qualitative research in case study

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

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

Research question

• Conceptual framework
• Conceptual vs. theoretical framework

Data collection

• Qualitative research methods
• Focus groups
• Observational research

What is a case study?

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

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

Case studies

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

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

Definition of a case study

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

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

Characteristics of case studies

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

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

The role of case studies in research

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

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

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

What is the purpose of a case study?

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

Why use case studies in qualitative research?

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

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

The explanatory, exploratory, and descriptive roles of case studies

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

The impact of case studies on knowledge development

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

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

Types of case studies

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

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

Exploratory case studies

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

Descriptive case studies

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

Explanatory case studies

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

Intrinsic, instrumental, and collective case studies

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

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

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

Critical information systems research

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

Health research

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

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

Asthma research studies

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

Other fields

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

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

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Understanding the key elements of case study design is crucial for conducting rigorous and impactful case study research. A well-structured design guides the researcher through the process, ensuring that the study is methodologically sound and its findings are reliable and valid. The main elements of case study design include the research question , propositions, units of analysis, and the logic linking the data to the propositions.

The research question is the foundation of any research study. A good research question guides the direction of the study and informs the selection of the case, the methods of collecting data, and the analysis techniques. A well-formulated research question in case study research is typically clear, focused, and complex enough to merit further detailed examination of the relevant case(s).

Propositions

Propositions, though not necessary in every case study, provide a direction by stating what we might expect to find in the data collected. They guide how data is collected and analyzed by helping researchers focus on specific aspects of the case. They are particularly important in explanatory case studies, which seek to understand the relationships among concepts within the studied phenomenon.

Units of analysis

The unit of analysis refers to the case, or the main entity or entities that are being analyzed in the study. In case study research, the unit of analysis can be an individual, a group, an organization, a decision, an event, or even a time period. It's crucial to clearly define the unit of analysis, as it shapes the qualitative data analysis process by allowing the researcher to analyze a particular case and synthesize analysis across multiple case studies to draw conclusions.

Argumentation

This refers to the inferential model that allows researchers to draw conclusions from the data. The researcher needs to ensure that there is a clear link between the data, the propositions (if any), and the conclusions drawn. This argumentation is what enables the researcher to make valid and credible inferences about the phenomenon under study.

Understanding and carefully considering these elements in the design phase of a case study can significantly enhance the quality of the research. It can help ensure that the study is methodologically sound and its findings contribute meaningful insights about the case.

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Conducting a case study involves several steps, from defining the research question and selecting the case to collecting and analyzing data . This section outlines these key stages, providing a practical guide on how to conduct case study research.

Defining the research question

The first step in case study research is defining a clear, focused research question. This question should guide the entire research process, from case selection to analysis. It's crucial to ensure that the research question is suitable for a case study approach. Typically, such questions are exploratory or descriptive in nature and focus on understanding a phenomenon within its real-life context.

Selecting and defining the case

The selection of the case should be based on the research question and the objectives of the study. It involves choosing a unique example or a set of examples that provide rich, in-depth data about the phenomenon under investigation. After selecting the case, it's crucial to define it clearly, setting the boundaries of the case, including the time period and the specific context.

Previous research can help guide the case study design. When considering a case study, an example of a case could be taken from previous case study research and used to define cases in a new research inquiry. Considering recently published examples can help understand how to select and define cases effectively.

Developing a detailed case study protocol

A case study protocol outlines the procedures and general rules to be followed during the case study. This includes the data collection methods to be used, the sources of data, and the procedures for analysis. Having a detailed case study protocol ensures consistency and reliability in the study.

The protocol should also consider how to work with the people involved in the research context to grant the research team access to collecting data. As mentioned in previous sections of this guide, establishing rapport is an essential component of qualitative research as it shapes the overall potential for collecting and analyzing data.

Collecting data

Gathering data in case study research often involves multiple sources of evidence, including documents, archival records, interviews, observations, and physical artifacts. This allows for a comprehensive understanding of the case. The process for gathering data should be systematic and carefully documented to ensure the reliability and validity of the study.

Analyzing and interpreting data

The next step is analyzing the data. This involves organizing the data , categorizing it into themes or patterns , and interpreting these patterns to answer the research question. The analysis might also involve comparing the findings with prior research or theoretical propositions.

Writing the case study report

The final step is writing the case study report . This should provide a detailed description of the case, the data, the analysis process, and the findings. The report should be clear, organized, and carefully written to ensure that the reader can understand the case and the conclusions drawn from it.

Each of these steps is crucial in ensuring that the case study research is rigorous, reliable, and provides valuable insights about the case.

The type, depth, and quality of data in your study can significantly influence the validity and utility of the study. In case study research, data is usually collected from multiple sources to provide a comprehensive and nuanced understanding of the case. This section will outline the various methods of collecting data used in case study research and discuss considerations for ensuring the quality of the data.

Interviews are a common method of gathering data in case study research. They can provide rich, in-depth data about the perspectives, experiences, and interpretations of the individuals involved in the case. Interviews can be structured , semi-structured , or unstructured , depending on the research question and the degree of flexibility needed.

Observations

Observations involve the researcher observing the case in its natural setting, providing first-hand information about the case and its context. Observations can provide data that might not be revealed in interviews or documents, such as non-verbal cues or contextual information.

Documents and artifacts

Documents and archival records provide a valuable source of data in case study research. They can include reports, letters, memos, meeting minutes, email correspondence, and various public and private documents related to the case.

These records can provide historical context, corroborate evidence from other sources, and offer insights into the case that might not be apparent from interviews or observations.

Physical artifacts refer to any physical evidence related to the case, such as tools, products, or physical environments. These artifacts can provide tangible insights into the case, complementing the data gathered from other sources.

Ensuring the quality of data collection

Determining the quality of data in case study research requires careful planning and execution. It's crucial to ensure that the data is reliable, accurate, and relevant to the research question. This involves selecting appropriate methods of collecting data, properly training interviewers or observers, and systematically recording and storing the data. It also includes considering ethical issues related to collecting and handling data, such as obtaining informed consent and ensuring the privacy and confidentiality of the participants.

Data analysis

Analyzing case study research involves making sense of the rich, detailed data to answer the research question. This process can be challenging due to the volume and complexity of case study data. However, a systematic and rigorous approach to analysis can ensure that the findings are credible and meaningful. This section outlines the main steps and considerations in analyzing data in case study research.

Organizing the data

The first step in the analysis is organizing the data. This involves sorting the data into manageable sections, often according to the data source or the theme. This step can also involve transcribing interviews, digitizing physical artifacts, or organizing observational data.

Categorizing and coding the data

Once the data is organized, the next step is to categorize or code the data. This involves identifying common themes, patterns, or concepts in the data and assigning codes to relevant data segments. Coding can be done manually or with the help of software tools, and in either case, qualitative analysis software can greatly facilitate the entire coding process. Coding helps to reduce the data to a set of themes or categories that can be more easily analyzed.

Identifying patterns and themes

After coding the data, the researcher looks for patterns or themes in the coded data. This involves comparing and contrasting the codes and looking for relationships or patterns among them. The identified patterns and themes should help answer the research question.

