not try. Rather, it provides cases related to common medical problems and introduces them in a way that allows for various... read more

Comprehensiveness rating: 4 see less

It would be extremely difficult for a book of clinical cases to comprehensively cover all of medicine, and this text does not try. Rather, it provides cases related to common medical problems and introduces them in a way that allows for various learning strategies to be employed to leverage the cases for deeper student learning and application.

The narrative form of the cases is less subject to issues of accuracy than a more content-based book would be. That said, the cases are realistic and reasonable, avoiding being too mundane or too extreme.

These cases are narrative and do not include many specific mentions of drugs, dosages, or other aspects of clinical care that may grow/evolve as guidelines change. For this reason, the cases should be “evergreen” and can be modified to suit different types of learners.

Clarity rating: 4

The text is written in very accessible language and avoids heavy use of technical language. Depending on the level of learner, this might even be too simplistic and omit some details that would be needed for physicians, pharmacists, and others to make nuanced care decisions.

The format is very consistent with clear labeling at transition points.

The authors point out in the introductory materials that this text is designed to be used in a modular fashion. Further, they have built in opportunities to customize each cases, such as giving dates of birth at “19xx” to allow for adjustments based on instructional objectives, etc.

The organization is very easy to follow.

I did not identify any issues in navigating the text.

The text contains no grammatical errors, though the language is a little stiff/unrealistic in some cases.

Cases involve patients and members of the care team that are of varying ages, genders, and racial/ethnic backgrounds

Reviewed by Trina Larery, Assistant Professor, Pittsburg State University on 4/5/22

The book covers common scenarios, providing allied health students insight into common health issues. The information in the book is thorough and easily modified if needed to include other scenarios not listed. The material was easy to understand... read more

The book covers common scenarios, providing allied health students insight into common health issues. The information in the book is thorough and easily modified if needed to include other scenarios not listed. The material was easy to understand and apply to the classroom. The E-reader format included hyperlinks that bring the students to subsequent clinical studies.

Content Accuracy rating: 4

The treatments were explained and rationales were given, which can be very helpful to facilitate effective learning for a nursing student or novice nurse. The case studies were accurate in explanation. The DVT case study incorrectly identifies the location of the clot in the popliteal artery instead of in the vein.

The content is relevant to a variety of different types of health care providers and due to the general nature of the cases, will remain relevant over time. Updates should be made annually to the hyperlinks and to assure current standard of practice is still being met.

Clear, simple and easy to read.

Consistent with healthcare terminology and framework throughout all eight case studies.

The text is modular. Cases can be used individually within a unit on the given disease process or relevant sections of a case could be used to illustrate a specific point providing great flexibility. The appendix is helpful in locating content specific to a certain diagnosis or a certain type of health care provider.

The book is well organized, presenting in a logical clear fashion. The appendix allows the student to move about the case study without difficulty.

The interface is easy and simple to navigate. Some links to external sources might need to be updated regularly since those links are subject to change based on current guidelines. A few hyperlinks had "page not found".

Few grammatical errors were noted in text.

The case studies include people of different ethnicities, socioeconomic status, ages, and genders to make this a very useful book.

I enjoyed reading the text. It was interesting and relevant to today's nursing student. There are roughly 25 broken online links or "pages not found", care needs to be taken to update at least annually and assure links are valid and utilizing the most up to date information.

Reviewed by Benjamin Silverberg, Associate Professor/Clinician, West Virginia University on 3/24/22

The appendix reviews the "key roles" and medical venues found in all 8 cases, but is fairly spartan on medical content. The table of contents at the beginning only lists the cases and locations of care. It can be a little tricky to figure out what... read more

Comprehensiveness rating: 3 see less

The appendix reviews the "key roles" and medical venues found in all 8 cases, but is fairly spartan on medical content. The table of contents at the beginning only lists the cases and locations of care. It can be a little tricky to figure out what is going on where, especially since each case is largely conversation-based. Since this presents 8 cases (really 7 with one being expanded upon), there are many medical topics (and venues) that are not included. It's impossible to include every kind of situation, but I'd love to see inclusion of sexual health, renal pathology, substance abuse, etc.

Though there are differences in how care can be delivered based on personal style, changing guidelines, available supplies, etc, the medical accuracy seems to be high. I did not detect bias or industry influence.

Relevance/Longevity rating: 4

Medications are generally listed as generics, with at least current dosing recommendations. The text gives a picture of what care looks like currently, but will be a little challenging to update based on new guidelines (ie, it can be hard to find the exact page in which a medication is dosed/prescribed). Even if the text were to be a little out of date, an instructor can use that to point out what has changed (and why).

Clear text, usually with definitions of medical slang or higher-tier vocabulary. Minimal jargon and there are instances where the "characters" are sorting out the meaning as well, making it accessible for new learners, too.

Overall, the style is consistent between cases - largely broken up into scenes and driven by conversation rather than descriptions of what is happening.

There are 8 (well, again, 7) cases which can be reviewed in any order. Case #2 builds upon #1, which is intentional and a good idea, though personally I would have preferred one case to have different possible outcomes or even a recurrence of illness. Each scene within a case is reasonably short.

Organization/Structure/Flow rating: 4

These cases are modular and don't really build on concepts throughout. As previously stated, case #2 builds upon #1, but beyond that, there is no progression. (To be sure, the authors suggest using case #1 for newer learners and #2 for more advanced ones.) The text would benefit from thematic grouping, a longer introduction and debriefing for each case (there are learning objectives but no real context in medical education nor questions to reflect on what was just read), and progressively-increasing difficulty in medical complexity, ethics, etc.

I used the PDF version and had no interface issues. There are minimal photographs and charts. Some words are marked in blue but those did not seem to be hyperlinked anywhere.

No noticeable errors in grammar, spelling, or formatting were noted.

I appreciate that some diversity of age and ethnicity were offered, but this could be improved. There were Canadian Indian and First Nations patients, for example, as well as other characters with implied diversity, but there didn't seem to be any mention of gender diverse or non-heterosexual people, or disabilities. The cases tried to paint family scenes (the first patient's dog was fairly prominently mentioned) to humanize them. Including more cases would allow for more opportunities to include sex/gender minorities, (hidden) disabilities, etc.

The text (originally from 2017) could use an update. It could be used in conjunction with other Open Texts, as a compliment to other coursework, or purely by itself. The focus is meant to be on improving communication, but there are only 3 short pages at the beginning of the text considering those issues (which are really just learning objectives). In addition to adding more cases and further diversity, I personally would love to see more discussion before and after the case to guide readers (and/or instructors). I also wonder if some of the ambiguity could be improved by suggesting possible health outcomes - this kind of counterfactual comparison isn't possible in real life and could be really interesting in a text. Addition of comprehension/discussion questions would also be worthwhile.

Reviewed by Danielle Peterson, Assistant Professor, University of Saint Francis on 12/31/21

This text provides readers with 8 case studies which include both chronic and acute healthcare issues. Although not comprehensive in regard to types of healthcare conditions, it provides a thorough look at the communication between healthcare... read more

This text provides readers with 8 case studies which include both chronic and acute healthcare issues. Although not comprehensive in regard to types of healthcare conditions, it provides a thorough look at the communication between healthcare workers in acute hospital settings. The cases are primarily set in the inpatient hospital setting, so the bulk of the clinical information is basic emergency care and inpatient protocol: vitals, breathing, medication management, etc. The text provides a table of contents at opening of the text and a handy appendix at the conclusion of the text that outlines each case’s issue(s), scenario, and healthcare roles. No index or glossary present.

Although easy to update, it should be noted that the cases are taking place in a Canadian healthcare system. Terms may be unfamiliar to some students including “province,” “operating theatre,” “physio/physiotherapy,” and “porter.” Units of measurement used include Celsius and meters. Also, the issue of managed care, health insurance coverage, and length of stay is missing for American students. These are primary issues that dictate much of the healthcare system in the US and a primary job function of social workers, nurse case managers, and medical professionals in general. However, instructors that wish to add this to the case studies could do so easily.

The focus of this text is on healthcare communication which makes it less likely to become obsolete. Much of the clinical information is stable healthcare practice that has been standard of care for quite some time. Nevertheless, given the nature of text, updates would be easy to make. Hyperlinks should be updated to the most relevant and trustworthy sources and checked frequently for effectiveness.

The spacing that was used to note change of speaker made for ease of reading. Although unembellished and plain, I expect students to find this format easy to digest and interesting, especially since the script is appropriately balanced with ‘human’ qualities like the current TV shows and songs, the use of humor, and nonverbal cues.

A welcome characteristic of this text is its consistency. Each case is presented in a similar fashion and the roles of the healthcare team are ‘played’ by the same character in each of the scenarios. This allows students to see how healthcare providers prioritize cases and juggle the needs of multiple patients at once. Across scenarios, there was inconsistency in when clinical terms were hyperlinked.

The text is easily divisible into smaller reading sections. However, since the nature of the text is script-narrative format, if significant reorganization occurs, one will need to make sure that the communication of the script still makes sense.

The text is straightforward and presented in a consistent fashion: learning objectives, case history, a script of what happened before the patient enters the healthcare setting, and a script of what happens once the patient arrives at the healthcare setting. The authors use the term, “ideal interactions,” and I would agree that these cases are in large part, ‘best case scenarios.’ Due to this, the case studies are well organized, clear, logical, and predictable. However, depending on the level of student, instructors may want to introduce complications that are typical in the hospital setting.

The interface is pleasing and straightforward. With exception to the case summary and learning objectives, the cases are in narrative, script format. Each case study supplies a photo of the ‘patient’ and one of the case studies includes a link to a 3-minute video that introduces the reader to the patient/case. One of the highlights of this text is the use of hyperlinks to various clinical practices (ABG, vital signs, transfer of patient). Unfortunately, a majority of the links are broken. However, since this is an open text, instructors can update the links to their preference.

Although not free from grammatical errors, those that were noticed were minimal and did not detract from reading.

Cultural Relevance rating: 4

Cultural diversity is visible throughout the patients used in the case studies and includes factors such as age, race, socioeconomic status, family dynamics, and sexual orientation. A moderate level of diversity is noted in the healthcare team with some stereotypes: social workers being female, doctors primarily male.

As a social work instructor, I was grateful to find a text that incorporates this important healthcare role. I would have liked to have seen more content related to advance directives, mediating decision making between the patient and care team, emotional and practical support related to initial diagnosis and discharge planning, and provision of support to colleagues, all typical roles of a medical social worker. I also found it interesting that even though social work was included in multiple scenarios, the role was only introduced on the learning objectives page for the oncology case.

case study definition public health

Reviewed by Crystal Wynn, Associate Professor, Virginia State University on 7/21/21

The text covers a variety of chronic diseases within the cases; however, not all of the common disease states were included within the text. More chronic diseases need to be included such as diabetes, cancer, and renal failure. Not all allied... read more

The text covers a variety of chronic diseases within the cases; however, not all of the common disease states were included within the text. More chronic diseases need to be included such as diabetes, cancer, and renal failure. Not all allied health care team members are represented within the case study. Key terms appear throughout the case study textbook and readers are able to click on a hyperlink which directs them to the definition and an explanation of the key term.

Content is accurate, error-free and unbiased.

The content is up-to-date, but not in a way that will quickly make the text obsolete within a short period of time. The text is written and/or arranged in such a way that necessary updates will be relatively easy and straightforward to implement.

The text is written in lucid, accessible prose, and provides adequate context for any jargon/technical terminology used

The text is internally consistent in terms of terminology and framework.

The text is easily and readily divisible into smaller reading sections that can be assigned at different points within the course. Each case can be divided into a chronic disease state unit, which will allow the reader to focus on one section at a time.

Organization/Structure/Flow rating: 3

The topics in the text are presented in a logical manner. Each case provides an excessive amount of language that provides a description of the case. The cases in this text reads more like a novel versus a clinical textbook. The learning objectives listed within each case should be in the form of questions or activities that could be provided as resources for instructors and teachers.

Interface rating: 3

There are several hyperlinks embedded within the textbook that are not functional.

The text contains no grammatical errors.

Cultural Relevance rating: 3

The text is not culturally insensitive or offensive in any way. More examples of cultural inclusiveness is needed throughout the textbook. The cases should be indicative of individuals from a variety of races and ethnicities.

Reviewed by Rebecca Hillary, Biology Instructor, Portland Community College on 6/15/21

This textbook consists of a collection of clinical case studies that can be applicable to a wide range of learning environments from supplementing an undergraduate Anatomy and Physiology Course, to including as part of a Medical or other health... read more

This textbook consists of a collection of clinical case studies that can be applicable to a wide range of learning environments from supplementing an undergraduate Anatomy and Physiology Course, to including as part of a Medical or other health care program. I read the textbook in E-reader format and this includes hyperlinks that bring the students to subsequent clinical study if the book is being used in a clinical classroom. This book is significantly more comprehensive in its approach from other case studies I have read because it provides a bird’s eye view of the many clinicians, technicians, and hospital staff working with one patient. The book also provides real time measurements for patients that change as they travel throughout the hospital until time of discharge.

Each case gave an accurate sense of the chaos that would be present in an emergency situation and show how the conditions affect the practitioners as well as the patients. The reader gets an accurate big picture--a feel for each practitioner’s point of view as well as the point of view of the patient and the patient’s family as the clock ticks down and the patients are subjected to a number of procedures. The clinical information contained in this textbook is all in hyperlinks containing references to clinical skills open text sources or medical websites. I did find one broken link on an external medical resource.

The diseases presented are relevant and will remain so. Some of the links are directly related to the Canadian Medical system so they may not be applicable to those living in other regions. Clinical links may change over time but the text itself will remain relevant.

Each case study clearly presents clinical data as is it recorded in real time.

Each case study provides the point of view of several practitioners and the patient over several days. While each of the case studies covers different pathology they all follow this same format, several points of view and data points, over a number of days.

The case studies are divided by days and this was easy to navigate as a reader. It would be easy to assign one case study per body system in an Anatomy and Physiology course, or to divide them up into small segments for small in class teaching moments.

The topics are presented in an organized way showing clinical data over time and each case presents a large number of view points. For example, in the first case study, the patient is experiencing difficulty breathing. We follow her through several days from her entrance to the emergency room. We meet her X Ray Technicians, Doctor, Nurses, Medical Assistant, Porter, Physiotherapist, Respiratory therapist, and the Lab Technicians running her tests during her stay. Each practitioner paints the overall clinical picture to the reader.

I found the text easy to navigate. There were not any figures included in the text, only clinical data organized in charts. The figures were all accessible via hyperlink. Some figures within the textbook illustrating patient scans could have been helpful but I did not have trouble navigating the links to visualize the scans.

I did not see any grammatical errors in the text.

The patients in the text are a variety of ages and have a variety of family arrangements but there is not much diversity among the patients. Our seven patients in the eight case studies are mostly white and all cis gendered.

Some of the case studies, for example the heart failure study, show clinical data before and after drug treatments so the students can get a feel for mechanism in physiological action. I also liked that the case studies included diet and lifestyle advice for the patients rather than solely emphasizing these pharmacological interventions. Overall, I enjoyed reading through these case studies and I plan to utilize them in my Anatomy and Physiology courses.

