case study interview research

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

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

Research question

• Conceptual framework
• Conceptual vs. theoretical framework

Data collection

• Qualitative research methods
• Focus groups
• Observational research

What is a case study?

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

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

Case studies

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

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

Definition of a case study

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

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

Characteristics of case studies

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

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

The role of case studies in research

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

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

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

What is the purpose of a case study?

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

Why use case studies in qualitative research?

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

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

The explanatory, exploratory, and descriptive roles of case studies

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

The impact of case studies on knowledge development

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

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

Types of case studies

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

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

Exploratory case studies

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

Descriptive case studies

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

Explanatory case studies

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

Intrinsic, instrumental, and collective case studies

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

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

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

Critical information systems research

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

Health research

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

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

Asthma research studies

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

Other fields

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

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

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

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

Propositions

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

Units of analysis

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

Argumentation

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

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

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

Defining the research question

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

Selecting and defining the case

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

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

Developing a detailed case study protocol

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

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

Collecting data

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

Analyzing and interpreting data

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

Writing the case study report

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

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

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

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

Observations

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

Documents and artifacts

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

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

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

Ensuring the quality of data collection

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

Data analysis

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

Organizing the data

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

Categorizing and coding the data

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

Identifying patterns and themes

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

Interpreting the data

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

Verification of the data

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

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

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

Benefits include the following:

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

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

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

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

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Case Study – Methods, Examples and Guide

Table of Contents

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

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

Types of Case Study

Types and Methods of Case Study are as follows:

Single-Case Study

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

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

Multiple-Case Study

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

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

Exploratory Case Study

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

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

Descriptive Case Study

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

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

Instrumental Case Study

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

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

Case Study Data Collection Methods

Here are some common data collection methods for case studies:

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

Observations

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

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

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

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

How to conduct Case Study Research

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

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

Examples of Case Study

Here are some examples of case study research:

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

Application of Case Study

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

Business and Management

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

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

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

Social Sciences

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

Law and Ethics

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

Purpose of Case Study

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

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

Case studies can also serve other purposes, including:

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

Advantages of Case Study Research

There are several advantages of case study research, including:

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

Limitations of Case Study Research

There are several limitations of case study research, including:

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

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Muhammad Hassan

Researcher, Academic Writer, Web developer

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• Published: 05 October 2018

Interviews and focus groups in qualitative research: an update for the digital age

• P. Gill 1 &
• J. Baillie 2  

British Dental Journal volume  225 ,  pages 668–672 ( 2018 ) Cite this article

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Highlights that qualitative research is used increasingly in dentistry. Interviews and focus groups remain the most common qualitative methods of data collection.

Suggests the advent of digital technologies has transformed how qualitative research can now be undertaken.

Suggests interviews and focus groups can offer significant, meaningful insight into participants' experiences, beliefs and perspectives, which can help to inform developments in dental practice.

Qualitative research is used increasingly in dentistry, due to its potential to provide meaningful, in-depth insights into participants' experiences, perspectives, beliefs and behaviours. These insights can subsequently help to inform developments in dental practice and further related research. The most common methods of data collection used in qualitative research are interviews and focus groups. While these are primarily conducted face-to-face, the ongoing evolution of digital technologies, such as video chat and online forums, has further transformed these methods of data collection. This paper therefore discusses interviews and focus groups in detail, outlines how they can be used in practice, how digital technologies can further inform the data collection process, and what these methods can offer dentistry.

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Introduction.

Traditionally, research in dentistry has primarily been quantitative in nature. 1 However, in recent years, there has been a growing interest in qualitative research within the profession, due to its potential to further inform developments in practice, policy, education and training. Consequently, in 2008, the British Dental Journal (BDJ) published a four paper qualitative research series, 2 , 3 , 4 , 5 to help increase awareness and understanding of this particular methodological approach.

Since the papers were originally published, two scoping reviews have demonstrated the ongoing proliferation in the use of qualitative research within the field of oral healthcare. 1 , 6 To date, the original four paper series continue to be well cited and two of the main papers remain widely accessed among the BDJ readership. 2 , 3 The potential value of well-conducted qualitative research to evidence-based practice is now also widely recognised by service providers, policy makers, funding bodies and those who commission, support and use healthcare research.