Interpreting the data

Once patterns and themes have been identified, the next step is to interpret these findings. This involves explaining what the patterns or themes mean in the context of the research question and the case. This interpretation should be grounded in the data, but it can also involve drawing on theoretical concepts or prior research.

Verification of the data

The last step in the analysis is verification. This involves checking the accuracy and consistency of the analysis process and confirming that the findings are supported by the data. This can involve re-checking the original data, checking the consistency of codes, or seeking feedback from research participants or peers.

Like any research method , case study research has its strengths and limitations. Researchers must be aware of these, as they can influence the design, conduct, and interpretation of the study.

Understanding the strengths and limitations of case study research can also guide researchers in deciding whether this approach is suitable for their research question . This section outlines some of the key strengths and limitations of case study research.

Benefits include the following:

• Rich, detailed data: One of the main strengths of case study research is that it can generate rich, detailed data about the case. This can provide a deep understanding of the case and its context, which can be valuable in exploring complex phenomena.
• Flexibility: Case study research is flexible in terms of design , data collection , and analysis . A sufficient degree of flexibility allows the researcher to adapt the study according to the case and the emerging findings.
• Real-world context: Case study research involves studying the case in its real-world context, which can provide valuable insights into the interplay between the case and its context.
• Multiple sources of evidence: Case study research often involves collecting data from multiple sources , which can enhance the robustness and validity of the findings.

On the other hand, researchers should consider the following limitations:

• Generalizability: A common criticism of case study research is that its findings might not be generalizable to other cases due to the specificity and uniqueness of each case.
• Time and resource intensive: Case study research can be time and resource intensive due to the depth of the investigation and the amount of collected data.
• Complexity of analysis: The rich, detailed data generated in case study research can make analyzing the data challenging.
• Subjectivity: Given the nature of case study research, there may be a higher degree of subjectivity in interpreting the data , so researchers need to reflect on this and transparently convey to audiences how the research was conducted.

Being aware of these strengths and limitations can help researchers design and conduct case study research effectively and interpret and report the findings appropriately.

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The Oxford Handbook of Qualitative Research (2nd edn)

Patricia Leavy Independent Scholar Kennebunk, ME, USA

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The Oxford Handbook of Qualitative Research, second edition, presents a comprehensive retrospective and prospective review of the field of qualitative research. Original, accessible chapters written by interdisciplinary leaders in the field make this a critical reference work. Filled with robust examples from real-world research; ample discussion of the historical, theoretical, and methodological foundations of the field; and coverage of key issues including data collection, interpretation, representation, assessment, and teaching, this handbook aims to be a valuable text for students, professors, and researchers. This newly revised and expanded edition features up-to-date examples and topics, including seven new chapters on duoethnography, team research, writing ethnographically, creative approaches to writing, writing for performance, writing for the public, and teaching qualitative research.

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Qualitative study design: Case Studies

• Qualitative study design
• Phenomenology
• Grounded theory
• Ethnography
• Narrative inquiry
• Action research

Case Studies

• Field research
• Focus groups
• Observation
• Surveys & questionnaires
• Study Designs Home

In depth description of the experience of a single person, a family, a group, a community or an organisation.

An example of a qualitative case study is a life history which is the story of one specific person.  A case study may be done to highlight a specific issue by telling a story of one person or one group. 

• Oral recording

Ability to explore and describe, in depth, an issue or event. 

Develop an understanding of health, illness and health care in context. 

Single case can be used to develop or disprove a theory. 

Can be used as a model or prototype .  

Limitations

Labour intensive and generates large diverse data sets which can be hard to manage. 

Case studies are seen by many as a weak methodology because they only look at one person or one specific group and aren’t as broad in their participant selection as other methodologies. 

Example questions

This methodology can be used to ask questions about a specific drug or treatment and its effects on an individual.

• Does thalidomide cause birth defects?
• Does exposure to a pesticide lead to cancer?

Example studies

• Choi, T. S. T., Walker, K. Z., & Palermo, C. (2018). Diabetes management in a foreign land: A case study on Chinese Australians. Health & Social Care in the Community, 26(2), e225-e232. 
• Reade, I., Rodgers, W., & Spriggs, K. (2008). New Ideas for High Performance Coaches: A Case Study of Knowledge Transfer in Sport Science.  International Journal of Sports Science & Coaching , 3(3), 335-354. 
• Wingrove, K., Barbour, L., & Palermo, C. (2017). Exploring nutrition capacity in Australia's charitable food sector.  Nutrition & Dietetics , 74(5), 495-501. 
• Green, J., & Thorogood, N. (2018). Qualitative methods for health research (4th ed.). London: SAGE. 
• University of Missouri-St. Louis. Qualitative Research Designs. Retrieved from http://www.umsl.edu/~lindquists/qualdsgn.html   
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• Last Updated: Apr 8, 2024 11:12 AM
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Qualitative Research: Case Studies

• Getting Started
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• Observation
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Help with case studies

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How To Write a Case Study

How to undertake case study research

From: http://www.emeraldgrouppublishing.com/products/case_studies/index.htm

What is a case study?

• Attempts to shed light on a phenomena by studying a single case example.
• Focuses on an individual person, an event, a group, or an institution.
• Allows for in-depth examination by prolonged engagement or cultural immersion
• Explores processes and outcomes
• Investigates the context and setting of a situation
• Can involve a number of data gathering methods

Duke Resources

• Philanthropy Central from Sanford School of Public Policy Case Study Database Provides real-life case studies of philanthropic initiatives. There are currently more than 600 case studies linked to in the Database.

Suggested Readings

• McNabb, D. (2010).  Case reseach in public management.  NY: M.E.Sharpe.
• Samuels, D. (2013).  Case studies in comparative politics .  NY: Pearson Education.
• Stark, R. (1995). The  art of case study research, Thousand Oaks: Sage.
• Yin, R.K. (2009) Case study research: Design and methods. Los Angeles: Sage.
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• Last Updated: Mar 1, 2024 10:13 AM
• URL: https://guides.library.duke.edu/qualitative-research

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Research Writing and Analysis

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Writing a Case Study

What is a case study?

A Case study is: 

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

What are the different types of case studies?

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

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

Who are your case study participants?

What is triangulation ? 

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

How to write a Case Study?

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

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The case study approach

Sarah crowe.

1 Division of Primary Care, The University of Nottingham, Nottingham, UK

Kathrin Cresswell

2 Centre for Population Health Sciences, The University of Edinburgh, Edinburgh, UK

Ann Robertson

3 School of Health in Social Science, The University of Edinburgh, Edinburgh, UK

Anthony Avery

Aziz sheikh.

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.

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 ​ Tables1, 1 , ​ ,2, 2 , ​ ,3 3 and ​ and4) 4 ) and those of others to illustrate our discussion[ 3 - 7 ].

Example of a case study investigating the reasons for differences in recruitment rates of minority ethnic people in asthma research[ 3 ]

Example of a case study investigating the process of planning and implementing a service in Primary Care Organisations[ 4 ]

Example of a case study investigating the introduction of the electronic health records[ 5 ]

Example of a case study investigating the formal and informal ways students learn about patient safety[ 6 ]

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 ​ (Table5), 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.