Reviewed by Richard Tarpey, Assistant Professor, Middle Tennessee State University on 5/11/21

As a case study book, there is no index or glossary. However, medical and technical terms provide a useful link to definitions and explanations that will prove useful to students unfamiliar with the terms. The information provided is appropriate... read more

As a case study book, there is no index or glossary. However, medical and technical terms provide a useful link to definitions and explanations that will prove useful to students unfamiliar with the terms. The information provided is appropriate for entry-level health care students. The book includes important health problems, but I would like to see coverage of at least one more chronic/lifestyle issue such as diabetes. The book covers adult issues only.

Content is accurate without bias

The content of the book is relevant and up-to-date. It addresses conditions that are prevalent in today's population among adults. There are no pediatric cases, but this does not significantly detract from the usefulness of the text. The format of the book lends to easy updating of data or information.

The book is written with clarity and is easy to read. The writing style is accessible and technical terminology is explained with links to more information.

Consistency is present. Lack of consistency is typically a problem with case study texts, but this book is consistent with presentation, format, and terminology throughout each of the eight cases.

The book has high modularity. Each of the case studies can be used independently from the others providing flexibility. Additionally, each case study can be partitioned for specific learning objectives based on the learning objectives of the course or module.

The book is well organized, presenting students conceptually with differing patient flow patterns through a hospital. The patient information provided at the beginning of each case is a wonderful mechanism for providing personal context for the students as they consider the issues. Many case studies focus on the problem and the organization without students getting a patient's perspective. The patient perspective is well represented in these cases.

The navigation through the cases is good. There are some terminology and procedure hyperlinks within the cases that do not work when accessed. This is troubling if you intend to use the text for entry-level health care students since many of these links are critical for a full understanding of the case.

There are some non-US variants of spelling and a few grammatical errors, but these do not detract from the content of the messages of each case.

The book is inclusive of differing backgrounds and perspectives. No insensitive or offensive references were found.

I like this text for its application flexibility. The book is useful for non-clinical healthcare management students to introduce various healthcare-related concepts and terminology. The content is also helpful for the identification of healthcare administration managerial issues for students to consider. The book has many applications.

Reviewed by Paula Baldwin, Associate Professor/Communication Studies, Western Oregon University on 5/10/21

The different case studies fall on a range, from crisis care to chronic illness care. read more

The different case studies fall on a range, from crisis care to chronic illness care.

The contents seems to be written as they occurred to represent the most complete picture of each medical event's occurence.

These case studies are from the Canadian medical system, but that does not interfere with it's applicability.

It is written for a medical audience, so the terminology is mostly formal and technical.

Some cases are shorter than others and some go in more depth, but it is not problematic.

The eight separate case studies is the perfect size for a class in the quarter system. You could combine this with other texts, videos or learning modalities, or use it alone.

As this is a case studies book, there is not a need for a logical progression in presentation of topics.

No problems in terms of interface.

I have not seen any grammatical errors.

I did not see anything that was culturally insensitive.

I used this in a Health Communication class and it has been extraordinarily successful. My studies are analyzing the messaging for the good, the bad, and the questionable. The case studies are widely varied and it gives the class insights into hospital experiences, both front and back stage, that they would not normally be able to examine. I believe that because it is based real-life medical incidents, my students are finding the material highly engaging.

Reviewed by Marlena Isaac, Instructor, Aiken Technical College on 4/23/21

This text is great to walk through patient care with entry level healthcare students. The students are able to take in the information, digest it, then provide suggestions to how they would facilitate patient healing. Then when they are faced with... read more

This text is great to walk through patient care with entry level healthcare students. The students are able to take in the information, digest it, then provide suggestions to how they would facilitate patient healing. Then when they are faced with a situation in clinical they are not surprised and now how to move through it effectively.

The case studies provided accurate information that relates to the named disease.

It is relevant to health care studies and the development of critical thinking.

Cases are straightforward with great clinical information.

Clinical information is provided concisely.

Appropriate for clinical case study.

Presented to facilitate information gathering.

Takes a while to navigate in the browser.

Cultural Relevance rating: 1

Text lacks adequate representation of minorities.

Reviewed by Kim Garcia, Lecturer III, University of Texas Rio Grande Valley on 11/16/20

The book has 8 case studies, so obviously does not cover the whole of medicine, but the cases provided are descriptive and well developed. Cases are presented at different levels of difficulty, making the cases appropriate for students at... read more

The book has 8 case studies, so obviously does not cover the whole of medicine, but the cases provided are descriptive and well developed. Cases are presented at different levels of difficulty, making the cases appropriate for students at different levels of clinical knowledge. The human element of both patient and health care provider is well captured. The cases are presented with a focus on interprofessional interaction and collaboration, more so than teaching medical content.

Content is accurate and un-biased. No errors noted. Most diagnostic and treatment information is general so it will remain relevant over time. The content of these cases is more appropriate for teaching interprofessional collaboration and less so for teaching the medical care for each diagnosis.

The content is relevant to a variety of different types of health care providers (nurses, radiologic technicians, medical laboratory personnel, etc) and due to the general nature of the cases, will remain relevant over time.

Easy to read. Clear headings are provided for sections of each case study and these section headings clearly tell when time has passed or setting has changed. Enough description is provided to help set the scene for each part of the case. Much of the text is written in the form of dialogue involving patient, family and health care providers, making it easy to adapt for role play. Medical jargon is limited and links for medical terms are provided to other resources that expound on medical terms used.

The text is consistent in structure of each case. Learning objectives are provided. Cases generally start with the patient at home and move with the patient through admission, testing and treatment, using a variety of healthcare services and encountering a variety of personnel.

The text is modular. Cases could be used individually within a unit on the given disease process or relevant sections of a case could be used to illustrate a specific point. The appendix is helpful in locating content specific to a certain diagnosis or a certain type of health care provider.

Each case follows a patient in a logical, chronologic fashion. A clear table of contents and appendix are provided which allows the user to quickly locate desired content. It would be helpful if the items in the table of contents and appendix were linked to the corresponding section of the text.

The hyperlinks to content outside this book work, however using the back arrow on your browser returns you to the front page of the book instead of to the point at which you left the text. I would prefer it if the hyperlinks opened in a new window or tab so closing that window or tab would leave you back where you left the text.

No grammatical errors were noted.

The text is culturally inclusive and appropriate. Characters, both patients and care givers are of a variety of races, ethnicities, ages and backgrounds.

I enjoyed reading the cases and reviewing this text. I can think of several ways in which I will use this content.

Reviewed by Raihan Khan, Instructor/Assistant Professor, James Madison University on 11/3/20

The book contains several important health issues, however still missing some chronic health issues that the students should learn before they join the workforce, such as diabetes-related health issues suffered by the patients. read more

The book contains several important health issues, however still missing some chronic health issues that the students should learn before they join the workforce, such as diabetes-related health issues suffered by the patients.

The health information contained in the textbook is mostly accurate.

I think the book is written focusing on the current culture and health issues faced by the patients. To keep the book relevant in the future, the contexts especially the culture/lifestyle/health care modalities, etc. would need to be updated regularly.

The language is pretty simple, clear, and easy to read.

There is no complaint about consistency. One of the main issues of writing a book, consistency was well managed by the authors.

The book is easy to explore based on how easy the setup is. Students can browse to the specific section that they want to read without much hassle of finding the correct information.

The organization is simple but effective. The authors organized the book based on what can happen in a patient's life and what possible scenarios students should learn about the disease. From that perspective, the book does a good job.

The interface is easy and simple to navigate. Some links to external sources might need to be updated regularly since those links are subject to change that is beyond the author's control. It's frustrating for the reader when the external link shows no information.

The book is free of any major language and grammatical errors.

The book might do a little better in cultural competency. e.g. Last name Singh is mainly for Sikh people. In the text Harj and Priya Singh are Muslim. the authors can consult colleagues who are more familiar with those cultures and revise some cultural aspects of the cases mentioned in the book.

The book is a nice addition to the open textbook world. Hope to see more health issues covered by the book.

Reviewed by Ryan Sheryl, Assistant Professor, California State University, Dominguez Hills on 7/16/20

This text contains 8 medical case studies that reflect best practices at the time of publication. The text identifies 5 overarching learning objectives: interprofessional collaboration, client centered care, evidence-based practice, quality... read more

This text contains 8 medical case studies that reflect best practices at the time of publication. The text identifies 5 overarching learning objectives: interprofessional collaboration, client centered care, evidence-based practice, quality improvement, and informatics. While the case studies do not cover all medical conditions or bodily systems, the book is thorough in conveying details of various patients and medical team members in a hospital environment. Rather than an index or glossary at the end of the text, it contains links to outside websites for more information on medical tests and terms referenced in the cases.

The content provided is reflective of best practices in patient care, interdisciplinary collaboration, and communication at the time of publication. It is specifically accurate for the context of hospitals in Canada. The links provided throughout the text have the potential to supplement with up-to-date descriptions and definitions, however, many of them are broken (see notes in Interface section).

The content of the case studies reflects the increasingly complex landscape of healthcare, including a variety of conditions, ages, and personal situations of the clients and care providers. The text will require frequent updating due to the rapidly changing landscape of society and best practices in client care. For example, a future version may include inclusive practices with transgender clients, or address ways medical racism implicitly impacts client care (see notes in Cultural Relevance section).

The text is written clearly and presents thorough, realistic details about working and being treated in an acute hospital context.

The text is very straightforward. It is consistent in its structure and flow. It uses consistent terminology and follows a structured framework throughout.

Being a series of 8 separate case studies, this text is easily and readily divisible into smaller sections. The text was designed to be taken apart and used piece by piece in order to serve various learning contexts. The parts of each case study can also be used independently of each other to facilitate problem solving.

The topics in the case studies are presented clearly. The structure of each of the case studies proceeds in a similar fashion. All of the cases are set within the same hospital so the hospital personnel and service providers reappear across the cases, giving a textured portrayal of the experiences of the various service providers. The cases can be used individually, or one service provider can be studied across the various studies.

The text is very straightforward, without complex charts or images that could become distorted. Many of the embedded links are broken and require updating. The links that do work are a very useful way to define and expand upon medical terms used in the case studies.

Grammatical errors are minimal and do not distract from the flow of the text. In one instance the last name Singh is spelled Sing, and one patient named Fred in the text is referred to as Frank in the appendix.

The cases all show examples of health care personnel providing compassionate, client-centered care, and there is no overt discrimination portrayed. Two of the clients are in same-sex marriages and these are shown positively. It is notable, however, that the two cases presenting people of color contain more negative characteristics than the other six cases portraying Caucasian people. The people of color are the only two examples of clients who smoke regularly. In addition, the Indian client drinks and is overweight, while the First Nations client is the only one in the text to have a terminal diagnosis. The Indian client is identified as being Punjabi and attending a mosque, although there are only 2% Muslims in the Punjab province of India. Also, the last name Singh generally indicates a person who is a Hindu or Sikh, not Muslim.

Reviewed by Monica LeJeune, RN Instructor, LSUE on 4/24/20

Has comprehensive unfolding case studies that guide the reader to recognize and manage the scenario presented. Assists in critical thinking process. read more

Has comprehensive unfolding case studies that guide the reader to recognize and manage the scenario presented. Assists in critical thinking process.

Accurately presents health scenarios with real life assessment techniques and patient outcomes.

Relevant to nursing practice.

Clearly written and easily understood.

Consistent with healthcare terminology and framework

Has a good reading flow.

Topics presented in logical fashion

Easy to read.

No grammatical errors noted.

Text is not culturally insensitive or offensive.

Good book to have to teach nursing students.

Reviewed by april jarrell, associate professor, J. Sargeant Reynolds Community College on 1/7/20

The text is a great case study tool that is appropriate for nursing school instructors to use in aiding students to learn the nursing process. read more

The text is a great case study tool that is appropriate for nursing school instructors to use in aiding students to learn the nursing process.

The content is accurate and evidence based. There is no bias noted

The content in the text is relevant, up to date for nursing students. It will be easy to update content as needed because the framework allows for addition to the content.

The text is clear and easy to understand.

Framework and terminology is consistent throughout the text; the case study is a continual and takes the student on a journey with the patient. Great for learning!

The case studies can be easily divided into smaller sections to allow for discussions, and weekly studies.

The text and content progress in a logical, clear fashion allowing for progression of learning.

No interface issues noted with this text.

No grammatical errors noted in the text.

No racial or culture insensitivity were noted in the text.

I would recommend this text be used in nursing schools. The use of case studies are helpful for students to learn and practice the nursing process.

Reviewed by Lisa Underwood, Practical Nursing Instructor, NTCC on 12/3/19

The text provides eight comprehensive case studies that showcase the different viewpoints of the many roles involved in patient care. It encompasses the most common seen diagnoses seen across healthcare today. Each case study comes with its own... read more

The text provides eight comprehensive case studies that showcase the different viewpoints of the many roles involved in patient care. It encompasses the most common seen diagnoses seen across healthcare today. Each case study comes with its own set of learning objectives that can be tweaked to fit several allied health courses. Although the case studies are designed around the Canadian Healthcare System, they are quite easily adaptable to fit most any modern, developed healthcare system.

Content Accuracy rating: 3

Overall, the text is quite accurate. There is one significant error that needs to be addressed. It is located in the DVT case study. In the study, a popliteal artery clot is mislabeled as a DVT. DVTs are located in veins, not in arteries. That said, the case study on the whole is quite good. This case study could be used as a learning tool in the classroom for discussion purposes or as a way to test student understanding of DVTs, on example might be, "Can they spot the error?"

At this time, all of the case studies within the text are current. Healthcare is an ever evolving field that rests on the best evidence based practice. Keeping that in mind, educators can easily adapt the studies as the newest evidence emerges and changes practice in healthcare.

All of the case studies are well written and easy to understand. The text includes several hyperlinks and it also highlights certain medical terminology to prompt readers as a way to enhance their learning experience.

Across the text, the language, style, and format of the case studies are completely consistent.

The text is divided into eight separate case studies. Each case study may be used independently of the others. All case studies are further broken down as the focus patient passes through each aspect of their healthcare system. The text's modularity makes it possible to use a case study as individual work, group projects, class discussions, homework or in a simulation lab.

The case studies and the diagnoses that they cover are presented in such a way that educators and allied health students can easily follow and comprehend.

The book in itself is free of any image distortion and it prints nicely. The text is offered in a variety of digital formats. As noted in the above reviews, some of the hyperlinks have navigational issues. When the reader attempts to access them, a "page not found" message is received.

There were minimal grammatical errors. Some of which may be traced back to the differences in our spelling.

The text is culturally relevant in that it includes patients from many different backgrounds and ethnicities. This allows educators and students to explore cultural relevance and sensitivity needs across all areas in healthcare. I do not believe that the text was in any way insensitive or offensive to the reader.

By using the case studies, it may be possible to have an open dialogue about the differences noted in healthcare systems. Students will have the ability to compare and contrast the Canadian healthcare system with their own. I also firmly believe that by using these case studies, students can improve their critical thinking skills. These case studies help them to "put it all together".

Reviewed by Melanie McGrath, Associate Professor, TRAILS on 11/29/19

The text covered some of the most common conditions seen by healthcare providers in a hospital setting, which forms a solid general base for the discussions based on each case. read more

The text covered some of the most common conditions seen by healthcare providers in a hospital setting, which forms a solid general base for the discussions based on each case.