Besides increasing standalone use, qualitative methods are now also routinely incorporated into larger mixed method study designs, such as clinical trials, as they can offer additional, meaningful insights into complex problems that simply could not be provided by quantitative methods alone. Qualitative methods can also be used to further facilitate in-depth understanding of important aspects of clinical trial processes, such as recruitment. For example, Ellis et al . investigated why edentulous older patients, dissatisfied with conventional dentures, decline implant treatment, despite its established efficacy, and frequently refuse to participate in related randomised clinical trials, even when financial constraints are removed. 7 Through the use of focus groups in Canada and the UK, the authors found that fears of pain and potential complications, along with perceived embarrassment, exacerbated by age, are common reasons why older patients typically refuse dental implants. 7

The last decade has also seen further developments in qualitative research, due to the ongoing evolution of digital technologies. These developments have transformed how researchers can access and share information, communicate and collaborate, recruit and engage participants, collect and analyse data and disseminate and translate research findings. 8 Where appropriate, such technologies are therefore capable of extending and enhancing how qualitative research is undertaken. 9 For example, it is now possible to collect qualitative data via instant messaging, email or online/video chat, using appropriate online platforms.

These innovative approaches to research are therefore cost-effective, convenient, reduce geographical constraints and are often useful for accessing 'hard to reach' participants (for example, those who are immobile or socially isolated). 8 , 9 However, digital technologies are still relatively new and constantly evolving and therefore present a variety of pragmatic and methodological challenges. Furthermore, given their very nature, their use in many qualitative studies and/or with certain participant groups may be inappropriate and should therefore always be carefully considered. While it is beyond the scope of this paper to provide a detailed explication regarding the use of digital technologies in qualitative research, insight is provided into how such technologies can be used to facilitate the data collection process in interviews and focus groups.

In light of such developments, it is perhaps therefore timely to update the main paper 3 of the original BDJ series. As with the previous publications, this paper has been purposely written in an accessible style, to enhance readability, particularly for those who are new to qualitative research. While the focus remains on the most common qualitative methods of data collection – interviews and focus groups – appropriate revisions have been made to provide a novel perspective, and should therefore be helpful to those who would like to know more about qualitative research. This paper specifically focuses on undertaking qualitative research with adult participants only.

Overview of qualitative research

Qualitative research is an approach that focuses on people and their experiences, behaviours and opinions. 10 , 11 The qualitative researcher seeks to answer questions of 'how' and 'why', providing detailed insight and understanding, 11 which quantitative methods cannot reach. 12 Within qualitative research, there are distinct methodologies influencing how the researcher approaches the research question, data collection and data analysis. 13 For example, phenomenological studies focus on the lived experience of individuals, explored through their description of the phenomenon. Ethnographic studies explore the culture of a group and typically involve the use of multiple methods to uncover the issues. 14

While methodology is the 'thinking tool', the methods are the 'doing tools'; 13 the ways in which data are collected and analysed. There are multiple qualitative data collection methods, including interviews, focus groups, observations, documentary analysis, participant diaries, photography and videography. Two of the most commonly used qualitative methods are interviews and focus groups, which are explored in this article. The data generated through these methods can be analysed in one of many ways, according to the methodological approach chosen. A common approach is thematic data analysis, involving the identification of themes and subthemes across the data set. Further information on approaches to qualitative data analysis has been discussed elsewhere. 1

Qualitative research is an evolving and adaptable approach, used by different disciplines for different purposes. Traditionally, qualitative data, specifically interviews, focus groups and observations, have been collected face-to-face with participants. In more recent years, digital technologies have contributed to the ongoing evolution of qualitative research. Digital technologies offer researchers different ways of recruiting participants and collecting data, and offer participants opportunities to be involved in research that is not necessarily face-to-face.

Research interviews are a fundamental qualitative research method 15 and are utilised across methodological approaches. Interviews enable the researcher to learn in depth about the perspectives, experiences, beliefs and motivations of the participant. 3 , 16 Examples include, exploring patients' perspectives of fear/anxiety triggers in dental treatment, 17 patients' experiences of oral health and diabetes, 18 and dental students' motivations for their choice of career. 19

Interviews may be structured, semi-structured or unstructured, 3 according to the purpose of the study, with less structured interviews facilitating a more in depth and flexible interviewing approach. 20 Structured interviews are similar to verbal questionnaires and are used if the researcher requires clarification on a topic; however they produce less in-depth data about a participant's experience. 3 Unstructured interviews may be used when little is known about a topic and involves the researcher asking an opening question; 3 the participant then leads the discussion. 20 Semi-structured interviews are commonly used in healthcare research, enabling the researcher to ask predetermined questions, 20 while ensuring the participant discusses issues they feel are important.