Definitions of a case study

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 ​ (Table1), 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 ​ Tables2, 2 , ​ ,3 3 and ​ and4) 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 ​ (Table2) 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 ​ Tables2 2 and ​ and3, 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 ​ (Table4 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 ​ (Table6). 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 ].

Example of epistemological approaches that may be used in case study research

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 ​ Table7 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 ].

Example of a checklist for rating a case study proposal[ 8 ]

For example, in our evaluation of the introduction of electronic health records in English hospitals (Table ​ (Table3), 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 ​ (Table1) 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 ​ Table3) 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 ​ (Table2 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 ​ (Table1 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 ​ (Table3 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 ​ (Table4 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 ​ Table3, 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 ​ (Table4), 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 ​ Table8 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 ​ (Table9 9 )[ 8 ].

Potential pitfalls and mitigating actions when undertaking case study research

Stake's checklist for assessing the quality of a case study report[ 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.

Competing interests

The authors declare that they have no competing interests.

Authors' contributions

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

Pre-publication history

The pre-publication history for this paper can be accessed here:

http://www.biomedcentral.com/1471-2288/11/100/prepub

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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6 Qualitative data examples for thorough market researchers

Types of qualitative data in market research, 6 qualitative data examples, get nuanced insights from qualitative market research.

There are plenty of ways to gather consumer insights for fresh campaigns and better products, but qualitative research is up there with the best sources of insight.

This guide is packed with examples of how to turn qualitative data into actionable insights, to spark your creativity and sharpen your research strategy. You’ll see how qualitative data, especially through surveys, opens doors to deeper understanding by inviting consumers to share their experiences and thoughts freely, in their own words — and how qualitative data can transform your brand.

Before we dig into some examples of how qualitative data can empower your teams to make focused, confident and quick decisions on anything from product to marketing, let’s go back to basics. We can categorize qualitative data into roughly three categories: binary, nominal and ordinal data. Here’s how each of them is used in qualitative data analysis.

Binary data

Binary data represents a choice between two distinct options, like ‘yes’ or ‘no’. In market research, this type of qualitative data is useful for filtering responses or making clear distinctions in consumer preferences.

Binary data in qualitative research is great for straightforward insights, but has its limits. Here’s a quick guide on when to use it and when to opt for qualitative data that is more detailed:

Binary data is great for:

• Quick Yes/No questions : like “Have you used our app? Yes or No.”
• Initial screening : to quickly sort participants for further studies.
• Clear-cut answers : absolute factors, such as ownership or usage.

Avoid binary data for:

• Understanding motivations : it lacks the depth to explore why behind actions.
• Measuring intensity : can’t show how much someone likes or uses something.
• Detail needed for product development : misses the nuanced feedback necessary for innovations.

Nominal data

Nominal data categorizes responses without implying any order. For example, when survey respondents choose their favorite brand from a list, the data collected is nominal, offering insights into brand preferences among different demographics.

Some other examples of qualitative data that can be qualified as nominal are asking participants to name their primary information source about products in categories like social media, friends, or online reviews. Or in focus groups, discussing brand perceptions could classify brands into categories such as luxury, budget-friendly, or eco-conscious, based on participant descriptions.

Nominal data is great for:

• Categorizing responses : such as types of consumer complaints (product quality, customer service, delivery issues).
• Identifying preferences : like favorite product categories (beverages, electronics, apparel).
• Segmentation : grouping participants based on attributes (first-time buyers, loyal customers).

Nominal data is not for:

• Measuring quantities : it can’t quantify how much more one category is preferred over another.
• Ordering or ranking responses : it doesn’t indicate which category is higher or lower in any hierarchy.
• Detailed behavioral analysis : While it can group behaviors, it doesn’t delve into the frequency or intensity of those behaviors.

Ordinal data

Ordinal data introduces a sense of order, ranking preferences or satisfaction levels. In qualitative analysis, it’s particularly useful for understanding how consumers prioritize features or products, giving researchers a clearer picture of market trends.

Other examples of qualitative data analyses that use ordinal data, are for instance a study on consumer preferences for coffee flavors, participants might rank flavors in order of preference, providing insights into flavor trends. You can also get ordinal data from focus groups on things like customer satisfaction surveys or app usability, by asking users to rate their ease of use or happiness on an ordinal scale.

Ordinal data is great for:

• Ranking preferences : asking participants to rank product features from most to least important.
• Measuring satisfaction levels : using scales like “very satisfied,” “satisfied,” “neutral,” “dissatisfied,” “very dissatisfied.”
• Assessing Agreement : with statements on a scale from “strongly agree” to “strongly disagree.”

Ordinal data is not for:

• Quantifying differences : it doesn’t show how much more one rank is preferred over another, just the order.
• Precise measurements : can’t specify the exact degree of satisfaction or agreement, only relative positions.

This mix of qualitative and quantitative data will give you a well-rounded view of participant attitudes and preferences.

The things you can do with qualitative data are endless. But this article shouldn’t turn into a work of literature, so we’ll highlight six ways to collect qualitative data and give you examples of how to use these qualitative research methods to get actionable results.

How to get qual insights with Attest

You can get to the heart of what your target customers think, with reliable qualitative insights from Attest Video Responses

1. Highlighting brand loyalty drivers with open-ended surveys and questionnaires

Open-ended surveys and questionnaires are great at finding out what makes customers choose and stick with a brand. Here’s why this qualitative data analysis tool is so good for gathering qualitative data on things like brand loyalty and customer experience:

Straight from the source

Open-ended survey responses show the actual thoughts and feelings of your target audience in their own words, while still giving you structure in your data analysis.

Understanding ‘why’

Numbers can show us how many customers are loyal; open-ended survey responses explain why they are. You can also easily add thematic analysis to the mix by counting certain keywords or phrases.

Guiding decisions

The insights from these surveys can help a brand decide where to focus its efforts, from making sure their marketing highlights what customers love most to improving parts of their product.

Surveys are one of the most versatile and efficient qualitative data collection methods out there. We want to bring the power of qualitative data analysis to every business and make it easy to gather qualitative data from the people who matter most to your brand. Check out our survey templates to hit the ground running. And you’re not limited to textual data as your only data source — we also enable you to gather video responses to get additional context from non verbal cues and more.

2. Trend identification with observation notes

Observation notes are a powerful qualitative data analysis tool for spotting trends as they naturally unfold in real-world settings. Here’s why they’re particularly valuable insights and effective for identifying new trends:

Real behavior

Observing people directly shows us how they actually interact with products or services, not just how they say they do. This can highlight emerging trends in consumer behavior or preferences before people can even put into words what they are doing and why.

Immediate insights

By watching how people engage with different products, we can quickly spot patterns or changes in behavior. This immediate feedback is invaluable for catching trends as they start.

Context matters

Observations give you context. You can see not just what people do, but where and how they do it. This context can be key to understanding why a trend is taking off.

Unprompted reactions

Since people don’t know they’re being observed for these purposes, their actions are genuine. This leads to authentic insights about what’s really catching on.