I saw no areas of inaccuracy

As in all healthcare texts, treatments and/or tests will change frequently. However, everything is currently up-to-date thus it should be a good reference for several years.

Each case is written so that any level of healthcare student would understand. Hyperlinks in the text is also very helpful.

All of the cases are written in a similar fashion.

Although not structured as a typical text, each case is easily assigned as a stand-alone.

Each case is organized clearly in an appropriate manner.

I did not see any issues.

I did not see any grammatical errors

The text seemed appropriately inclusive. There are no pediatric cases and no cases of intellectually-impaired patients, but those types of cases introduce more advanced problem-solving which perhaps exceed the scope of the text. May be a good addition to the text.

I found this text to be an excellent resource for healthcare students in a variety of fields. It would be best utilized in inter professional courses to help guide discussion.

Reviewed by Lynne Umbarger, Clinical Assistant Professor, Occupational Therapy, Emory and Henry College on 11/26/19

While the book does not cover every scenario, the ones in the book are quite common and troublesome for inexperienced allied health students. The information in the book is thorough enough, and I have found the cases easy to modify for educational... read more

While the book does not cover every scenario, the ones in the book are quite common and troublesome for inexperienced allied health students. The information in the book is thorough enough, and I have found the cases easy to modify for educational purposes. The material was easily understood by the students but challenging enough for classroom discussion. There are no mentions in the book about occupational therapy, but it is easy enough to add a couple words and make inclusion simple.

Very nice lab values are provided in the case study, making it more realistic for students.

These case studies focus on commonly encountered diagnoses for allied health and nursing students. They are comprehensive, realistic, and easily understood. The only difference is that the hospital in one case allows the patient's dog to visit in the room (highly unusual in US hospitals).

The material is easily understood by allied health students. The cases have links to additional learning materials for concepts that may be less familiar or should be explored further in a particular health field.

The language used in the book is consistent between cases. The framework is the same with each case which makes it easier to locate areas that would be of interest to a particular allied health profession.

The case studies are comprehensive but well-organized. They are short enough to be useful for class discussion or a full-blown assignment. The students seem to understand the material and have not expressed that any concepts or details were missing.

Each case is set up like the other cases. There are learning objectives at the beginning of each case to facilitate using the case, and it is easy enough to pull out material to develop useful activities and assignments.

There is a quick chart in the Appendix to allow the reader to determine the professions involved in each case as well as the pertinent settings and diagnoses for each case study. The contents are easy to access even while reading the book.

As a person who attends carefully to grammar, I found no errors in all of the material I read in this book.

There are a greater number of people of different ethnicities, socioeconomic status, ages, and genders to make this a very useful book. With each case, I could easily picture the person in the case. This book appears to be Canadian and more inclusive than most American books.

I was able to use this book the first time I accessed it to develop a classroom activity for first-year occupational therapy students and a more comprehensive activity for second-year students. I really appreciate the links to a multitude of terminology and medical lab values/issues for each case. I will keep using this book.

Reviewed by Cindy Krentz, Assistant Professor, Metropolitan State University of Denver on 6/15/19

The book covers eight case studies of common inpatient or emergency department scenarios. I appreciated that they had written out the learning objectives. I liked that the patient was described before the case was started, giving some... read more

The book covers eight case studies of common inpatient or emergency department scenarios. I appreciated that they had written out the learning objectives. I liked that the patient was described before the case was started, giving some understanding of the patient's background. I think it could benefit from having a glossary. I liked how the authors included the vital signs in an easily readable bar. I would have liked to see the labs also highlighted like this. I also felt that it would have been good written in a 'what would you do next?' type of case study.

The book is very accurate in language, what tests would be prudent to run and in the day in the life of the hospital in all cases. One inaccuracy is that the authors called a popliteal artery clot a DVT. The rest of the DVT case study was great, though, but the one mistake should be changed.

The book is up to date for now, but as tests become obsolete and new equipment is routinely used, the book ( like any other health textbook) will need to be updated. It would be easy to change, however. All that would have to happen is that the authors go in and change out the test to whatever newer, evidence-based test is being utilized.

The text is written clearly and easy to understand from a student's perspective. There is not too much technical jargon, and it is pretty universal when used- for example DVT for Deep Vein Thrombosis.

The book is consistent in language and how it is broken down into case studies. The same format is used for highlighting vital signs throughout the different case studies. It's great that the reader does not have to read the book in a linear fashion. Each case study can be read without needing to read the others.

The text is broken down into eight case studies, and within the case studies is broken down into days. It is consistent and shows how the patient can pass through the different hospital departments (from the ER to the unit, to surgery, to home) in a realistic manner. The instructor could use one or more of the case studies as (s)he sees fit.

The topics are eight different case studies- and are presented very clearly and organized well. Each one is broken down into how the patient goes through the system. The text is easy to follow and logical.

The interface has some problems with the highlighted blue links. Some of them did not work and I got a 'page not found' message. That can be frustrating for the reader. I'm wondering if a glossary could be utilized (instead of the links) to explain what some of these links are supposed to explain.

I found two or three typos, I don't think they were grammatical errors. In one case I think the Canadian spelling and the United States spelling of the word are just different.

This is a very culturally competent book. In today's world, however, one more type of background that would merit delving into is the trans-gender, GLBTQI person. I was glad that there were no stereotypes.

I enjoyed reading the text. It was interesting and relevant to today's nursing student. Since we are becoming more interprofessional, I liked that we saw what the phlebotomist and other ancillary personnel (mostly different technicians) did. I think that it could become even more interdisciplinary so colleges and universities could have more interprofessional education- courses or simulations- with the addition of the nurse using social work, nutrition, or other professional health care majors.

Reviewed by Catherine J. Grott, Interim Director, Health Administration Program, TRAILS on 5/5/19

The book is comprehensive but is specifically written for healthcare workers practicing in Canada. The title of the book should reflect this. read more

The book is comprehensive but is specifically written for healthcare workers practicing in Canada. The title of the book should reflect this.

The book is accurate, however it has numerous broken online links.

Relevance/Longevity rating: 3

The content is very relevant, but some links are out-dated. For example, WHO Guidelines for Safe Surgery 2009 (p. 186) should be updated.

The book is written in clear and concise language. The side stories about the healthcare workers make the text interesting.

The book is consistent in terms of terminology and framework. Some terms that are emphasized in one case study are not emphasized (with online links) in the other case studies. All of the case studies should have the same words linked to online definitions.

Modularity rating: 3

The book can easily be parsed out if necessary. However, the way the case studies have been written, it's evident that different authors contributed singularly to each case study.

The organization and flow are good.

Interface rating: 1

There are numerous broken online links and "pages not found."

The grammar and punctuation are correct. There are two errors detected: p. 120 a space between the word "heart" and the comma; also a period is needed after Dr (p. 113).

I'm not quite sure that the social worker (p. 119) should comment that the patient and partner are "very normal people."

There are roughly 25 broken online links or "pages not found." The BC & Canadian Guidelines (p. 198) could also include a link to US guidelines to make the text more universal . The basilar crackles (p. 166) is very good. Text could be used compare US and Canadian healthcare. Text could be enhanced to teach "soft skills" and interdepartmental communication skills in healthcare.

Reviewed by Lindsey Henry, Practical Nursing Instructor, Fletcher on 5/1/19

I really appreciated how in the introduction, five learning objectives were identified for students. These objectives are paramount in nursing care and they are each spelled out for the learner. Each Case study also has its own learning... read more

I really appreciated how in the introduction, five learning objectives were identified for students. These objectives are paramount in nursing care and they are each spelled out for the learner. Each Case study also has its own learning objectives, which were effectively met in the readings.

As a seasoned nurse, I believe that the content regarding pathophysiology and treatments used in the case studies were accurate. I really appreciated how many of the treatments were also explained and rationales were given, which can be very helpful to facilitate effective learning for a nursing student or novice nurse.

The case studies are up to date and correlate with the current time period. They are easily understood.

I really loved how several important medical terms, including specific treatments were highlighted to alert the reader. Many interventions performed were also explained further, which is great to enhance learning for the nursing student or novice nurse. Also, with each scenario, a background and history of the patient is depicted, as well as the perspectives of the patient, patients family member, and the primary nurse. This really helps to give the reader a full picture of the day in the life of a nurse or a patient, and also better facilitates the learning process of the reader.

These case studies are consistent. They begin with report, the patient background or updates on subsequent days, and follow the patients all the way through discharge. Once again, I really appreciate how this book describes most if not all aspects of patient care on a day to day basis.

Each case study is separated into days. While they can be divided to be assigned at different points within the course, they also build on each other. They show trends in vital signs, what happens when a patient deteriorates, what happens when they get better and go home. Showing the entire process from ER admit to discharge is really helpful to enhance the students learning experience.

The topics are all presented very similarly and very clearly. The way that the scenarios are explained could even be understood by a non-nursing student as well. The case studies are very clear and very thorough.

The book is very easy to navigate, prints well on paper, and is not distorted or confusing.

I did not see any grammatical errors.

Each case study involves a different type of patient. These differences include race, gender, sexual orientation and medical backgrounds. I do not feel the text was offensive to the reader.

I teach practical nursing students and after reading this book, I am looking forward to implementing it in my classroom. Great read for nursing students!

Reviewed by Leah Jolly, Instructor, Clinical Coordinator, Oregon Institute of Technology on 4/10/19

Good variety of cases and pathologies covered. read more

Good variety of cases and pathologies covered.

Content Accuracy rating: 2

Some examples and scenarios are not completely accurate. For example in the DVT case, the sonographer found thrombus in the "popliteal artery", which according to the book indicated presence of DVT. However in DVT, thrombus is located in the vein, not the artery. The patient would also have much different symptoms if located in the artery. Perhaps some of these inaccuracies are just typos, but in real-life situations this simple mistake can make a world of difference in the patient's course of treatment and outcomes.

Good examples of interprofessional collaboration. If only it worked this way on an every day basis!

Clear and easy to read for those with knowledge of medical terminology.

Good consistency overall.

Broken up well.

Topics are clear and logical.

Would be nice to simply click through to the next page, rather than going through the table of contents each time.

Minor typos/grammatical errors.

No offensive or insensitive materials observed.

Reviewed by Alex Sargsyan, Doctor of Nursing Practice/Assistant Professor , East Tennessee State University on 10/8/18

Because of the case study character of the book it does not have index or glossary. However it has summary for each health case study outlining key elements discussed in each case study. read more

Because of the case study character of the book it does not have index or glossary. However it has summary for each health case study outlining key elements discussed in each case study.

Overall the book is accurately depicting the clinical environment. There are numerous references to external sites. While most of them are correct, some of them are not working. For example Homan’s test link is not working "404 error"

Book is relevant in its current version and can be used in undergraduate and graduate classes. That said, the longevity of the book may be limited because of the character of the clinical education. Clinical guidelines change constantly and it may require a major update of the content.

Cases are written very clearly and have realistic description of an inpatient setting.

The book is easy to read and consistent in the language in all eight cases.

The cases are very well written. Each case is subdivided into logical segments. The segments reflect different setting where the patient is being seen. There is a flow and transition between the settings.

Book has eight distinct cases. This is a great format for a book that presents distinct clinical issues. This will allow the students to have immersive experiences and gain better understanding of the healthcare environment.

Book is offered in many different formats. Besides the issues with the links mentioned above, overall navigation of the book content is very smooth.

Book is very well written and has no grammatical errors.

Book is culturally relevant. Patients in the case studies come different cultures and represent diverse ethnicities.

Reviewed by Justin Berry, Physical Therapist Assistant Program Director, Northland Community and Technical College, East Grand Forks, MN on 8/2/18

This text provides eight patient case studies from a variety of diagnoses, which can be utilized by healthcare students from multiple disciplines. The cases are comprehensive and can be helpful for students to determine professional roles,... read more

This text provides eight patient case studies from a variety of diagnoses, which can be utilized by healthcare students from multiple disciplines. The cases are comprehensive and can be helpful for students to determine professional roles, interprofessional roles, when to initiate communication with other healthcare practitioners due to a change in patient status, and treatment ideas. Some additional patient information, such as lab values, would have been beneficial to include.

Case study information is accurate and unbiased.

Content is up to date. The case studies are written in a way so that they will not be obsolete soon, even with changes in healthcare.

The case studies are well written, and can be utilized for a variety of classroom assignments, discussions, and projects. Some additional lab value information for each patient would have been a nice addition.

The case studies are consistently organized to make it easy for the reader to determine the framework.

The text is broken up into eight different case studies for various patient diagnoses. This design makes it highly modular, and would be easy to assign at different points of a course.

The flow of the topics are presented consistently in a logical manner. Each case study follows a patient chronologically, making it easy to determine changes in patient status and treatment options.

The text is free of interface issues, with no distortion of images or charts.

The text is not culturally insensitive or offensive in any way. Patients are represented from a variety of races, ethnicities, and backgrounds

This book would be a good addition for many different health programs.

Reviewed by Ann Bell-Pfeifer, Instructor/Program Director, Minnesota State Community and Technical College on 5/21/18

The book gives a comprehensive overview of many types of cases for patient conditions. Emergency Room patients may arrive with COPD, heart failure, sepsis, pneumonia, or as motor vehicle accident victims. It is directed towards nurses, medical... read more

The book gives a comprehensive overview of many types of cases for patient conditions. Emergency Room patients may arrive with COPD, heart failure, sepsis, pneumonia, or as motor vehicle accident victims. It is directed towards nurses, medical laboratory technologists, medical radiology technologists, and respiratory therapists and their roles in caring for patients. Most of the overview is accurate. One suggestion is to provide an embedded radiologist interpretation of the exams which are performed which lead to the patients diagnosis.

Overall the book is accurate. Would like to see updates related to the addition of direct radiography technology which is commonly used in the hospital setting.

Many aspects of medicine will remain constant. The case studies seem fairly accurate and may be relevant for up to 3 years. Since technology changes so quickly in medicine, the CT and x-ray components may need minor updates within a few years.

The book clarity is excellent.

The case stories are consistent with each scenario. It is easy to follow the structure and learn from the content.

The book is quite modular. It is easy to break it up into cases and utilize them individually and sequentially.

The cases are listed by disease process and follow a logical flow through each condition. They are easy to follow as they have the same format from the beginning to the end of each case.

The interface seems seamless. Hyperlinks are inserted which provide descriptions and references to medical procedures and in depth definitions.

The book is free of most grammatical errors. There is a place where a few words do not fit the sentence structure and could be a typo.

The book included all types of relationships and ethnic backgrounds. One type which could be added is a transgender patient.

I think the book was quite useful for a variety of health care professionals. The authors did an excellent job of integrating patient cases which could be applied to the health care setting. The stories seemed real and relevant. This book could be used to teach health care professionals about integrated care within the emergency department.

Reviewed by Shelley Wolfe, Assistant Professor, Winona State University on 5/21/18

This text is comprised of comprehensive, detailed case studies that provide the reader with multiple character views throughout a patient’s encounter with the health care system. The Table of Contents accurately reflected the content. It should... read more

This text is comprised of comprehensive, detailed case studies that provide the reader with multiple character views throughout a patient’s encounter with the health care system. The Table of Contents accurately reflected the content. It should be noted that the authors include a statement that conveys that this text is not like traditional textbooks and is not meant to be read in a linear fashion. This allows the educator more flexibility to use the text as a supplement to enhance learning opportunities.

The content of the text appears accurate and unbiased. The “five overarching learning objectives” provide a clear aim of the text and the educator is able to glean how these objectives are captured into each of the case studies. While written for the Canadian healthcare system, this text is easily adaptable to the American healthcare system.

Overall, the content is up-to-date and the case studies provide a variety of uses that promote longevity of the text. However, not all of the blue font links (if using the digital PDF version) were still in working order. I encountered links that led to error pages or outdated “page not found” websites. While the links can be helpful, continued maintenance of these links could prove time-consuming.

I found the text easy to read and understand. I enjoyed that the viewpoints of all the different roles (patient, nurse, lab personnel, etc.) were articulated well and allowed the reader to connect and gain appreciation of the entire healthcare team. Medical jargon was noted to be appropriate for the intended audience of this text.

The terminology and organization of this text is consistent.

The text is divided into 8 case studies that follow a similar organizational structure. The case studies can further be divided to focus on individual learning objectives. For example, the case studies could be looked at as a whole for discussing communication or could be broken down into segments to focus on disease risk factors.

The case studies in this text follow a similar organizational structure and are consistent in their presentation. The flow of individual case studies is excellent and sets the reader on a clear path. As noted previously, this text is not meant to be read in a linear fashion.

This text is available in many different forms. I chose to review the text in the digital PDF version in order to use the embedded links. I did not encounter significant interface issues and did not find any images or features that would distract or confuse a reader.

No significant grammatical errors were noted.

The case studies in this text included patients and healthcare workers from a variety of backgrounds. Educators and students will benefit from expanding the case studies to include discussions and other learning opportunities to help develop culturally-sensitive healthcare providers.

I found the case studies to be very detailed, yet written in a way in which they could be used in various manners. The authors note a variety of ways in which the case studies could be employed with students; however, I feel the authors could also include that the case studies could be used as a basis for simulated clinical experiences. The case studies in this text would be an excellent tool for developing interprofessional communication and collaboration skills in a variety healthcare students.

Reviewed by Darline Foltz, Assistant Professor, University of Cincinnati - Clermont College on 3/27/18

This book covers all areas listed in the Table of Contents. In addition to the detailed patient case studies, there is a helpful section of "How to Use this Resource". I would like to note that this resource "aligns with the open textbooks... read more

This book covers all areas listed in the Table of Contents. In addition to the detailed patient case studies, there is a helpful section of "How to Use this Resource". I would like to note that this resource "aligns with the open textbooks Clinical Procedures for Safer Patient Care and Anatomy and Physiology: OpenStax" as noted by the authors.

The book appears to be accurate. Although one of the learning outcomes is as follows: "Demonstrate an understanding of the Canadian healthcare delivery system.", I did not find anything that is ONLY specific to the Canadian healthcare delivery system other than some of the terminology, i.e. "porter" instead of "transporter" and a few french words. I found this to make the book more interesting for students rather than deter from it. These are patient case studies that are relevant in any country.

The content is up-to-date. Changes in medical science may occur, i.e. a different test, to treat a diagnosis that is included in one or more of the case studies, however, it would be easy and straightforward to implement these changes.

This book is written in lucid, accessible prose. The technical/medical terminology that is used is appropriate for medical and allied health professionals. Something that would improve this text would to provide a glossary of terms for the terms in blue font.

This book is consistent with current medical terminology

This text is easily divided into each of the 6 case studies. The case studies can be used singly according to the body system being addressed or studied.

Because this text is a collection of case studies, flow doesn't pertain, however the organization and structure of the case studies are excellent as they are clear and easy to read.

There are no distractions in this text that would distract or confuse the reader.

I did not identify any grammatical errors.

This text is not culturally insensitive or offensive in any way and uses patients and healthcare workers that are of a variety of races, ethnicities and backgrounds.

I believe that this text would not only be useful to students enrolled in healthcare professions involved in direct patient care but would also be useful to students in supporting healthcare disciplines such as health information technology and management, medical billing and coding, etc.

Table of Contents

  • Introduction

Case Study #1: Chronic Obstructive Pulmonary Disease (COPD)

  • Learning Objectives
  • Patient: Erin Johns
  • Emergency Room

Case Study #2: Pneumonia

  • Day 0: Emergency Room
  • Day 1: Emergency Room
  • Day 1: Medical Ward
  • Day 2: Medical Ward
  • Day 3: Medical Ward
  • Day 4: Medical Ward

Case Study #3: Unstable Angina (UA)

  • Patient: Harj Singh

Case Study #4: Heart Failure (HF)

  • Patient: Meryl Smith
  • In the Supermarket
  • Day 0: Medical Ward

Case Study #5: Motor Vehicle Collision (MVC)

  • Patient: Aaron Knoll
  • Crash Scene
  • Operating Room
  • Post Anaesthesia Care Unit (PACU)
  • Surgical Ward

Case Study #6: Sepsis

  • Patient: George Thomas
  • Sleepy Hollow Care Facility

Case Study #7: Colon Cancer

  • Patient: Fred Johnson
  • Two Months Ago
  • Pre-Surgery Admission

Case Study #8: Deep Vein Thrombosis (DVT)

  • Patient: Jamie Douglas

Appendix: Overview About the Authors

Ancillary Material

About the book.

Health Case Studies is composed of eight separate health case studies. Each case study includes the patient narrative or story that models the best practice (at the time of publishing) in healthcare settings. Associated with each case is a set of specific learning objectives to support learning and facilitate educational strategies and evaluation.

The case studies can be used online in a learning management system, in a classroom discussion, in a printed course pack or as part of a textbook created by the instructor. This flexibility is intentional and allows the educator to choose how best to convey the concepts presented in each case to the learner.

Because these case studies were primarily developed for an electronic healthcare system, they are based predominantly in an acute healthcare setting. Educators can augment each case study to include primary healthcare settings, outpatient clinics, assisted living environments, and other contexts as relevant.

About the Contributors

Glynda Rees teaches at the British Columbia Institute of Technology (BCIT) in Vancouver, British Columbia. She completed her MSN at the University of British Columbia with a focus on education and health informatics, and her BSN at the University of Cape Town in South Africa. Glynda has many years of national and international clinical experience in critical care units in South Africa, the UK, and the USA. Her teaching background has focused on clinical education, problem-based learning, clinical techniques, and pharmacology.

Glynda‘s interests include the integration of health informatics in undergraduate education, open accessible education, and the impact of educational technologies on nursing students’ clinical judgment and decision making at the point of care to improve patient safety and quality of care.

Faculty member in the critical care nursing program at the British Columbia Institute of Technology (BCIT) since 2003, Rob has been a critical care nurse for over 25 years with 17 years practicing in a quaternary care intensive care unit. Rob is an experienced educator and supports student learning in the classroom, online, and in clinical areas. Rob’s Master of Education from Simon Fraser University is in educational technology and learning design. He is passionate about using technology to support learning for both faculty and students.

Part of Rob’s faculty position is dedicated to providing high fidelity simulation support for BCIT’s nursing specialties program along with championing innovative teaching and best practices for educational technology. He has championed the use of digital publishing and was the tech lead for Critical Care Nursing’s iPad Project which resulted in over 40 multi-touch interactive textbooks being created using Apple and other technologies.

Rob has successfully completed a number of specialist certifications in computer and network technologies. In 2015, he was awarded Apple Distinguished Educator for his innovation and passionate use of technology to support learning. In the past five years, he has presented and published abstracts on virtual simulation, high fidelity simulation, creating engaging classroom environments, and what the future holds for healthcare and education.

Janet Morrison is the Program Head of Occupational Health Nursing at the British Columbia Institute of Technology (BCIT) in Burnaby, British Columbia. She completed a PhD at Simon Fraser University, Faculty of Communication, Art and Technology, with a focus on health information technology. Her dissertation examined the effects of telehealth implementation in an occupational health nursing service. She has an MA in Adult Education from St. Francis Xavier University and an MA in Library and Information Studies from the University of British Columbia.

Janet’s research interests concern the intended and unintended impacts of health information technologies on healthcare students, faculty, and the healthcare workforce.

She is currently working with BCIT colleagues to study how an educational clinical information system can foster healthcare students’ perceptions of interprofessional roles.

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  • Research article
  • Open access
  • Published: 10 May 2006

Reliability of case definitions for public health surveillance assessed by Round-Robin test methodology

  • Gérard Krause 1 ,
  • Bonita Brodhun 1 ,
  • Doris Altmann 1 ,
  • Hermann Claus 1 &
  • Justus Benzler 1  

BMC Public Health volume  6 , Article number:  129 ( 2006 ) Cite this article

10k Accesses

17 Citations

Metrics details

Case definitions have been recognized to be important elements of public health surveillance systems. They are to assure comparability and consistency of surveillance data and have crucial impact on the sensitivity and the positive predictive value of a surveillance system. The reliability of case definitions has rarely been investigated systematically.

We conducted a Round-Robin test by asking all 425 local health departments (LHD) and the 16 state health departments (SHD) in Germany to classify a selection of 68 case examples using case definitions. By multivariate analysis we investigated factors linked to classification agreement with a gold standard, which was defined by an expert panel.

A total of 7870 classifications were done by 396 LHD (93%) and all SHD. Reporting sensitivity was 90.0%, positive predictive value 76.6%. Polio case examples had the lowest reporting precision, salmonellosis case examples the highest (OR = 0.008; CI: 0.005–0.013). Case definitions with a check-list format of clinical criteria resulted in higher reporting precision than case definitions with a narrative description (OR = 3.08; CI: 2.47–3.83). Reporting precision was higher among SHD compared to LHD (OR = 1.52; CI: 1.14–2.02).

Our findings led to a systematic revision of the German case definitions and build the basis for general recommendations for the creation of case definitions. These include, among others, that testable yes/no criteria in a check-list format is likely to improve reliability, and that software used for data transmission should be designed in strict accordance with the case definitions. The findings of this study are largely applicable to case definitions in many other countries or international networks as they share the same structural and editorial characteristics of the case definitions evaluated in this study before their revision.

Peer Review reports

Case definitions have been recognized to be important elements of public health surveillance systems [ 1 ]. They are to assure comparability and consistency of surveillance data and have crucial impact on the sensitivity and the positive predictive value of a surveillance system. The World Health Organization has been encouraging the use of case definitions to make surveillance data comparable between countries. One of the first case definitions used for national disease reporting was the case definition for AIDS published by the Centers for Disease Control and Prevention (CDC) in 1982 [ 2 ]. In 1985 Sacks published a survey among all 50 US states, Puerto Rico, and Washington, DC, that revealed important variations in the case definitions between the different states, and concluded the necessity to unify case definitions if surveillance data between states are to be compared [ 3 ]. In 1990 the CDC in collaboration with the Council of State and Territorial Epidemiologists published an edition of case definitions for public health surveillance [ 4 , 5 ].

Since then case definitions have become an important tool of other national surveillance systems and international surveillance networks. Koo and colleagues have analyzed surveillance data for Cholera in Latin America and have described the importance of uniform case definitions to make data comparable between countries [ 6 ]. In 2003 the European Union (EU) case definitions for the European networks have reached obligatory status for the member states reporting to the EU [ 7 ]. During the SARS epidemic the case definition had a major impact on whether and how countries were considered affected or not, resulting in severe political and economic consequences for a number of countries [ 8 ].

Coggon and colleagues have demonstrated the difficulties of determining optimal case definitions if a satisfactory diagnostic gold standard is lacking [ 9 ]. In sharp contrast to the importance of case definitions hardly any research has been published on the performance of surveillance case definitions. Studies are rare on how local health departments and other health professionals are able to understand case definitions and to what extent case definitions are unambiguous enough to really assure reliability. To our knowledge, the only publication investigating this issue was focused on case definitions for nosocomial infections: Gastmeier and colleagues had investigated how uniform the case definitions of the nosocomial infections surveillance system in Germany had been applied by different investigators using a set of 60 case studies [ 10 ]. Due to the general importance of case definition for public health surveillance and the current need for harmonization in international surveillance systems we conducted a systematic evaluation of the national case definitions with the objective to identify general as well as specific criteria and recommendations for improvement of case definitions.

Notification and reporting procedure

Germany is a federal republic with 16 states subdivided into 440 counties. As in many countries the local (county) health departments (total number: 425) are the primary recipients of infectious disease notifications made by physicians and laboratories. Local health departments verify the incoming notifications and assess the need for public health action. Local health departments use one of five software products on the market to classify the case reports according to the national edition of case definitions and to report these cases electronically to the state health department. From there the report is being forwarded to the Robert Koch Institute (RKI), the federal institution in charge of national infectious disease surveillance in Germany [ 11 ].

Introduction of case definitions

The edition of national case definitions for all notifiable infectious diseases was introduced in Germany in 2001, following the implementation of a new law to control infectious diseases (Infektionsschutzgesetz, IfSG) [ 12 – 14 ]. The IfSG determines the set of diseases and pathogens to be notified by physicians and laboratories throughout the Federal Republic of Germany. The five eastern states, which formerly belonged to the Democratic Republic of Germany (East Germany) and the State of Berlin have enacted complementary rules that make certain diseases additionally notifiable within the state jurisdiction, that are not notifiable in all of Germany.

The case definitions were developed by the RKI, using the delphi method including the expertise of state epidemiologists, national reference laboratories and medical and scientific associations for the specific diseases. The case definitions for infectious conditions under public health surveillance published by the CDC were also taken into account [ 5 , 15 ]. After having published the IfSG case definitions in the fall of 2000 to be implemented with the beginning of 2001 the RKI also published additional case definitions in January 2002 for some of the diseases exclusively notifiable in the eastern states jurisdictions [ 11 , 16 ]. From June 2002 to September 2003 we had conducted a systematic evaluation of the case definitions with the purpose to revise them by the end of 2003.

Structure and classification of case definitions

The German case definitions are divided into three types of evidence: Clinical picture, laboratory detection, and epidemiological confirmation. The types of evidence are specifically defined for each disease (see table 1 ). Based on whether or not requirements for these three types of evidence are fulfilled a case is classified into five categories. In the revised 2004 edition of case definitions these categories are named: A) clinically diagnosed illness (neither epidemiologically nor laboratory-confirmed), B) clinically and epidemiologically confirmed illness (not laboratory-confirmed), C) clinically and laboratory-confirmed illness, D) laboratory-detected infection not fulfilling clinical criteria, E) laboratory-detected infection with unknown clinical picture. (In the 2001 edition of case definitions these five categories were named slightly differently)

For most notifiable diseases only categories B, C, D and E are reportable from the local health department to the next level, requiring at least laboratory detection of the pathogen or epidemiological confirmation. For some exceptions (e.g. tuberculosis, polio, measles, Creutzfeldt-Jakob disease), cases are also reported from the local health department to the next level if category A – the clinical picture alone – is fulfilled.

Round-Robin test

In June 2002 we conducted a Round-Robin test in analogy to the established quality control procedure of laboratories and other testing units [ 17 ]. Round-Robin tests are mainly used in proficiency tests in order to determine laboratory performance by means of comparing tests on identical items by two or more laboratories in accordance with predetermined conditions [ 18 ].