3. Understanding consumer sentiments through semi-structured interviews

Semi-structured interviews for qualitative data analysis are an effective method for data analysts to get a deep understanding of consumer sentiments. It provides a structured yet flexible approach to gather in-depth insights. Here’s why they’re particularly useful for this type of research question:

Personal connection

These interviews create a space for a real conversation, allowing consumers to share their feelings, experiences, and opinions about a brand or product in a more personal setting.

Flexibility

The format lets the interviewer explore interesting points that come up during the conversation, diving deeper into unexpected areas of discussion. This flexibility uncovers richer insights than strictly structured interviews.

Depth of understanding

By engaging in detailed discussions, brands can understand not just what consumers think but why they think that way and what stations their train of thought passes by.

Structure and surprise

Semi-structured interviews can be tailored to explore specific areas of interest while still allowing for new insights to emerge.

4. Using focus groups for informing market entry strategies

Using a focus group to inform market entry strategies provides a dynamic way to discover your potential customers’ needs, preferences, and perceptions before launching a product or entering a new market. Here’s how focus groups can be particularly effective for this kind of research goal:

Real conversations

Focus groups allow for real-time, interactive discussions, giving you a front-row seat to hear what your potential customers think and feel about your product or service idea.

Diverse Perspectives

By bringing together people from various backgrounds, a focus group can offer a wide range of views and insights, highlighting different consumer needs and contextual information that you might miss out on in a survey.

Spotting opportunities and challenges

The dynamic nature of focus groups can help uncover unique market opportunities or potential challenges that might not be evident through other research methods, like cultural nuances.

Testing ideas

A focus group is a great way to test and compare reactions to different market entry strategies, from pricing models to distribution channels, providing clear direction on what approach might work best.

5. Case studies to gain a nuanced understanding of consumers on a broad level

Case studies in qualitative research zoom in on specific stories from customers or groups using a product or service, great for gaining a nuanced understanding of consumers at a broad level. Here’s why case studies are a particularly effective qualitative data analysis tool for this type of research goal:

In-depth analysis

Case studies can provide a 360-degree look at the consumer experience, from initial awareness to post-purchase feelings.

This depth of insight reveals not just what consumers do, but why they do it, uncovering motivations, influences, and decision-making processes.

Longitudinal insight

Case studies can track changes in consumer behavior or satisfaction over time, offering a dynamic view of how perceptions evolve.

This longitudinal perspective is crucial for giving context to the lifecycle of consumer engagement with a brand.

Storytelling power

The narrative nature of case studies — when done right — makes them powerful tools for communicating complex consumer insights in an accessible and engaging way, which can be especially useful for internal strategy discussions or external marketing communications.

6. Driving product development with diary studies

Diary studies are a unique qualitative research method that involves participants recording their thoughts, experiences, or behaviors over a period of time, related to using a product or service. This qualitative data analysis method is especially valuable for driving product development for several reasons:

Real-time insights

Diary studies capture real-time user experiences and feedback as they interact with a product in their daily lives.

This ongoing documentation provides a raw, unfiltered view of how a product fits into the user’s routine, highlighting usability issues or unmet needs that might not be captured in a one-time survey or interview.

Realistic user journey mapping

By analyzing diary entries, you can map out the entire user journey, identifying critical touch points where users feel delighted, frustrated, or indifferent.

This then enables you to implement targeted improvements and innovations at the moments that matter most.

Identifying patterns

Over the course of a diary study, patterns in behavior, preferences, and challenges can emerge, which is great for thematic analysis.

It can guide product developers to prioritize features or fixes that will have the most significant impact on user satisfaction, which is especially great if they don’t know what areas to focus on first.

Qualitative research brings your consumers’ voices directly to your strategy table. The examples we’ve explored show how qualitative data analysis methods like surveys, interviews, and case studies illuminate the ‘why’ behind consumer choices, guiding more informed decisions. Using these insights means crafting products and messages that resonate deeply, ensuring your brand not only meets but exceeds consumer expectations.

Customer Research Manager 

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Qualitative Case Study on Virtual Simulations Engaging Educational Leadership Candidates in Ethical Scenarios that Positively Impacted Leadership Skills

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• Published: 30 May 2024

Longitudinal qualitative study on the psychological experiences of COVID-19 patients based on timing it right framework

• Liangyan Zhang 1 ,
• Chen Zhang 2 ,
• Kesang Li 1 &
• Yan Zhang 3  

Scientific Reports volume  14 , Article number:  12409 ( 2024 ) Cite this article

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• Health care

Timing it right framework was used as a framework to explore the illness experiences of patients infected with COVID-19 and to analyze the patients' perceptions of the disease and their true inner feelings to provide a reference for the control of infectious diseases. This research adopted a phenomenological research approach to develop a longitudinal qualitative study. A purposive sampling method was used to select participants and 37 patients were recruited. Depending on the principle that participants should have maximum variation and sampling should cease when interviews content saturation is achieved, 16 COVID-19 patients in an isolation ward in Ningbo City, Zhejiang Province were finally included. Data were collected using semi-structured interviews, and the content of the interviews was analyzed by Colaizzi’s 7-step method. The themes of COVID-19 patients’ experiences at various phase were presented as follows: multiple emotions intertwined at the time of diagnosis (anxiety, stressful panic, facing the diagnosis calmly), multiple pressures during the hospitalization period (concerns about the disease, unable to adapt to the ward environment, worrying about future hardship), growth of positive illness experience during the isolation and observation period (sublimated outlook on life, affirmation of the government's anti-epidemic policy, more concerned about their own health), adjustment after returning to society (stigma, loss of previous living environment, problems caused by nucleic acid testing), and adaptation to social life (return to normal life, avoidance of illness experience, post-covid-19 syndrome). The illness experience of COVID-19 patients changed dynamically with time, but a sense of shame and uncertainty about recovery was present throughout the process. Interventions should be developed according to the needs of the patients at different times to inform subsequent optimization of care and management of infectious diseases.

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COVID-19 pandemic influence on self-reported health status and well-being in a society

Introduction.

The ongoing global epidemic of coronavirus disease 2019 (COVID-19) has had a significant impact on human society, primarily in terms of public health. As of 2 February 2023, the reported cumulative number of confirmed cases worldwide is approximately 753 million, with approximately 6,814,900 deaths 1 . Importantly, the actual number of infections worldwide may be higher than the reported data due to factors such as limited testing capacity. The Omicron and Delta strains are variants of coronaviruses with high loads, high infectivity, short incubation times, and antigenic escape 2 . Patients experience long viral nucleic acid conversion times and are more likely to develop severe and critical illnesses, with long periods of hospital isolation and medical observation 3 . Studies have shown 4 that patients with COVID-19 who stay in isolation are prone to psychological problems such as anxiety, depression, and fear. The study 5 showed that infected patients had problems such as fatigue, sleep difficulties, and anxiety after discharge from the hospital, and those with severe lung damage during hospitalization were even more likely to be in the target population for long-term rehabilitation interventions after discharge; however, the study was conducted on patients at the beginning of the 2019 outbreak, and the characteristics of the coronavirus variants can cause various psychological experiences in infected patients. There are currently few studies exploring mild COVID-19 patients' experiences during hospitalization and after reintegration into society 6 . The Timing it Right (TIR) framework was proposed by Cameron et al. 7 in the study of stroke care; it divides the process of disease development into five phases: diagnosis, stabilization, preparation, implementation and adaptation. At present, a number of scholars have used different research methods to study the dynamic needs of patients and caregivers with the TIR framework, and have achieved initial results 8 . Based on the TIR framework, it is possible to understand the changes in the experience of COVID-19 patients at different stages of illness, and formulate corresponding support plans, so that the intervention timing and intervention content can match the needs of patients at the current phase of disease 9 , 10 . Therefore, based on the five phases of disease development in the TIR framework, this research explore the illness experiences of COVID-19 patients in a longitudinal study to provide a reference for the subsequent care of patients with infectious diseases and the development of epidemic prevention and control strategies.