We asked each local and state health department to classify a selection of 68 written case examples on the basis of the case definitions that were implemented in 2001 (2002 respectively for disease only notifiable in East German States). While proficiency tests generally intent to assess the ability of laboratories in finding identical results, we applied this method to assess to which extend the case definitions were unambiguous enough to assure identical classification by the health departments.

Definitions of outcome variables

We applied four different outcome variables in our analysis:

Disease identification: A disease was defined as being correctly identified if the participant of the Round-Robin test was able to identify the correct disease of the case example.

Case categorization: A case example was considered correctly categorized if the participant classified the case example with the correct disease and the correct case definition category as defined in the gold standard.

Reporting: The decision on reportability was considered correct if a case that should have been reported to the next level would have been forwarded according to the case definition category, given that the correct disease was identified. Inversely decision on reporting was also seen to be correct if a case that should not have been reported to the next level was in fact classified in a way that the case would have been held back. However, cases forwarded with wrong disease identification (see above) were a priori considered incorrect. Thus reporting was based on the question whether the case needed to be forwarded to the state level or not, which is a direct result of the disease identification and the case definition category. Sensitivity of reporting was defined as the number of cases that would have been correctly forwarded divided by the number of cases that should have been forwarded according to the gold standard. The positive predictive value of reporting was defined as the number of cases that should have been forwarded among those that would have been forwarded. Precision of reporting is defined as the number of cases that would have been either correctly forwarded to the state level, or would have been correctly held back at the local health department level, divided by the total number of case examples. Unless stated otherwise, reporting precision was the outcome parameter used in the following analysis.

Clinical classification: To specifically assess the effect of different styles in formulating case definitions, a fourth outcome variable was used. The clinical classification was considered correct if the part regarding the clinical picture was classified according to the gold standard, regardless whether other parts of the case definition were correctly classified or not. This analysis was done to compare case definitions with narrative description of the clinical picture (as in all former IfSG case definitions) to case definitions with a more explicit check-list format of clinical criteria, that was implemented for diseases additionally notifiable in specific states and for the new IfSG case definitions.

Case examples

The case examples consisted in facsimile excerpts of one or more of the following sources: laboratory report form, physician form, and protocol of the patient interview [see additional file 1]. The case examples were created based on real cases that have come to the attention of the RKI in the quality control process and in the information service hotline that the RKI is offering to the health departments. The case examples were pre-tested among epidemiologists within the RKI and among epidemiologists and public health nurses in the state and local health departments.

Selection and distribution of case examples

A total of 68 case examples for 17 different diseases were created. In order to limit the time needed to classify the case examples, each local health department in West Germany (including Berlin) received four different case examples each for four different notifiable diseases resulting in 16 case examples to be classified. Local health departments in East Germany (excluding Berlin) received an additional set of four case examples for one of four diseases additionally notifiable in East German states, resulting in a total of 20 case examples.

In order to stratify the case examples of the 17 diseases among the local health departments, we created eight sets of case examples, as shown in table 2 . Sets A to D were randomly distributed among local health departments in each West German state; sets E to H were randomly distributed among local health departments of each East German state. As shown in table 3 , the Salmonella case examples appeared in all eight sets, in order to have the possibility to compare between local health departments and other determinants based on identical case examples.

Epidemiologists in state health departments participating in the study received set A (West Germany) or set E (East Germany). Epidemiologists at the RKI, not involved in designing the case examples, were asked to fill out all 68 case examples. For the analysis the variable "group" was defined as indicated in table 2 in order to control for a possible allocation bias of participants.

Gold standard definition

After the data of the respondents had been analyzed, the classification originally intended while creating the case definition, was challenged with the results of the respondents. Three epidemiologists then reassessed each individual case example and re-examined whether the classification originally intended was still justified. Based on this process the gold standard was defined for each case example.

Quantitative analysis

We compared the responses to the established gold standard and stratified by the following variables: health department being in an East German versus a West German state, disease of the case example, whether or not physicians participate in routine quality control of case reports (versus this being done exclusively by public health nurses), institutional level (local health department, state health department, RKI), acceptance and style of case definitions (check-list vs. text) and software used at local health department. Because of the selection and distribution of case examples described above, we conducted the individual analyses for each group. After univariate analysis we conducted a multivariate analysis using SPSS 13.0 for Windows (Version 13.0.1).

Qualitative analysis

The distribution of the classifications was compared to the gold standard, in order to identify common discrepancies. Based on these discrepancies we identified which part of the case definition was affected and identified specific aspects of the case definitions that had repeatedly been interpreted differently by the participants, indicating failure of the case definition to be unambiguous and reliable. These aspects were then summarized in order to deduct commonalities which could then lead to specific recommendations on how to improve this particular case definition and also on how to improve formulation of case definitions in general.

In May 2002 – simultaneously with the Round-Robin test – we conducted a written survey addressed to all 425 local health departments in Germany. Among various questions on the structure and equipment of the local health departments, and their experiences with the new IfSG, we also asked about the profession of the person who had actually filled the questionnaire and about his or her attitudes and experiences towards the case definitions.

Study population

We received completed forms from 396 (93%) of 425 local health departments. Additionally, 30 epidemiologists from all 16 states and 18 epidemiologists within the RKI had completed the forms. This resulted in a total of 7870 classifications of case examples.

The survey was completed by 400 (94%) of the 425 health departments.

Quantitative analysis of Round-Robin test

The overall result of the Round-Robin test shows that in 7003 case examples (89.0% of all 7870 classified case examples) the correct disease was identified (disease identification). In 4073 case examples (51.8%) the participants classified the case in the expected case definition category (case categorization). In 5042 case examples (64.1%) the correct disease was classified such that the case would have been reported and in 4847 case examples (61.6%) the clinical categorization was correct. Of 4291 case examples that were reportable, 3860 (90.0%) were classified such that they would have been reported (reporting sensitivity); of 5042 case examples that would have been reported to the state health department, 3860 (76.6%) were actually reportable (positive predictive value of reporting), while 1182 (23.4%) should have been excluded from reporting. Of all 7870 case examples the precision of reporting was 79.5%.

Group-wise multivariate analysis

The multivariate analysis was limited to data from the local health departments and without additional case examples for the East German states (n = 5995). Only statistically significant associations are mentioned in the following.

The disease of the case examples was for all groups significantly associated with reporting (p < 0.001 in group 1, 2 and 4, p = 0.022 in group 3).

Software used at local health department

Local health departments using the RKI-software showed a higher chance to identify the disease (disease identification) of the case example according to the gold standard compared to health departments using any of the commercially available software programs (group 2: OR = 1.85, CI: 1.20 – 2.84 and group 3: OR = 1.76, CI: 1.17 – 2.66). Additionally health departments in group 3 using the RKI software had a higher chance of classifying case examples (clinical classification) according to the gold standard (OR = 1.32, CI: 1.01 – 1.70).

East Germany versus West Germany

Analysis of case examples used in both East and West Germany showed that local health departments in East Germany had a lower chance of identifying the disease correctly compared to West German local health departments in group 1 (OR = 0.40, CI: 0.27 – 0.58), of identifying the case definition category correctly in group 2 (OR = 0.76, CI: 0.58 – 1.00) and of correctly reporting in group1 (OR = 0.73, CI: 0.54 – 0.99).

Participating professions

Local health departments where the physician was involved in applying the case definition in the daily routine, showed a lower chance of agreement in disease identification in group 1 (OR = 0.61, CI: 0.41 – 0.89) and a higher chance of agreement in reporting in group 4 (OR = 1.36, CI: 1.02 – 1.81).

Attitudes towards case definitions

Local health departments that stated that case definitions were a valuable tool had higher rates of agreement with the gold standard for disease identification (OR = 2.09, CI: 1.16 – 3.75) and case categorization (OR = 1.71, CI: 1.10 – 2.65) in group 1.

Summarized multivariate analysis

In order to assess whether there might have been a bias in allocating participating health departments to specific groups of case examples we made a separate analysis exclusively with the 4 Salmonella -like case examples which all groups had in common. The analysis among the 1508 classified case examples showed no significant association between group and reporting, suggesting no evidence for allocation bias.

In the summarized model, in which the responses of all groups were analyzed, the disease of the case examples was significantly associated with reporting (p < 0.001). Local health departments where a physician was involved in applying the case definition in the daily routine, showed a lower chance to identify the disease correctly (OR = 0.82, CI: 0.68 – 0.99). Local health departments in East Germany had a lower chance to identify the disease correctly (OR = 0.74, CI: 0.62 – 0.88) and of reporting correctly to the next level compared to West German local health departments (OR = 0.84, CI: 0.73 – 0.96).

Comparing the diseases

For the outcome variable 'reporting' the case examples of Salmonella had higher rates of agreement with the gold standard compared to case examples of all other diseases. For this reason separate analyses were done comparing the different diseases by using Salmonella cases examples as the reference variable adjusted for East/West. Based on the magnitude of the odds ratios, we found that the examples for CJD (OR = 0.012, CI: 0.008 – 0.017) and Polio (OR = 0.008, CI: 0.005 – 0.013) had the lowest chance of reporting precision compared to Salmonella case examples. Details are shown in table 1 .

Narrative format versus check-list format

The classification of the clinical picture, one element of the case definition, was separately analyzed in a model including exclusively data from East German health departments (n = 2019) and RKI (n = 1016). These were the only participants exposed to case examples of disease nationally reportable (with narrative description of the clinical picture) and to case examples of diseases only notifiable in East German states (check-list format). The results of the univariate analysis show, that agreement in case classification with the gold standard was more than three times as high when the respective case definitions had listed the clinical criteria in a check-list format instead of a narrative description (OR = 3.08, CI: 2.47 – 3.83).

Administrative level

The administrative level at which the respondents worked, was significantly associated with the outcome reporting. For the analysis we used all cases of set A and set E (without the additionally diseases for the East German States, n = 2213). Adjusted for the diseases the chance of correct reporting to the next level was 1.5 times higher in cases done by state level staff compared to those done by local health department staff (OR = 1.52, CI: 1.14 – 2.02).

Qualitative results

The following observations have been made in the qualitative analysis of the responses:

The concept of epidemiological confirmation was not well understood. For example travel in endemic countries was equivocally seen as an epidemiological confirmation (e.g. haemorrhagic fever and travel to Egypt). Re-evaluation of the case definitions showed that in fact there was only a vague definition of the epidemiological confirmation.

Participants appeared to have difficulties in deciding whether all clinical signs and symptoms mentioned in the case definition had to be existent in a case, or whether they were only listed as descriptive examples.

Case examples of diarrheal disease without any evidence of a specific pathogen, were frequently classified as salmonellosis.

Laboratory findings with only one elevated antibody value in serum were repeatedly classified as laboratory detection although the case definition required a rise in antibody level.

In some case definitions detection of the pathogen is only accepted if the detection was done in specific materials (normally sterile material such as blood for detecting N. meningitidis ). This limitation was frequently neglected.

Some of the information in the case definition intended to serve as additional background information was mistakenly used as selection criteria (e.g. statement that clinician described rash as "very typical" for measles, but fever was missing).

Survey results

When asked about the availability of the case definitions, 395 (99%) of 398 local health departments responded that the case definition were accessible at the work place. The case definitions were seen as useful by 377 (95%) of 397 health departments who answered this question and not useful by 20 (5%). The clarity of the individual sections of the case definitions was rated differently: The section on the clinical picture of the case definitions was seen as unambiguous in all case definitions by 72 respondents (18%), in the majority of case definitions by 305 (76%), in the minority by 20 (5%), and in none of the case definitions by one (0.3%) of the respondents (n = 398 respondents). The section on the laboratory confirmation of the case definitions was seen as unambiguous in all case definitions by 137 respondents (34%), in the majority of case definitions by 248 (62%), and in the minority by 11 (3%) (n = 396).

Three-hundred and three (87%) of 347 health departments stated that case classifications were done exclusively or primarily by public health nurses. With respect to the case examples presented to the participants, 220 (55%) of 396 respondents (from the local health departments) stated that the case examples were realistic.

The results of our evaluation have shown that although case definitions may appear to be clearly defined, they may be interpreted quite differently by their users, which may result in severe misclassifications and reduced sensitivity and positive predictive value. This study is believed to be the first to systematically assess these effects quantitatively on a large scale, covering 396 (93%) of 425 local health departments in Germany providing at the same time clear evidence on how case definitions can be improved.

The sensitivity and the positive predictive value calculated from this Round-Robin test does not have the intention to represent the respective values of the real surveillance data, these values serve as comparative measurements within the study. It must be kept in mind that we created the case examples specifically to identify need for improvement of the case definitions. Therefore the majority of case examples were intentionally characterized by borderline constellations, meant to represent realistic challenges to the case definition and its user. We also intentionally included rare diseases with high public health importance. The fact that 56% of the participants perceived the case examples to be realistic, indicates that daily routine might generally confront health departments with case reports that might be easier to classify. This explains why case examples of polio (no reported cases since 1998) and CJD (approx. 80 cases per year) had extremely lower rates of agreement compared to Salmonella case examples (approx. 57.000 cases per year) [ 19 , 20 ].

Also the complexity of the case definition itself is likely to affect reporting precision. Unfortunately much of the complexity of the case definition is a result of methodological limitations of available laboratory tests and cannot be influenced. The case definition system with its three different types of evidence leading to five different categories may appear very complex and less intuitive that the classical categories of "suspect", "probable" and "confirmed". The detailed differentiation of the German case definitions however enables us to apply computer algorithms in order to translate these to the EU case definitions and thus make the data compatible to the standards of various European surveillance networks and to WHO reports.

Reassessment of the gold standard after receipt of the responses resulted in modifications of 5 of the 68 case examples. This procedure took place in an initial review process of gold standard before the actual analysis was done. We believe it was legitimate and necessary in order to correct for biases caused by unforeseen ambiguity of the case examples.

The software used at the local health department was significantly associated with the quality of the data in only some subgroups and outcomes. Apparently the software is not a very strong determinant in the given study design, although our experience in implementing the electronic surveillance system in Germany showed that commercially available software products often do not fully implement the standards published by the RKI for data transmission software or they do so with a delay of several years [ 21 ].

The other interesting finding is that the administrative level of the participants was significantly associated with the outcome: Participants from state health departments had a significantly higher rate of agreement with the reporting gold standard than the participants from local health departments. This might be explained by the fact that staff at the state level is generally higher trained in epidemiology and infectious diseases than local health department staff and they are routinely involved in quality control of incoming case reports and also training and supervision of local health departments' staff.

Classification of the clinical picture resulted in significantly better results in the univariate analysis if the relevant case definition had a check-list format of the clinical picture (for diseases notifiable only in eastern states) as opposed to case examples of diseases for which the relevant case definition had a narrative description of the clinical picture (as in the old version of the national case definitions which participants had used as a reference). The dominant effect of the disease-variable, however, made this association disappear in the multivariate model. The most convincing explanation for this effect is, that after initial experience with the national case definitions, RKI had already changed the way of defining the clinical picture when creating case definitions for the diseases only notifiable in Eastern German states: The clinical picture was now defined in a clear check-list of signs and symptoms, instead of an unspecific mentioning of various possible signs and symptoms, such as in the first edition of the IfSG case definitions. Based on the findings of this study we have in the meanwhile applied this principle of a clear check-list in the second edition of the IfSG case definitions.