Design and participants

This study utilized a phenomenological research approach to develop a longitudinal qualitative study using the TIR framework. To conduct a longitudinal qualitative study, it is necessary to select specific time points for data collection, and the chosen time frame should be adequate for observing changes in the phenomenon under investigation 11 . In this study, the time frame for data collection was established through two interviews. The first interview (T1) took place during the period when the infected individuals were isolated, and the second interview (T2) occurred 6 months after their reintegration into society. The study employed a purposive sampling method to select patients who had been diagnosed with COVID-19 and were admitted to an isolation ward in Ningbo City, Zhejiang Province, between January and October 2022. The inclusion criteria were as follows: (1) confirmed COVID-19 infection; (2) age above 18 years; and (3) voluntary participation in this study and providing informed consent. The exclusion criteria were as follows: (1) those who were seriously ill and unable to communicate and (2) those with serious psychological or cognitive dysfunction. Those who automatically withdrew or were lost to follow-up during the interview were dropped from the study. A total of 37 patients were recruited for the study, and the sample size of the study was determined based on information saturation of the interviewees 12 . The specificity of the sampling was measured by demographic characteristics and the Self-Rating Depression Scale (SDS) 13 . Sampling ceased when interviews content saturation was achieved. Finally, 16 cases of representative infected patients were included in the study, including patients with no depression (9 cases, 56%), suspected mild depression (1 case, 6%), and suspected moderate depression (6 cases, 37.5%), numbered "N1" to "N16". In this study, two in-depth interviews were conducted with the infected patients, one during their isolation period and another after 6 months of reintegrating into society. Notably, during the second interview, two of the participants exhibited evasive behavior. For example, one participant was very talkative in the first interview, and he was able to talk more about his true feelings and describe them in more details based on the experience of the illness. However, in the second interview, he spoke less and only answered yes, no or fine, showing an evasive attitude. In order to fully understand the thoughts of the participants and enhance the integrity and continuity of the study, after obtaining informed consent, the interviewer supplemented the interview content by contacting their relatives, and returned the transcript of the interview content to the participants for confirmation, so as to ensure the authenticity of the content. The basic information of the study participants is shown in Table 1 .

Data collection

The participants provided informed consent and completed the demographic scale and SDS scale assessment before the interview. The interview outline was designed according to the five phases of diagnosis, stabilization, preparation, implementation and adaptation in the TIR framework. Longitudinal qualitative studies require researchers to use the insights gained from previous interviews to inform the focus of subsequent data collection 14 . The researcher preinterviewed two infected individuals prior to the formal interview and amended the interview outline. The interview outline was as follows. During Phase 1 (T1), the following questions were asked: ① How did you feel when you were diagnosed with COVID-19? ② What was your initial feeling after arriving at the isolation ward? ③ What are your needs and feelings during hospitalization? ④ How do you feel when you go to the quarantine point for medical observation? ⑤ How will the Spring Festival affect you? ⑥ If you are cured and returned to society, what expectations or concerns do you have? During Phase 2 (T2), the following questions were asked: ① What was your mood at the beginning of reintegration? Give an example of 1–2 things that were particularly impressive at that time. ② How do you feel now? How has your life changed? ③ Is there anything particularly troubling you at present? How do you solve these troubles? Do you have any hopes or suggestions? Due to the requirements of epidemic prevention and control, the interview was conducted by telephone, and the interview time was 15–60 min.

Data analysis

The interview content was analyzed by Colaizzi’s 7-step method. The steps are as follows: (1) two researchers carefully read all the original data; (2) they independently identify significant statements that were repeated by multiple participants and were important and meaningful to the research question; (3) they code repetitive and meaningful views by temporarily "suspending" their assumptions and value judgments; (4) they gather ideas after coding to form the prototype of the theme; (5) they write a detailed typical original description; (6) they identify similar ideas and condense them into themes; and (7) they return the topic structure to the participants for verification. The results of the SDS questionnaire were descriptive statistical analyzed by SPSS 25.0.

Quality control

SDS questionnaire collection: during hospitalization, a researcher issued and collected the questionnaire, explained the questions appropriately, and checked the completeness of the answers on the spot. (2) Interview data collection: all researchers in the study received professional training in qualitative research, and all interview data collection was completed by the first author (isolation ward nurse). The researcher kept in touch with the participants during the follow-up period to establish trust and friendly relationships. The researcher used the daily chat information as supplementary information. At the end of each interview, the researcher transcribed the audio-recorded information within 24 h and recorded the tone of voice, pitch change and other information of the participants. (3) Data analysis: data collection and analysis were carried out in parallel, with each of the 2 researchers listening to the audio-recordings and reading the textual information repeatedly, independently summarizing statements of significance, and summarizing the text of the statements. And the themes and subthemes extracted from the collected data were repeated to the participants by instant messaging software to further confirm whether they had the same feeling or experience and record any possible supplemental information. It was explained to the participants at the first interview that the preliminary results would be reported back to them for verification.

This study was reviewed and approved by the Ethics Committee of Ningbo No.2 Hospital (YJ-NBEY-KY-2022-102-01). All methods were performed in accordance with the relevant guidelines and regulations such as ethical standards of the institutional ethics committee and with the Declaration of Helsinki. All participants signed informed consent forms.

An interpretive understanding of the illness experiences of patients infected with COVID-19 was constructed in this study. The analysis yielded five categories and fifteen sub-categories (Table 2 ).

Theme 1: multiple emotions intertwined at the time of diagnosis

Due to different personality characteristics and understanding of the disease, infected patients showed the following emotional changes in the early stage of diagnosis.

Anxiety: since most infected patients learned about their infection suddenly, most of them had significant fidgeting, irritability, insomnia, and felt inexplicably nervous and worried when they were diagnosed or preparing for medical isolation. N5-T1: "I was so anxious when I was diagnosed that I felt like the sky was falling." N9-T1: "Since that time I have not been able to sleep well at night, I wake up after an hour of sleep." N2-T1: "I felt like it was going by so slowly and every day felt like years. Before the quarantine, I was worried that I wouldn't eat or sleep well, and that was true." Some of the infected patients felt upset when they were first diagnosed, as they received many calls for epidemiological investigations from various departments and organizations. N6-T1: "The initial phase has been very busy. I was the first to be infected, and there was a particular focus on me. At that time, my sleep was disturbed."

Stressful panic: the knowledge that there was no effective treatment, the uncertainty of the sequelae and the possibility of recurrence all put the infected patients in fear of the disease at the time of diagnosis, with three infected patients displaying more pronounced despair. N12-T1: "At that time, I was lying in bed for two days feeling like I was going to die. It was bad anyway. I was scared, scared of the after-effects, scared for my life (emotional)." N9-T1: "[Messages on my mobile phone] made me think nonsense. If the virus in my body had stayed, I would have been locked up forever. It gave me a feeling of panic."

Facing the diagnosis calmly: some of the infected patients were not so afraid of the diagnosis because people around them had already been infected. N1-T1: "The mood was a bit panicky, not particularly panicky. Because my in-laws have already been diagnosed, I already have a general idea in my mind." Some infected patients had a more comprehensive understanding of the corresponding symptoms of infection and were more receptive. N11-T1: "Not afraid of the disease. I have read the news that most of the foreign countries are infected, so I am calm." N3-T1: "It was mild… and curable, so I just didn't have much stress anyway."

Theme 2: multiple pressures during the hospitalization period

When patients were hospitalized, the disease itself, positivity for 2019-nCoV nucleic acid, and the specificity of the isolation environment made them feel deeply stressed.

Concerns about the disease: the threat to COVID-19 patients' lives and safety during hospitalization was stressful for those infected, either because of their own experiences of repositivity or because they witnessed others experiencing repositivity. N11-T1: "The biggest concern was that I didn't know how long it would take to be discharged from the hospital, how long it would take to recover … I didn't know if there were any after effects and whether there would be a relapse." N5-T1: "(After being repositive for the third time) I cried all the time during those 2 days when I was isolated again. The last 2 days were fine, (my mood) calmed down, and today I'm a little bit annoyed again, my wife and my youngest daughter they don't seem to have a good nucleic acid result. That aspect is affecting me a lot, a lot of stress (speaking faster)." N14-T1: "There is a feeling of fear in my heart. This is the first time I've had a repositive, and I've heard that there are a lot of repositive people, and I'm scared in my heart." Due to the special nature of COVID-19 patients, the vast majority of them chose to conceal their condition to avoid worrying about their families. N3-T1: "I didn't dare to make a video call to my mother. I was afraid that if my mother knew I was inside the hospital, she would have to worry about me."

Unable to adapt to the ward environment: most infected patients were transferred to isolation wards for medical observation and treatment, and the unfamiliar and confined environment often made them feel uncomfortable. N4-T1: "It feels unreal to be here, the air is treated and the rooms are airtight." Meanwhile, due to the shortage of beds, most isolation wards housed many people, to which some infected patients are not accustomed, and some infected patients were deeply stressed about secondary infections. N2-T2: "I don't like to sleep with other people in the same room. But, since I was a child, I have been timid and I am afraid to sleep alone. I am not used to sleeping in the hospital." N12-T1: "I was worried about my problems and whether sleeping in the same ward would spread the virus to each other, so I never took off my mask." Isolation also prevents infected patients from spending time with their families. During the festive season, which symbolizes reunion, they had to spend time alone. N10-T1: "The arrival of Chinese New Year had an impact on me. There are so many things I can't do because (I can't) be reunited with my family."

Worrying about future hardship: because the whole family was quarantined or because they themselves were the main laborer in the family, most infected patients reported that the long period of isolation had affected their financial income and were worried about the future. N5-T1: "There has been no income for a few months now, which means that life may be hard in the future." Due to the release of information from epidemiological surveys, infected patients are often worried about having the disease known to their acquaintances. N5-T2: "[The flow survey information] would be better to change that column where the surname is written to a number. Because we are the only ones infected in the factory, it is easy for others to guess." Infectious patients worry about social discrimination brought about by the disease and about whether they will still be able to have a suitable learning environment, job, and residence in the future. N5-T1: "I worry about whether it will affect my youngest daughter's ability to go to a better kindergarten." N10-T1: "I feel that I will not be able to find a job if people know about my disease. … I am sure I will be treated differently." "N2-T1: "We are renting a house outside, the landlord knows about it and may not let us stay in this place. What should we do?"

Theme 3: growth of positive illness experience during the isolation and observation period

Patients were under medical isolation and observation during this period. There is deeper thinking after enduring pressure from all sides, and some patients gain growth.

Sublimated outlook on life. Some infected patients were grateful for the dedication of healthcare workers. N1-T1: "Really, I feel that you are all very good. Doctors have it so hard. I didn't feel it before." Some patients thanked the teachers for caring for their children during the infection. N1-T2: "The teachers and classmates are very caring for my daughter. In particular, her class teacher was really nice. There was no one to look after her when she first came out (family members were quarantined for infection). My daughter was alone at home, and I was worried. Her teacher let my daughter go to her house. The teacher said I am not afraid." Some infected patients also said that during the isolation period, they had time to calm down and question their souls and thought more about life. N6-T1: "Actually, when I was in the isolation ward, I had more time and space to think, and then I might think more deeply about something, like the meaning of life. I would find so many things that I just naturally realized."

Affirmation of the government's anti-epidemic policy. N6-T1: "I think our government departments are very committed because our national situation is different from that of foreign countries, with a large population. If our country really doesn't care about controlling the epidemic at all, the medical resources can't keep up." N9-T1: "I fully comply with the rules and regulations of the isolation ward. The country invests a lot of resources. We eat and live medically for free."

More concerned about their own health. The experience of falling ill has made more patients pay more attention to their own health, and they actively participate in sports and pay attention to physical checkups and rest. N11-T1: "It's better to have a medical checkup to see if this virus has any other effects on your body. In the future, I will have regular medical check-ups once every six months or a year. Now, I also started to run (during the quarantine phase), I didn't run much before."

Theme 4: adjustment after returning to society

The infected often return to society in a state of fear and with a deep sense of stigma. Some infected patients have lost their former jobs and living environments, and their finances and lives have been greatly affected. At the same time, the nucleic acid test also brought troubles to their lives after returning to society.

Stigma: infected patients often have a heavy self-psychological burden when they return to society. They are afraid of being rejected and treated differently. The main manifestations are fear of stigma and concealment of medical history. N1-T2: "We definitely have to report to the community when we go back. We have to explain the situation. After explaining the situation, the people in the village will be scared to death, they will ostracize them (brother, parents), and then it will definitely have an impact on my parents and my brother's lives, so we didn't dare to go back." Some infected patients were worried that they would cause others to become infected, causing them to be quarantined as well. N16-T1: "I'm worried that if I go back to being positive in the future, I will infect others, even if it doesn't hurt, will I have to quarantine people for so many days?" With the shame of the disease, many infected patients were unable to go home to their families. N1-T2: "I would love to go back to my hometown. Because my parents are also 70 years old, and I can't take care of them when I'm out of town. But, now I can't go back to my hometown."