The results of the study were integrated in a case example book, which contains each of the 68 case examples followed by the required gold standard classification, descriptive statistics of the responses and a commentary interpreting these results and explaining the required gold standard. This case example book was mailed to all participants after termination of the study and is also available on the RKI website [ 22 ].

All the observed quantitative effects and their propagated explanations merge into the one main conclusion: Case definitions must be very carefully formulated in order to assure their unambiguous interpretation by local health department personnel. The detailed evaluation of our study has resulted in a substantially revised edition of the German case definitions [ 23 , 24 ]:

We rephrased the case definitions in a check-list format indicating clearly how many of the symptoms and signs had to be fulfilled in which combination.

Some diseases previously jointly described in one case definition were defined separately (Dengue was separated from other haemorrhagic fever; hemolytic uraemic syndrome was created new, separately from EHEC and Shigella .)

We rephrased the definitions in a way that for serologic confirmation the necessity for two samples is clearly apparent at the beginning of the phrase.

The material in which the pathogen has to be detected is now highlighted and is only listed if it is relevant for the case definition.

A glossary now defines the expressions that are being used repeatedly in the case definitions

The case definitions are now limited to criteria relevant for the decision process. All additional explanatory information is clearly indicated as such in a separate section of the case definition

The evidence type "epidemiological confirmation" was completely redesigned and replaces the previously used term "epidemiological link". The accepted types of epidemiological links are now specified individually for each case definition.

One practical implication, that is supported by this analysis is, that software used at the local health department must be designed with strict accordance to the case definitions using identical terminology and structuring which would have been more easily archived if all local health departments had been equipped with one identical software system developed within or under supervision of one institution. Possibly other countries in the process of developing or implementing new electronic surveillance systems might want to learn form this experience [ 21 , 25 ].

The case example book, which resulted from this study, constitutes a detailed feed back for the participants of the study and is now being used as training material for public health nurses.

We have demonstrated that rigorous reduction of case definitions to testable yes/no-criteria in a check-list format is likely to improve their reliability. Reducing the differential diagnostic complexity of a disease to a limited number of yes/no-criteria, is a major challenge, but it also carries the benefit of facilitating computerized testing algorithms for quality control and for case classifications.

As the reliability of epidemiologic surveillance largely depends on the reliability of its case definitions, it is essential to create and revise case definitions based on systematic evaluations [ 9 ]. Most of the basic principles for the revision of the German case definition edition deducted from this analysis may also be applicable for case definitions in other countries (such as the United States, Ireland, Sweden, Mexico) or international networks (EU, WHO) as they share the same structural and editorial characteristics that we identified to be problematic in the first edition of the German case definitions [ 4 , 7 , 8 , 26 , 27 ]. We therefore believe that our findings are highly relevant for many national and international surveillance systems.

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Acknowledgements

We would like to thank all participating colleagues at the local and state health departments and at the RKI. Miriam Friedemann and Gerlinde Gloeckner made valuable contributions to this study, and Inge Mücke in preparation of this manuscript. Thank you to all of them.

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Gérard Krause, Bonita Brodhun, Doris Altmann, Hermann Claus & Justus Benzler

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Authors' contributions

GK conceived of the study and is responsible for the design of the study, the creation of case examples and the gold standard definition. He supervised the study and is responsible for the analysis and interpretation of the data and the literature research.

BB is responsible for the pilot testing of case examples and survey, the study management, data entry and data management, and participated in the data analysis.

DA participated in the statistical analysis.

HC participated in the management of the data, the design of the study and the data analysis.

JB participated in the definition of the gold standard, the analysis and the interpretation of data and is responsible for the revision of new case definitions.

All authors read and approved the final manuscript.

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Krause, G., Brodhun, B., Altmann, D. et al. Reliability of case definitions for public health surveillance assessed by Round-Robin test methodology. BMC Public Health 6 , 129 (2006). https://doi.org/10.1186/1471-2458-6-129

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DOI : https://doi.org/10.1186/1471-2458-6-129

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National Academy of Medicine

Systems Thinking for Public Health: A Case Study Using U.S. Public Education

case study definition public health

ABSTRACT | The initial response to the COVID-19 pandemic in the United States largely focused on addressing the immediate health consequences from the emergent pathogen. This initial focus often ignored the related impacts from the pandemic and from mitigation measures, including how existing social determinants of health compounded physical, social, and economic impacts on individuals who have historically been marginalized. The consequences of decisions around closing and reopening primary and secondary (K–12 in the United States) public schools exemplify the complex impacts of pandemic mitigation measures. Ongoing COVID-19 mitigation and recovery efforts have gradually begun addressing indirect consequences, but these efforts were slow to be identified and adopted through much of the acute phase of the pandemic, mirroring the decades-long neglect of contributors to the overall health and well-being of populations that have been made to be vulnerable.

A systems approach for decision-making and problem solving holistically considers the effects of complex interacting factors. Taking a systems approach at the start of the next health emergency could encourage response strategies that consider various competing public health needs throughout different sectors of society, account for existing disparities, and preempt undesirable consequences before and during response implementation. There is a need to understand how a systems approach can be better integrated into decision-making to improve future responses to public health emergencies. A wide range of stakeholders should contribute expertise to these models, and these partnerships should be formed in advance of a public health emergency.

Introduction

In September 2021 the National Academies of Sciences, Engineering, and Medicine hosted a workshop titled “Towards a Post-Pandemic World: Lessons from COVID-19 for Now and the Future.” (NASEM, 2022) In this article, select workshop participants further explore the application of systems thinking in evaluating COVID-19 mitigation measures.

Systems Thinking in Public Health

A systems science approach to outbreak response planning is a useful tool for broadening strategic thinking to consider critical factors driving the short- and long-term consequences of crisis response measures, including how such decisions will impact health disparities (Bradley et al., 2020). A conceptual framework, systems thinking accounts for the relationship between individual factors within a scenario as well as their contributions to the whole, and can facilitate the synthesis of response plans that match the scale and complexity of the problem at hand (Trochim et al., 2006).

Specifically for public health, a systems approach “applies scientific insights to understand the elements that influence health outcomes; models the relationships between those elements; and alters design, processes or policies based on the resultant knowledge” (Kaplan et al., 2013). Complex and interconnected risk factors collectively influenced health outcomes in the COVID-19 pandemic. Response to an evolving public health emergency requires a systems approach that can weigh disparate needs and account for systemic inequities to quickly generate solutions while remaining adaptable as new data emerges.

In this article, we use the issue of K–12 public school closures in the United States to illustrate the need for systems approaches in public health situations. Mapping tools, such as causal loop diagrams, can show the complexity of interconnected factors and their use should be prioritized to guide evidence-based decisions in complex and evolving circumstances. This article argues for the adoption of a systems science approach to outbreak decision-making that:

  • addresses the inherent complexity of societal impacts during public health emergencies,
  • accounts for social determinants of health, and
  • includes perspectives from a wide range of stakeholders

COVID-19 Decision-Making and Unintended Consequences

At the start of the COVID-19 pandemic, policy decisions and responses were enacted quickly to contain the spread of disease. However, the public health implications of COVID-19 extend beyond the disease itself, as the pandemic exacerbated disparities in health outcomes closely correlated with social determinants of health and structural inequalities (Karmakar et al., 2021; Liao and De Maio 2021; Webb Hooper et al., 2020). While strong infection control measures, such as lockdowns and school closures, were considered essential when COVID-19 was an emergent disease, these responses resulted in unintended consequences that were not prioritized in the early decision-making process (Turcotte-Tremblay et al., 2021).

This trade-off may have been necessary at the time, given the rapid disease spread and lack of data about the disease to guide initial decisions. However, as the potential for containment or eradication of COVID-19 dimmed, decision-makers were slow to update mitigation measures based on evolving knowledge and accounting for the broader population health needs. The COVID-19 response stemmed largely from concern about acute infections, reflecting a mindset that was more focused on medical response than broader public health impacts.

Biological factors (e.g., age or comorbidities such as hypertension, diabetes, lung disease, or immunodeficiencies) and social determinants of health (e.g., disparities stemming from marginalized socioeconomic status, lack of access to housing and transportation, race and ethnicity, and language and literacy barriers) interact to affect health and well-being (WHO, 2023; Gao et al., 2021). While awareness of biological risk factors for severe illness grew rapidly and mitigation measures were enacted to protect individuals at risk, consideration for social risk factors in COVID response plans were not equally prioritized (Laylavi, 2021).

For example, while the federal government heavily invested in the development of vaccines and anti-viral treatments early in the pandemic (Lalani et al., 2023), expanded unemployment support to address pandemic-related job losses and educational support for students during school closures were deprioritized and debated at length in government. This inaction slowed critical support for populations disproportionately impacted by pandemic spread-related closures.

The neglect of programs that would create a social safety net for the populations most marginalized is not specific to the pandemic, but is an exacerbation of systematic neglect over decades (Mody et al., 2022; Dorn et al., 2020; Saenz and Sparks, 2020). Even when educational support programs were rolled out, they were implemented inconsistently and did not specifically consider the additional needs of populations that have been made to be vulnerable and that were more likely to be disproportionately impacted by school closures and loss of income due to pandemic restrictions (Wright, 2021).

Officials did not give significant attention to the secondary impacts of the COVID-19 pandemic as the pandemic progressed. While these social disparities existed before the onset of COVID-19, decisions made in response to the pandemic widened many of these gaps.

There have been earlier calls to apply a systems approach to improve public health outcomes, and many examples exist to illustrate the strength of a systems approach in successfully addressing complex public health challenges (Kaplan et al., 2013; Honoré et al., 2011). The example of public school closures demonstrates how the social impacts of mitigation measures widened existing disparities. The example also highlights the need for holistic, systems-based approaches in addressing future public health crises.

Public School Closures and Remote Learning: A Case for Applying Systems Thinking to Improve Health Outcomes during Future Disease Outbreaks

The issue of school closures during the pandemic serves as a case study for how factors affecting health were not holistically considered during decision-making. School closures can exacerbate social and health disparities, with long-lasting consequences (NASEM, 2020). Many students rely on school systems for adequate nutrition, safety, supervision, and socioemotional and cognitive development (Van Lancker and Parolin, 2020). In addition, substantial evidence shows that remote learning is an inadequate and unequitable substitute for in-person learning and does not completely mitigate learning losses during school closures (Agostinelli et al., 2022; Engzell et al., 2021; Bettinger and Loeb, 2017).

Furthermore, school closures may have a greater impact on students in underserved communities. Systemically disadvantaged students (e.g., those who are experiencing poverty or are from racial or ethnic minority communities) are less likely to have access to the technology or broadband internet that is necessary for remote learning. They are less likely to have parents who are able to work from home and supervise them and often encounter other barriers to achieving learning goals (Smith and Reeves, 2020). Students with special educational needs have had disproportionate learning losses and have limited access to other supportive resources otherwise provided through schools while schools are closed (Hurwitz et al., 2021; Nelson and Murakami, 2020).

Importantly, education access and achievement are associated with improved health outcomes, and the above-mentioned educational disparities may translate to worsened health disparities among the different communities (Dorn et al., 2021; Zajacova and Lawrence, 2018).

The decision-making surrounding school closures is complex (Allen, 2021; World Bank Group Education, 2020). While decision makers now know that K–12 public school children have reduced physical risk to severe disease outcomes from COVID-19 compared to adults, school closures were implemented early in the pandemic, when this risk was unknown and there was limited time for decision-making. Students experienced related impacts from pandemic mitigation measures, and some have suffered mentally, emotionally, and developmentally as a direct result of school closures specifically (Viner et al., 2022; Engzell et al., 2021).

However, decisions about school closures and transitions to remote learning at the start of the COVID-19 pandemic generally focused on physical health risk factors (e.g., preventing transmission and mortality) rather than holistic evaluations of children’s multifaceted developmental needs (e.g., socialization in cognitive and emotional development; Viner et al., 2022). Factors such as public fear and parental pressure may have also affected decisions both to close and reopen schools. Many under-resourced schools may have also had limited ability to facilitate a safe return to in-person learning. The many factors affecting school closure decisions further demonstrates the overall need for a systematic, context-specific model for decision-making in future emergencies.

Widespread school closures lasted well into 2021, despite early and repeated warnings about the potential costs to student well-being (Allen, 2021; Kaffenberger, 2021; Balingit and Meckler, 2020) and evidence that with adequate interventions, in-person schooling could be made safe (Alonso et al., 2022; Rotevatn et al., 2022; Head et al., 2021).

Furthermore, school closures were experienced unequally. A nationwide study by Parolin and Lee (2021) found a correlation between school closures in fall 2021 and the racial and ethnic composition of the student body, with nearly 70 percent in-person attendance in schools with a high majority of White students and more than 70 percent closure among schools with large proportions of non-White students. This difference was observed across the United States and within local metro areas.

For example, in Los Angeles County, schools with the highest proportion of racial and ethnic minority students stayed closed at higher rates and for longer durations than schools with the highest proportion of White students (see Figure 1 ). Many factors could have contributed to this observation, including governance, demographic distribution in urban and suburban areas, differences in resource availability in public schools (including school health services), and differences in transmission rates due to population density.

case study definition public health

A separate study by Grossmann et al. (2021) also suggested that other outside factors, such as political pressure and strength of teachers unions, may have had significant influence over school closure decisions. A diversity of factors impact student well-being; thus, a systems approach would support informed decision-making in school closure policies.

Multiple factors must also be accounted for in remediation plans, not just initial decision-making, in response to a public health crisis. In July 2021, the Center on Reinventing Public Education (CRPE, 2022) evaluated published plans from 100 major US school districts on spending the more than $43 billion allocated from the Elementary and Secondary School Emergency Relief Fund. While most districts included learning loss and social, emotional, and mental health as key target areas for remediation, only about 30 percent of schools accounted for special needs, equity, and community engagement in their remediation plans (see Figure 2 ). This data revealed that many school districts have attempted to address pandemic-related health outcomes, but these efforts can be further improved with a more holistic approach to decision-making regarding public education and student health.

case study definition public health

Students’ well-being and long-term health outcomes are not the only considerations in deciding when best to resume in-person learning. Plans for safe and sustainable resumption of in-person learning also need to consider the needs and concerns of other stakeholders, such as parents, school staff (including nurses and health human resources), and public officials. For example, federal school reopening strategies included practices to safeguard the well-being of educators and other school staff (Department of Education, 2021). Other concerns include the need for data to understand and mitigate transmission dynamics within classrooms and in the local community, especially with the emergence of new viral variants (Honein et al., 2021). These complexities further underline the need for a holistic decision-making strategy that accounts for different needs and dynamics as information unfolds during a public health emergency such as the COVID-19 pandemic.

Using Systems Thinking to Redefine Strategies for Public Health Preparedness

Implementing a systems approach to public health planning requires tools, trained experts, and collaboration with stakeholders. Causal loop diagrams (CLDs) are analytical tools used to map a complex set of factors and forces in a system. They can be used to analyze interplay between factors or develop response strategies. CLDs are gaining attention in public health spheres and can be developed for various purposes, including for influencing policy and practice and for system dynamics modeling (Baugh Littlejohns et al., 2021).