Loss of previous living environment. Some infected patients lost their original living and working environments after returning to society. Some COVID-19 patients moved away from their original environments of their own initiative because they were afraid that others would know that they had been infected by COVID-19. N1-T2: "We moved home. But, we are still afraid of bumping into people we know: "Some infected patients were asked not to go to work or to change their working environments for fear of mutual infection in their workplaces. N2-T2: "We were not allowed to go to work in the factory at that time because the other employees didn't agree to let us go to work." N9-T2: "She used to work in Department 5, but the original department didn't want her anymore." A new environment means a new start, which leads to greater pressure on the lives of infected patients. N1-T2: The pressure on my husband's life is too great. I also went to look for a job. After looking for a few days, I felt very sad and found that I could only do more flexible work like takeaway. Life is difficult, we've borrowed a lot of money now, and there's a lot of financial pressure and mental stress."

Problems caused by nucleic acid testing. Because of previous infections, policies require infected patients to have a separate nucleic acid test. This often meant that they had to spend time and effort looking for a separate site where they could do a separate nucleic acid test. N1-T2: "My child can't do a separate nucleic acid test at school anyway, so we have to find a nucleic acid test site by ourselves." When doing the nucleic acid test alone, they were split into two teams, separate from the people doing the mixed nucleic acid test, and the people in their team were faced with more inquiries about infection, which put more pressure on them." N1-T2: "When we went to do the nucleic acid test, the security guard at the door asked once, then the person who checked the identity after the questioning asked again, and the sampler asked again. I had nightmares every day." In addition, they were concerned that doing the nucleic acid test alone would increase the risk of reinfection. N5-T2: "When we do the nucleic acid test alone, we are with people who are at high risk. The book they have registered in we touch it again, register it again and go with them. If I get infected again, I reckon I'm going to go mad." Because of the fear of repositivity, infected patients are extremely concerned about the results of their own and their family's nucleic acid tests." N3-T2: "To be honest, some people, like my wife, have repeated repositive and go to quarantine sites over and over again. Very upset and depressed. I'm worried about my own and my wife's nucleic acid test results."

Theme 5: adaptation to social life

Six months after returning to society, most of the infected patients returned to normal life with the support and tolerance of society, but some of them still avoided infection and concealed their status as recovered persons. Some of the infected patients developed post-COVID-19 syndrome.

Return to normal life. Some infected patients integrated into society with the tolerance of colleagues and friends around them. N2-T2: "Still working as normal. My friends and I still play well and sit together for meals." N8-T2: "I was a bit afraid that my colleagues would laugh at me in various ways before I came to work. But, none of them did." Nucleic acid testing is also gradually becoming less frequent. N7-T2: "In the beginning, it was a single test, now it's all mixed." Some infected patients said that they no longer avoided the fact that they were infected under self-regulation and gradually returned to normal life. T12-N2: "When I first came out of quarantine, whenever people talked about this stuff, I wanted to avoid it and didn't want to hear about it. Now, when people talk about doing nucleic acids, I seem to slowly be able to accept it."

Avoidance of illness experience. Some infected patients still avoided infection and concealed their identities as a recovered person. N16-T2 Husband added: "Whoever mentions this, she is anxious about it. Some old folks called me and asked about this, and she was also a little anxious in her heart. There is nervousness in her heart, and she doesn't want to talk about it anymore." During the interview with N5-T2, the infected patient herself said, "I don't feel anything, it doesn't affect me at the moment. Everything is fine. Don't want to think about it." However, interviewing his lover, he said, "He used to look like a child, he used to laugh and joke around, but now he looks sad every day. He doesn't talk much in his free time." This experience has changed his personality.

Post-COVID-19 syndrome. Some infected patients still have residual weakness, chest tightness, loss of smell, sleep disorders, etc. N14-T2: "The body is a bit different anyway. I'm more tired than I used to be at work, and I'm not as fit as I used to be. Sleep has been bad, easy to wake up. I have no sense of smell." N15-T2: "I feel a bit breathless sometimes when I walk a few steps. I feel tired."

This study conducted a longitudinal exploration of COVID-19 patients' experience based on the TIR framework. In general, the TIR framework has played a good guiding role in the exploration of COVID-19 patients' illness experience. During the diagnosis phase, COVID-19 patients were usually very concerned about their own health problems, and due to great pressure caused by isolation, they were prone to psychological problems. The stabilization and preparation phase of COVID-19 patients were in the long isolation treatment. Patients gradually adapted to isolation treatment and started to plan their life after discharge. They were worried about discrimination and worried that they would never go back to the original life. In addition, because COVID-19 patients were kept in isolation for a long time, some patients began to reflect on the experience of the disease and the past life status, and thus gained growth. The stigma of COVID-19 patients was felt throughout the course of the illness, but it was particularly evident during the implementation and adaptation phase. Due to the stigma and discrimination, some patients actually made great changes to their work and life during this two phase. At this time, social support was particularly important for patients to reintegrate into society. The following discussion provides detailed analysis of the above phenomena.

The results of this study showed that all infected patients diagnosed for the first time had psychological problems such as anxiety, fear, and sleep disorders, and seven patients (43.75%) were suspected of having mild to moderate depression according to the SDS scores, which is similar to the results of the study by Deng et al. 15 . This may be due to the highly contagious nature of COVID-19 and the lack of specific treatment, resulting in infected patients being prone to excessive stress, panic, and even psychological stress disorder at the early stage of diagnosis 16 . At the same time, 14 cases (87.5%) of the infected patients expressed concern about the possibility of "repositivity" after recovery and the existence of sequelae. A related study found that noninfectious viral RNA persisted in most of the "repositive" cases, which may be due to slow disease regression 17 . A positive test does not always mean that the patient is infectious, as it may detect fragments of viral nucleic acid 18 . However, most patients know little about this and develop more anxiety and fear. In contrast, those patients who have knowledge of the new coronavirus tend to have less fear and worry. Cheng Hualing et al. 19 meta-integrated the psychological experience of COVID-19 patients in China and found that more information provided by medical personnel to infected patients about the treatment and prognosis of the disease could eliminate the anxiety caused by the patients' lack of knowledge. Therefore, health promotion should be strengthened, and patients should be encouraged to acquire knowledge of the disease in various aspects, including transmission channels, protective measures, symptom classification, prognosis, etc. Patients’ questions should be patiently answered based on their own conditions, and they should be encouraged to obtain correct information through official authoritative channels to avoid "information panic" 20 .