Several CLDs have been developed to demonstrate the variety and interconnectedness of issues related to COVID-19, including mitigation measures. In a series of workshops, Sahin et al. (2020) gathered a group of subject matter experts in various fields (e.g., public health, social science, systems thinking) to develop a CLD that maps the unintended impacts of COVID-19 mitigation measures on socioeconomic systems (see Figure 3 ). One of the loops shows that social distancing will likely decrease virus transmission but also has negative, lasting mental health consequences (loop B3). Sahin et al. (2020) note there is a “a high risk of catastrophic social order demise” if enacted policies do not account for impacts on society.

case study definition public health

Tools such as CLDs can facilitate understanding of varying factors within a public health system, a view that is needed to enact holistic solutions. This model captures the severity of social consequences, which were largely overlooked throughout the pandemic.

To further demonstrate their potential, we have created an example CLD that highlights components that could inform a more complex CLD addressing public education issues for children (see Figure 4 ). This illustrative CLD integrates several of the factors that have been discussed in this article (e.g., children’s physical health, mental and emotional health, family stressors). While not developed with the intent of immediate application, this example CLD could be modified and used for decision-making.

case study definition public health

An analysis of COVID-19 CLDs by Strelkovskii and Rovenskaya (2021) concluded that these tools can “draw the attention of policy makers to areas where unintended and unwanted effects may be anticipated”; they identified CLDs as useful tools for highlighting the diverse impacts of the pandemic. Their analysis also found that, while there have been numerous calls to apply systems thinking approaches to the impacts of COVID-19, there are few examples of practical applications. The authors highlighted that there have been relatively few examples of CLDs developed for COVID-19, and these have been developed for purposes other than influencing decision-making.

As with many aspects of the COVID-19 pandemic, there is an opportunity to develop tools, such as CLDs, that are more actionable and policy related. The means of developing the CLD are also critical to its use. Such development should include an interdisciplinary group of experts to capture the multiple layers of a complex system. Stakeholder and community participation in developing CLDs represent a step toward developing tools that are more comprehensive and that may be more actionable from a policy standpoint (Baugh Littlejohns et al., 2021). Collaborative groups that include experts, community members, and policy makers can be better poised to develop a dynamic model that can be useful in depicting complex social, physical, and economic relationships. These nuanced models could serve as critical tools for weighing the impacts of mitigation measures in a public health emergency, and developing system models in advance will facilitate immediate action at the onset of an emergency. While providing substantial benefits, developing CLDs also presents challenges. Because systems are inherently complex, it is difficult to capture all relevant factors in a diagram while maintaining the detail that is needed to be useful. Also, translating a CLD into action can be challenging, as evidenced by the lack of actionable CLDs that address the impacts of the COVID-19 pandemic. Despite these challenges, CLDs remain a useful tool for providing a decision-making framework in complex situations with interconnected factors.

The U.S. response strategy to the COVID-19 pandemic suffered from a lack of a holistic and systems-oriented approach to decision-making. This paper outlines the complexities that should have been considered in making the shift to fully remote learning inK–12 schools during COVID-19. There is a need to integrate diverse perspectives from interdisciplinary experts, stakeholders, and community members in developing models that influence decision-making. In the example of school closures, educators, parents, school health leaders, and community leaders are relevant stakeholders for public health decisions that affect health outcomes in schools.

Systems approaches facilitate more comprehensive assessments to inform decision-making, and CLDs are a valuable tool that can be used for response planning. Time is of the essence in a public health emergency, especially when there is minimal information about an emerging threat. Systems models can be built to respond to an emerging threat and developed as information is gained.

We assert that using CLDs as part of a systems approach can improve the transparency, inclusiveness, and credibility of the decision-making process during future public health emergencies. Systems thinking, and tools such as CLDs, should be prioritized in future public health emergencies.

Despite the widely acknowledged usefulness of CLDs, there are few examples of CLDs that were applied during the COVID-19 pandemic to influence decision-making. Partnerships between public health experts and decision-makers should be developed in advance of public health emergencies, so they will be poised to respond immediately. Further, perspectives from the economic and social sectors should also be sought, to understand the complex impact of emergencies, including the impacts of mitigation measures. Increased stakeholder engagement can result in tools that are more actionable and effective.

A commitment to incorporate systems thinking will require broadening the preparedness planning approach for public health decision-making, emphasizing the inclusion of physical and related impacts, and securing buy-in from decision-makers (Zięba, 2021; Klement, 2020). This type of thinking would also require training, so the public health workforce can learn to design and implement these methods.

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https://doi.org/10.31478/202311a

Suggested Citation

Ashby, E., C. Minicucci, J. Liao, D. Buonsenso, S. González- Dambrauskas, R. Obregón, M. Zahn, W. Hallman, and C. John. 2023. Systems thinking for public health: A case study using U.S. public education. NAM Perspectives . Discussion Paper, National Academy of Medicine, Washington, DC. https://doi.org/10.31478/202311a .

Author Information

Elizabeth Ashby, MS, is Associate Program Officer, National Academies of Sciences, Engineering, and Medicine. Charlie Minicucci, BS, is Research Associate, National Academies of Sciences, Engineering, and Medicine.  Julie Liao, PhD, is Program Officer, National Academies of Sciences, Engineering, and Medicine. Danilo Buonsenso, MD, PhD, is Pediatric Infectious Disease Physician, Department of Woman & Child Health & Public Health, Fondazione Policlinico Universitario Agostino Gemelli IRCCS. Sebastián González-Dambrauskas, MD, is Founder and Chair, LARed: Red Colaborativa Pediátrica de Latinoamérica and Adjunct Professor, Departamento de Pediatría y Unidad de Cuidados Intensivos de Niños, Universidad de la República. Rafael Obregón, PhD, is Country Representative, Paraguay, UNICEF. Matt Zahn, MD, is Pediatric Infectious Disease Physician, Children’s Hospital of Orange County. William Hallman, PhD, is Professor and Chair, Department of Human Ecology, School of Environmental and Biological Sciences, Rutgers University. Chandy John, MD, MS, is Professor of Pediatrics, Indiana University School of Medicine.

Acknowledgments

Charlie Minicucci and Elizabeth Ashby contributed equally to this work.

This manuscript benefited from the thoughtful input of Jessica G. Burke , University of Pittsburgh; Erin D. Maughan , George Mason University; and Carol Walsh , National Association of School Nurses.

Conflict-of-Interest Disclosures

Danilo Buonsenso reports funding from Pfizer outside the submitted work.

Correspondence

Questions or comments about this paper should be directed to Charlie Minicucci at [email protected].

The views expressed in this paper are those of the authors and not necessarily of the authors’ organizations, the National Academy of Medicine (NAM), or the National Academies of Sciences, Engineering, and Medicine (the National Academies). The paper is intended to help inform and stimulate discussion. It is not a report of the NAM or the National Academies. Copyright by the National Academy of Sciences. All rights reserved.

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  • Systematic Review
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  • Published: 10 May 2023

What is public health? a scoping review

  • Razieh Azari 1 &
  • Bettina Borisch 1 , 2  

Archives of Public Health volume  81 , Article number:  86 ( 2023 ) Cite this article

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during the last hundred years, several major public health issues have already afflicted humanity. Most frequently cited definitions of public health have stemmed from long-standing definitions, which raises several concerns including whether these definitions can respond to today’s public health challenges. The present study aimed to identify and review available public health definitions in the first place.

in this scoping review, we undertook an electronic search in four databases (PubMed, Web of Science, Embase, and EBSCOhost) from inception until June 06, 2022, and a grey literature search in Google Scholar. Moreover, reference lists of publications included in the scoping review were screened manually for additional relevant publications. All types of scientific publications, in English, that focused on the definition of public health and provided an original definition were included. Year, type, disciplinary fields of publications, objectives of publications, and public health definitions were extracted.

5651 publications were identified through the scoping search, of which five were subjected to full-text review. Of these publications, two were included. An additional nine publications were identified through the manual screening. A total 11 of publications were included in the scoping review. Of the 11 definitions included in this review, the latest original definitions date back to about two decades ago.

Conclusions

there is a noticeable lack of updated definitions of public health. Considering our findings and the ever-changing nature of public health issues, there is an urgent need for re-assessing and updating public health definitions.

Peer Review reports

What is public health? It is a challenging concept that perhaps no single definition will satisfy everyone [ 1 , 2 , 3 , 4 , 5 ]. A national telephone survey of 1234 registered voters conducted in the United States (US) in 1999 found that over half of the respondents misunderstood the term public health [ 6 ]. The efforts to define the term public health can be traced back to a century ago to Charles-Edward A. Winslow’s definition which later Sir Donald Acheson in 1988 built on it and put forward his definition as “the art and science of preventing disease, prolonging life and promoting health through the organized efforts of society” [ 7 , 8 ]. Winslow’s definition is considered one of the most commonly cited definitions of public health [ 9 ]. It is still considered valid today [ 2 ]. Winslow’s influence can still be seen in many contemporary definitions of public health [ 1 ]. In 2011, a concept paper of the World Health Organization (WHO) European Region which investigated several definitions of public health from a selection of key stakeholders concluded that Acheson’s definition can be a useful point of departure [ 8 , 10 ].

Several studies insisted on the important role of public health definition [ 9 , 10 ]. According to the Pan American Health Organization (PAHO), [ 9 ]. the definition of public health strengthens public health. “Operationalising activities, intelligence, systems, skills and competencies for public health is consequent on the definition of public health” [ 10 ]. A clear definition of public health helps people who work in, are served by, or study the system to sort out its components, understand it, and work to improve it [ 4 ].

During the last hundred years, several major epidemics and pandemics have afflicted humanity. Currently, the world has been confronting Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) causing Coronavirus disease 2019 (COVID-19). Since December 2019 when the first cases of COVID-19 have emerged in Wuhan, China, this novel infectious disease has spread to millions of people worldwide [ 11 ]. The outbreak of COVID-19 was characterized as a pandemic by WHO on 11 March 2020 [ 11 ]. In addition to these major public health issues, there are new phenomena such as atmospheric warming, sea level rise, mountain glacier loss, and ocean acidification [ 12 ]. These phenomena lead to extreme weather events such as storms, floods, droughts, heatwaves, fires, and many more, which threaten the lives of billions of people around the world [ 12 ]. Whether these new phenomena can be considered and called public health issues depends on the definition of public health [ 1 ]. Needless to say, by considering a phenomenon as a public health issue, attention is drawn to the fact that such an issue is common or increasing within a population [ 1 ]. Calling a phenomenon public health issue could highlight the fact that such an issue does not solely depend on individual actions but is influenced by other conditions including socio-economic situations [ 1 ]. When a phenomenon is considered a public health issue, it might trigger the idea that it should be treated differently, perhaps through collective or governmental rather than individual action [ 1 ]. Prioritisation and treatment with a particular urgency could be expected when a phenomenon is labelled as a public health issue [ 1 ]. These consequences are not exclusive and many more can be expected [ 1 ].

The concept of public health is not fixed and has been changing over time [ 9 , 13 ]. What is included in public health has been evolving in accordance with our understanding of reality and the instruments available for intervention [ 9 , 5 ]. Due to the complexity of public health in today’s world, it is a multifaceted concept in constant flux [ 9 ]. “All the different facets of this concept deserve to be examined carefully from all possible angles, as they manifest themselves through the many different ways in which they are defined and acted on” [ 9 ]. The ever-changing nature of public health requires a continuous need for reassessing and updating its definition [ 14 ]. Recently, Nutbeam and Muscat talked about Health Promotion Glossary 2021 which is the first full review and revision of the first Health Promotion Glossary commissioned by the WHO in 1986, fully revised in 1998 [ 15 , 16 , 17 ]. “This revision provides an updated overview of the many ideas and concepts which are central to contemporary health promotion” [ 15 ]. One of the definitions modified in this revision was public health [ 15 ]. However, this modified definition is taken from the Dictionary of Public Health published in 2007 [ 18 ].

This background leads us to a consideration of whether current definitions stemming from long-standing definitions can respond to today’s public health challenges. Before taking this point into consideration, we needed to identify and review available public health definitions, which was the objective of the current study. To achieve this objective, a scoping review of the literature was conducted, which is discussed in detail in the next section.

Search strategy and selection criteria

A scoping review of peer-reviewed and grey literature was conducted to identify available public health definitions. This review was prepared according to the framework of the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) guidelines [ 19 ].

In order to gain familiarity with the previous studies and aid with the identification of key concepts and words, several preliminary searches were conducted. Then, four databases including PubMed (from its inception until June 06, 2022), Web of Science (from its inception until June 06, 2022), EBSCOhost (from its inception until June 06, 2022), and Embase (from its inception until June 08, 2022) were searched to identify relevant literature. Grey literature was searched using Google Scholar (from its inception until June 06, 2022) and the first 100 search results sorted by relevance were compared against the inclusion criteria. Moreover, reference lists of publications included in the scoping review were screened manually for additional relevant publications. No language restriction was applied at this stage.

The search for the relevant literature was conducted using the following keywords in the title and abstract of the literature: “public”, “health”, “definition”, and “meaning”. The final search results were exported into an Excel spreadsheet, and duplicates were removed.

Publications were included if they satisfied all of the following eligibility criteria: (1) All types of scientific publications such as articles, editorials, viewpoints, guidelines, etc.; (2) English-language publications providing an original definition of public health.

The selection of relevant publications was conducted in three stages: (1) Screening of the title and abstract conducted by the first author (RA); (2) Full text screening completed independently by the first and second authors (RA and BB). Raised discrepancies resolved through discussion until consensus was reached; and (3) data extraction and collation. These stages were summarized in the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) flow diagram (see Fig.  1 ).

figure 1

Flow diagram of the scoping review process (from inception until June 06, 2022) based on the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) [ 19 ]

Figure  1 : Flow diagram of the scoping review process (from inception until June 06, 2022) based on the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) [ 19 ]

Data analysis

Eligible publications were reviewed by RA and BB independently and the following data were extracted: Title, author(s), year of publication, country/region, type of publication, disciplinary fields of publications, aims and objectives of the publication, and public health definitions (see Table  1 ). Discrepancies were resolved through discussion until a consensus was reached.

The electronic searches conducted in the above-mentioned databases identified a total of 5651 publications, resulting in 3675 unique publications to be screened for inclusion following the removal of duplicates (see Fig.  1 ). Based on the eligibility criteria, the titles and abstracts were assessed for their relevance, resulting in five publications being retained. Of these, two publications were excluded as their abstracts and full texts were not available [ 20 , 21 ]. The full texts of the remaining publications, three publications, were obtained and after applying the eligibility criteria, one publication was excluded as it did not introduce a new definition of public health [ 22 ]. Therefore, two publications were included [ 14 , 23 ]. An additional nine publications were identified through the manual screening [ 4 , 7 , 8 , 9 , 24 , 25 , 26 , 27 , 28 ]. A total 11 of publications were included in the scoping review (see Fig.  1 ). Characteristics of the included publications are shown in Table  1 .

Of the 11 publications included in this review, six publications were original research articles published in 1920, 2001, 2002, and 2003 [ 7 , 26 , 27 , 28 , 14 , 23 ]. Four publications were books published in 1988, 1999, and 2002 [ 8 , 4 , 25 , 9 ]. One publication was a report published in 1998 [ 24 ]. All the publications were authored in North America and Europe mainly. Disciplinary fields of the publications included health, public health, medicine, law, ethics, bioethics, and human rights (see Table  1 ).

Of the 11 publications included in this review, only two publications set providing a new definition of public health as the aim and objective of their studies [ 14 , 23 ]. Formulating scopes and tendencies of modern public health, reviewing the future development of the public health function, analysing the public health situation in the US and presenting an action plan for a strong public health capability, providing expert assessments of the global health situation and projecting health trends, providing new health for all policy framework, investigating the use of research-based information in public health practice, providing a greater understanding of the related fields of public health, ethics, and human rights, providing a conceptual map of the terrain of public health ethics, and reflecting on public health in the context of Americas were stated as the aims and objectives of the other publications (see Table  1 ).

All the publications under review provided explicit definitions. All the definitions which are provided in Table  1 were formulated by their authors without any references to other definitions.

The publications under review reported several rationales for providing a new definition of public health. Winslow sought to provide a more inclusive definition [ 7 ]. “If the foregoing outline of the problems of public health be accepted as correct, it will be obvious that the field as thus visualized is no small and restricted one” [ 7 ] …. “If we are looking to the future we must conceive our subject in terms no smaller than those of the [provided] definition” [ 7 ]. Acheson looked for a wide definition of the term public health [ 8 ]. In the past, public health has been rather narrowly interpreted and associated with sanitary hygiene and epidemic disease control [ 8 ]. He preferred a broader definition which gives “as much weight to the importance of lifestyle as to environmental hygiene in the preservation and promotion of health” [ 8 ]. Institute of Medicine believed that understanding of public health should not be restricted to what health departments do [ 4 ]. A clear definition helps those who work in, are served by, or study the system to understand it and work to improve its performance [ 4 ]. The need for expanding and clarifying the meaning of public health based on public health challenges was another rationale stated by PAHO [ 9 ]. Traditional cornerstones of public health such as prevention and control of communicable diseases or environmental sanitation continue to be important; however, current definitions of public health should include much more [ 9 ]. Moreover, defining public health in terms of what the government does is no longer sufficient [ 9 ]. “Government should in fact play a central and fundamental role in public health today. However, not everything that government does in terms of health can be regarded as public health, just as public health cannot remain limited to government action” [ 9 ]. Rothstein sought to narrow the scope of public health definition and opposed using “the term “public health” as an open-ended descriptor of widely divergent efforts to improve the human condition” [ 14 ]. There is an ongoing need to reassess scientific, ethical, legal, and social underpinnings of public health as it evolves [ 15 ]. However, considering so many activities as public health just because they interfere with the health of individuals and populations does not mean that eliminating them is part of the mission of public health and can solve the problem of poor health [ 14 ]. Broad definition of public health will not eliminate forms of human privations to call them public health issues [ 14 ]. Heller and colleagues’ rationale was to offer a broader and more inclusive definition which helps public health professionals interpret their own roles [ 23 ]. They tried to provide a wider definition of public health by recognizing the centrality of the public [ 23 ]. “The practice of public health has been criticized as being too involved with a narrow, managerial agenda focused on health care rather than the wider horizons of public good” [ 23 ]. Moreover, they attempted to produce a clear definition that “meets the expectations of those who work in the discipline and the public to whom they are accountable” [ 23 ].

This scoping review was conducted to identify available public health definitions. While previous studies have emphasized the importance of re-assessing and updating definitions of public health, [ 1 , 10 ] the results of the present study indicated a noticeable lack of updated definitions. Of the 11 definitions included in this review, the latest original definitions date back to about 20 years ago. During the last two decades, the world has witnessed the emergence and reemergence of viral outbreaks of Severe Acute Respiratory Syndrome Coronavirus (SARS-CoV) in 2002, Influenza A virus subtype H1N1 (A/H1N1) in 2009, Middle East Respiratory Syndrome Coronavirus (MERS-CoV) in 2012, Ebola virus in 2013, and the SARS-CoV-2 in 2019 [ 29 , 30 ]. Findings of the study led us to a consideration of whether current definitions can fully respond to today’s public health challenges. The situation could be more challenging as public health is a “concept with shifting parameters and multiple interpretations” [ 10 ]. Scholars have insisted on the fact that public health is in constant flux [ 1 , 9 , 13 ]. Considering the findings of the study and the ever-changing nature of public health issues, it can be argued that there is an urgent need for re-assessing and updating public health definitions.

In the last twenty years, new phenomena, such as global warming and climate change, affect the health and well-being of billions of people around the world. Considering these phenomena as public health issues could lead to increased attention, prioritization, different treatment, and many more actions [ 1 ]. Whether these new phenomena can be considered and called public health issues depends on the definition of public health [ 1 ]. Therefore, it seems that updating public health definitions is needed.

The results indicated that the definition of public health plays a crucial role in reaching objectives such as analysing public health situations locally and globally, providing policies and action plans, and many more. This result was in accordance with what previous studies insisted on, which is the important role of public health definition in understanding, shaping, and strengthening public health [ 4 , 9 ]. It can be argued that updating public health definition is needed as an outdated definition might not be able to fulfil such an important role.

According to the findings of the study, a “narrow–broad distinction” [ 1 ] can be drawn between the identified public health definitions. One group of the definitions was provided to present a narrow approach, while the other group was provided to present a broad one. Narrow definitions focus more on health factors such as sanitation, infectious disease control, screening programmes, or health education [ 1 ]. Broad definitions deal with all of the factors that might affect health, including societal, cultural, and economic determinants of health [ 1 , 14 , 31 ]. Rickles called this distinction “local’ and ‘nonlocal’ since they concern factors that act directly on individuals in the former case and more indirectly in the latter case” [ 5 ].

According to the findings of the study, eight out of the 11 publications included in this review were authored in higher-income countries. In other words, the majority of available public health definitions were authored in higher-income countries, which may unevenly illustrate the interests and priorities of stakeholders from higher-income countries. The findings suggest a need for greater diversity and inclusion in providing definitions of public health.

Health, medicine, law, ethics, bioethics, and human rights were the disciplinary fields of the publications included in this review, which could be due to the fact that public health is a massively interdisciplinary field, incorporating epidemiology, biology, sociology, economics, psychology, and more [ 5 ].

The present study has the strength of being the first scoping review conducted to identify available public health definitions. However, the limitations of our study need to be considered. One limitation of our study is that only publications focused on definition of public health were included, which might lead to the absence of studies which provided a new definition of public health without focusing on the subject matter exclusively. Manual screening of reference lists of publications included in the scoping review was used to add relevant publications that had not been initially identified through database searching. This ensured that the review was exhaustive. However, it means that some conclusions may have been influenced by this manual search strategy. Despite not restricting the language of publication, only English keywords were searched, which could lead to the exclusion of non-English publications providing public health definitions. Another limitation is that only publications written in English were included. Future reviews should include non-English studies to have a better understanding of the situation.

Most frequently cited definitions of public health stemmed from long-standing definitions. Despite the emphasis on the importance of re-assessing and updating definitions of public health, there is a noticeable lack of updated definitions. This lack raises several concerns including responding to today’s public health challenges. Considering previous studies, the findings of this study, and the ever-changing nature of public health issues, there is an urgent need for re-assessing and updating public health definitions. Future studies could focus on providing new definitions that fit the present global society.

Data Availability

All data generated or analysed during this study are included in this published article.

Abbreviations

The United States

The World Health Organization

The Pan American Health Organization

Coronavirus disease 2019

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BB conceived the study aims. RA undertook the title and abstract screening. RA and BB undertook full-text screening, data extraction, and data analysis. RA drafted the initial manuscript and BB edited the initial draft. All authors interpreted the results and provided critical comments on the manuscript. All authors had full access to all the data in the study and had final responsibility for the decision to submit publication.“

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Step 3: Establish a Case Definition; Identify Cases

Case definitions, example #1: cdc case definition for giardiasis, example #2: cdc case definitions for viral hepatitis, clinical criteria for a case definition, categories of cases: confirmed, probable, and possible cases, case finding.

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By a case definition we mean the standard criteria for categorizing an individual as a case. Establishing a case definition (the criteria that need to be met in order to be considered "a case") can be tricky, particularly in the initial phases of the investigation. You want your definition to specific enough to identify true cases of disease, but you also want it to be broad enough and sensitive enough that it will identify most, if not all of the cases. As a result, the case definition may change during the investigation. In the earliest stages, it might be broader and less specific in order to make sure you identify all of the potential cases ("possible" cases), but later on, it might include more specific clinical or laboratory criteria that enable you to categorize individuals as "probable" or "confirmed" cases.

Case definitions may include four types of information:

  • clinical information such as symptoms or lab results, e.g. the presence of fever >101 o F and jaundice for hepatitis A or the presence of elevated IgM anti-HAV antibodies in an outbreak of hepatitis A
  • personal characteristics of the cases, e.g., individuals in a certain age group
  • limits with respect to the location of the case (e.g., residing or working on the South Shore of Massachusetts) 
  • a specified time period for this particular outbreak (e.g., during February and March 2009 or among people who attended a specific  wedding)

The CDC also makes well established case definitions available:

  •  CDC's Case Definitions for Infectious Conditions Under Public Health Surveillance
  •  CDC's Case Definitions for Chemical Poisoning

Clinical description

An illness caused by the protozoan Giardia lamblia and characterized by diarrhea, abdominal cramps, bloating, weight loss, or malabsorption. Infected persons may be asymptomatic.

Laboratory criteria for diagnosis

  • Demonstration of G. lamblia cysts in stool, or
  • Demonstration of G. lamblia trophozoites in stool, duodenal fluid, or small bowel biopsy, or
  • Demonstration of G. lamblia antigen in stool by a specific immunodiagnostic test such as enzyme-linked immunosorbent assay (ELISA)

Case classification

Clinical case definition

An illness with a) discrete onset of symptoms and b) jaundice or elevated serum aminotransferase levels

  • Hepatitis A: IgM anti-HAV-positive
  • Hepatitis B: IgM anti-HBc-positive (if done) or HBsAg-positive, and IgM anti-HAV negative (if done)
  • Non-A, Non-B Hepatitis:
  • IgM anti-HAV-negative, and
  • IgM anti-HBc-negative (if done) or HBsAg-negative, and
  • Serum aminotransferase levels >2 1/2 times the upper limit of normal
  • Delta Hepatitis: HBsAg- or IgM anti-HBc-positive and anti-HDV-positive

Comment: A serologic test for IgG antibody to the recently described hepatitis C virus is available, and many cases of non-A, non-B hepatitis may be demonstrated to be due to infection with the hepatitis C virus. With this assay, however, a prolonged interval between onset of disease and detection of antibody may occur. Until a more specific test for acute hepatitis C becomes available, these cases should be reported as non-A, non-B hepatitis. Chronic carriage or chronic hepatitis should not be reported.

These should be simple, objective, and discriminating (i.e. able to distinguish between people with disease and those without disease. For example,

  • the presence of fever >101 o F or
  • the presence of elevated titers of IgM anti-HAV or
  • three or more loose bowel movements per day or muscle aches severe enough to limit the patient's activities

Also, case definitions should not include risk factors that you may want to evaluate, since all of the cases would have the risk factor, and this would be misleading. A case definition is not the same as a clinical diagnosis. Case definitions are an aid to conducting an epidemiologic investigation, whereas a clinical diagnosis is used to make treatment decisions for individual patients.

Sometimes investigators will use a loose definition early on to help them identity the extent of the outbreak. However, once the investigation progresses to the stage of conducting analytic studies to test hypotheses, a more specific definition should be used in order to reduce misclassification which would bias the results.

  • Confirmed cases: These are usually laboratory confirmed cases, e.g., persons who attended a school's teacher appreciation luncheon on September 6, 2010 who had Salmonella isolated from a stool culture. Confirmed cases are best, because they are the most definitive. For most infectious diseases there will be a considerable number of infected people who have only mild symptoms (mildly symptomatic) or no symptoms at all (subclinical cases), and correctly identifying them as cases will rely on laboratory testing.
  • Probable cases: These usually have characteristic clinical features of the disease, but lack laboratory confirmation, e.g., persons with bloody diarrhea who attended a school's teacher appreciation luncheon on September 6, 2010, but without laboratory confirmation.
  • Possible cases: These have some of the clinical features, e.g., abdominal cramps and diarrhea (at least three stools in a 24-hour period) who attended a school's teacher appreciation luncheon on September 6, 2010.

Once a case definition has been established, there should be a concerted effort to identify as many cases as possible in order to accurately establish the magnitude and scope of the outbreak. The cases that are reported to the state and local health departments may represent only a small fraction of the total cases for the outbreak. Therefore, in addition to cases identified via passive surveillance (i.e., cases that self-report or are reported to the state and local health department by physicians' offices, clinics, hospitals, and laboratories) it is often fruitful to conduct active surveillance by calling hospitals, laboratories, clinics, and physicians offices in order to identify potential cases that otherwise would have gone unreported. As cases are identified, it can also be useful to ask them if they know of others who are similarly affected, e.g., family members and acquaintances. Occasionally, investigators will try to identify cases by posting notices in the media. These serve the dual purpose of alerting the public about potential hazards and identifying possible cases that have already become ill. For more information on case finding see Case Finding and Line Listing: A Guide for Investigators .

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Content ©2016. All Rights Reserved. Date last modified: May 3, 2016. Wayne W. LaMorte, MD, PhD, MPH

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  1. The case study approach

    A case study is a research approach that is used to generate an in-depth, multi-faceted understanding of a complex issue in its real-life context. It is an established research design that is used extensively in a wide variety of disciplines, particularly in the social sciences. A case study can be defined in a variety of ways (Table.

  2. Case Library

    The Harvard Chan Case Library is a collection of teaching cases with a public health focus, written by Harvard Chan faculty, case writers, and students, or in collaboration with other institutions and initiatives. Use the filters at right to search the case library by subject, geography, health condition, and representation of diversity and identity to find cases to fit your teaching needs.

  3. Continuing to enhance the quality of case study methodology in health

    Introduction. The popularity of case study research methodology in Health Services Research (HSR) has grown over the past 40 years. 1 This may be attributed to a shift towards the use of implementation research and a newfound appreciation of contextual factors affecting the uptake of evidence-based interventions within diverse settings. 2 Incorporating context-specific information on the ...

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  10. What is a case study?

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  11. Writing a case

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    The case example book, which resulted from this study, constitutes a detailed feed back for the participants of the study and is now being used as training material for public health nurses. We have demonstrated that rigorous reduction of case definitions to testable yes/no-criteria in a check-list format is likely to improve their reliability.

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    This scoping review was conducted to identify available public health definitions. While previous studies have emphasized the importance of re-assessing and updating definitions of public health, [1, 10] the results of the present study indicated a noticeable lack of updated definitions.Of the 11 definitions included in this review, the latest original definitions date back to about 20 years ago.

  22. How do we define the policy impact of public health research? A

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  23. Step 3: Establish a Case Definition; Identify Cases

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  24. Public health: who, what, and why?

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