Four infected patients (25%) in this study indicated that the relatively confined environment and instruments in the isolation area caused feelings of loneliness and helplessness. The isolation treatment measures separated the patients from the outside world, as they left their familiar working and living environments to enter a state of isolation, confinement and monotony. The patients' original lifestyles were completely disrupted, and certain financial losses were incurred. The unfamiliar environment and medical equipment increased the patients' fear and loneliness while also hindering the discharge of their negative emotions. This is consistent with the findings of Wang et al. 20 and Shaban et al. 21 . A retrospective study 22 found that isolation may cause unexpected mental trauma for patients and may even lead to self-injurious behaviors such as suicide. These effects persisted 3 years after desegregation. Psychological disorders can lead to low immunity and reduced motivation for treatment, thus negatively affecting disease recovery 23 . Currently, the treatment and care of patients in isolation wards are mainly focused on the disease itself, with relatively little attention given to the physical and psychological effects of isolation. Improving the treatment environment in isolation areas, providing as much stimulation as possible during the normal routine of work and rest, establishing a good lifestyle, and diversifying hospital activities are of great significance in relieving emotional tension, breaking psychological barriers, and promoting disease recovery 24 . Studies have shown that having sufficient sunlight is particularly effective for psychological relief 25 . Isolation areas should be set up to face south, and lighting measures should be strengthened. Public corridors can be set up in the isolation area so that infected patients can stagger their activities appropriately. Healthcare workers who are fully "armed" can paste their names on their protective clothing to improve communication between doctors and patients and reduce patients' sense of isolation. There are also studies 26 suggesting the use of the Rosenthal effect, that is, using praise, trust and expectation, and other psychological hints to help patients regain confidence and obtain positive motivation to change their own behaviors. By communicating with patients to understand their psychological needs, sources of negative emotions and specific factors affecting their emotions, healthcare professionals, in collaboration with teams from various disciplines, can encourage infected patients to cope positively and provide social support and psychological guidance to improve their quality of life 27 . The patients in this study were often in a state of confusion and worry before discharge and were also often unable to adjust to a good rhythm of life within a short period after discharge. Healthcare professionals can help patients develop a postdischarge transition plan during inpatient isolation so that they can quickly return to their original lives. At the same time, a scale of social reintegration behavior of infected patients with infectious diseases that is suitable for our country should be developed to prospectively investigate the current status of social reintegration of infected patients and to understand the changes in social reintegration behaviors in different periods to take corresponding measures to help such people adapt to their situations as soon as possible.

As a contagious disease, COVID-19 can lead to fear among the population as well as stigma and discrimination against specific groups of people 28 , and patients develop a sense of shame about their illness as a result. The results of this study show that patients often want to keep their experience of the disease confidential. The vast majority of infected patients in this study chose to conceal their illness from their family members. Due to the existence of a sense of shame, patients not only kept their disease experience secret but also often consciously reduced their mobility after discharge from the hospital to avoid infecting others. Patients may actively distance themselves from their friends and relatives, resulting in the loss of an important source of social support and a sense of isolation 29 . There were also patients who did not actively conceal their condition, but friends and colleagues of the infected patients intentionally chose to distance themselves from the infected patients out of fear and rejection after learning of their condition. Six patients (37.5%) in this study were thus forced to leave their original places of residence or work, causing them to develop more negative emotions. On the other hand, the infected patients who indicated that their colleagues and friends treated them no differently than before reported that they resumed normal life more quickly after returning to society. Yuan et al. 19 showed that the social support system of infected patients is an important factor in their posttraumatic growth. Social support based on kinship is the main way for most Chinese people to obtain social support. If this basic relationship is damaged, it prevents infected patients from obtaining the understanding and support of others, which can have a great impact on their physical and mental health 30 . The establishment of a good social support system will enhance psychological health; in contrast, the accumulation of negative emotions will lead to a variety of psychological problems 31 . Healthcare workers in the diagnosis and treatment of COVID-19 patients not only need to give the necessary treatment measures but also need to comprehensively assess the degree of understanding of the disease and social support system of infected patients. Healthcare workers should encourage infected patients to inform their families of their illnesses through daily communication, collaborate with their families to provide relevant psychological care, and improve the level of posttraumatic growth of patients 32 . In addition, the limitations of the public's knowledge of the disease will increase the individual's self-psychological burden, which will deepen the self-perception and experience of public stigma, resulting in the internalization of stigma 33 . Therefore, it is necessary to strengthen the information dissemination of infectious diseases, set up relevant policies for social groups such as communities and companies to avoid the public's rough treatment of infected patients returning to society, to protect the normal work and lives of infected patients and to reduce economic losses. This study shows that the policy benefits given by the government make infected patients believe in the national epidemic prevention policy and thus have confidence in the diagnosis and treatment of the disease. Therefore, state policy supports the reintegration of COVID-19 patients into society through macrocontrol.

Six months after returning to the community, some of the patients in this study still had sequelae of COVID-19, such as malaise, insomnia, chest tightness, and loss of smell. A recent study published in The Lancet 34 also confirmed this phenomenon. Similar studies have shown that the acute phase of COVID-19 and subsequent health damage involves multiple systems, such as the respiratory, neurological, and cardiovascular systems 18 . Given that infected patients at this stage need professional guidance to avoid delaying their illness, we call for greater collaboration among scholars from different countries to share experiences in the treatment of the disease to improve the physical and mental health of the population in the face of the postinfection syndrome caused by the global pandemic of COVID-19 patients.

This study found that there is a lack of clarity in the division of labor between departments and duplication of investigations by various departments in the process of epidemiological investigation.. It is recommended that the relevant departments should strengthen the integration and sharing of information by using big data and increase training in epidemiological investigation to improve efficiency 26 . Knowing the benefits of epidemiological investigation and personal information protection can reduce the uneasiness of infected patients, it is recommended that the media increase the scientific knowledge of epidemiological investigations and, at the same time, hide patients’ last names in the publication of epidemiological investigation information to protect the privacy of infected patients, and prohibit malicious human searches and other behaviors.

Limitations

While the study has its merits, it also has its limitations. First, this study interviewed COVID-19 patients only in Ningbo and did not include patients from multiple regions and centers. Second, this study was conducted during the control phase of the epidemic in China, and except for filling out the SDS scale, which was face-to-face, both interviews were conducted over the phone, and preventing the use of visual aids.

Conclusions

The objective of this study was to explore the perceptions and comprehension of patients infected with COVID-19 during the Chinese new coronavirus epidemic. COVID-19 patients encounter numerous psychological challenges while simultaneously experiencing physical discomfort, isolation, a sense of shame, and uncertainty regarding recovery. While some patients eventually adapt to their circumstances, not all are able to do so. Therefore, it is crucial for healthcare providers and families to provide support in order to facilitate patient adjustment to normal life. Interventions should be tailored according to the specific needs of patients at different stages, informing subsequent optimization of care and management strategies for infectious diseases.

Data availability

The datasets generated and analysed during the current study are not publicly available due privacy protection but are available from the corresponding author on reasonable request.

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This research was supported by Medical Scientific Research Foundation of Zhejiang Province under Grant No. 2023KY1091; Zhejiang Provincial Natural Science Foundation of China under Grant No. LY22H160006.

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Liangyan Zhang & Kesang Li

Intensive Care Unit, Ningbo No. 2 Hospital, Ningbo, Zhejiang, China

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Liangyan Zhang organized interviews and collected the data. Liangyan Zhang and Chen Zhang analyzed the data and wrote the main manuscript text. All authors reviewed the manuscript.

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Zhang, L., Zhang, C., Li, K. et al. Longitudinal qualitative study on the psychological experiences of COVID-19 patients based on timing it right framework. Sci Rep 14 , 12409 (2024). https://doi.org/10.1038/s41598-024-63215-4

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Received : 17 December 2023

Accepted : 27 May 2024

Published : 30 May 2024

DOI : https://doi.org/10.1038/s41598-024-63215-4

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