Interviews can be undertaken face-to-face or using digital methods when the researcher and participant are in different locations. Audio-recording the interview, with the consent of the participant, is essential for all interviews regardless of the medium as it enables accurate transcription; the process of turning the audio file into a word-for-word transcript. This transcript is the data, which the researcher then analyses according to the chosen approach.

Types of interview

Qualitative studies often utilise one-to-one, face-to-face interviews with research participants. This involves arranging a mutually convenient time and place to meet the participant, signing a consent form and audio-recording the interview. However, digital technologies have expanded the potential for interviews in research, enabling individuals to participate in qualitative research regardless of location.

Telephone interviews can be a useful alternative to face-to-face interviews and are commonly used in qualitative research. They enable participants from different geographical areas to participate and may be less onerous for participants than meeting a researcher in person. 15 A qualitative study explored patients' perspectives of dental implants and utilised telephone interviews due to the quality of the data that could be yielded. 21 The researcher needs to consider how they will audio record the interview, which can be facilitated by purchasing a recorder that connects directly to the telephone. One potential disadvantage of telephone interviews is the inability of the interviewer and researcher to see each other. This is resolved using software for audio and video calls online – such as Skype – to conduct interviews with participants in qualitative studies. Advantages of this approach include being able to see the participant if video calls are used, enabling observation of non-verbal communication, and the software can be free to use. However, participants are required to have a device and internet connection, as well as being computer literate, potentially limiting who can participate in the study. One qualitative study explored the role of dental hygienists in reducing oral health disparities in Canada. 22 The researcher conducted interviews using Skype, which enabled dental hygienists from across Canada to be interviewed within the research budget, accommodating the participants' schedules. 22

A less commonly used approach to qualitative interviews is the use of social virtual worlds. A qualitative study accessed a social virtual world – Second Life – to explore the health literacy skills of individuals who use social virtual worlds to access health information. 23 The researcher created an avatar and interview room, and undertook interviews with participants using voice and text methods. 23 This approach to recruitment and data collection enables individuals from diverse geographical locations to participate, while remaining anonymous if they wish. Furthermore, for interviews conducted using text methods, transcription of the interview is not required as the researcher can save the written conversation with the participant, with the participant's consent. However, the researcher and participant need to be familiar with how the social virtual world works to engage in an interview this way.

Conducting an interview

Ensuring informed consent before any interview is a fundamental aspect of the research process. Participants in research must be afforded autonomy and respect; consent should be informed and voluntary. 24 Individuals should have the opportunity to read an information sheet about the study, ask questions, understand how their data will be stored and used, and know that they are free to withdraw at any point without reprisal. The qualitative researcher should take written consent before undertaking the interview. In a face-to-face interview, this is straightforward: the researcher and participant both sign copies of the consent form, keeping one each. However, this approach is less straightforward when the researcher and participant do not meet in person. A recent protocol paper outlined an approach for taking consent for telephone interviews, which involved: audio recording the participant agreeing to each point on the consent form; the researcher signing the consent form and keeping a copy; and posting a copy to the participant. 25 This process could be replicated in other interview studies using digital methods.

There are advantages and disadvantages of using face-to-face and digital methods for research interviews. Ultimately, for both approaches, the quality of the interview is determined by the researcher. 16 Appropriate training and preparation are thus required. Healthcare professionals can use their interpersonal communication skills when undertaking a research interview, particularly questioning, listening and conversing. 3 However, the purpose of an interview is to gain information about the study topic, 26 rather than offering help and advice. 3 The researcher therefore needs to listen attentively to participants, enabling them to describe their experience without interruption. 3 The use of active listening skills also help to facilitate the interview. 14 Spradley outlined elements and strategies for research interviews, 27 which are a useful guide for qualitative researchers:

Greeting and explaining the project/interview

Asking descriptive (broad), structural (explore response to descriptive) and contrast (difference between) questions

Asymmetry between the researcher and participant talking

Expressing interest and cultural ignorance

Repeating, restating and incorporating the participant's words when asking questions

Creating hypothetical situations

Asking friendly questions

Knowing when to leave.

For semi-structured interviews, a topic guide (also called an interview schedule) is used to guide the content of the interview – an example of a topic guide is outlined in Box 1 . The topic guide, usually based on the research questions, existing literature and, for healthcare professionals, their clinical experience, is developed by the research team. The topic guide should include open ended questions that elicit in-depth information, and offer participants the opportunity to talk about issues important to them. This is vital in qualitative research where the researcher is interested in exploring the experiences and perspectives of participants. It can be useful for qualitative researchers to pilot the topic guide with the first participants, 10 to ensure the questions are relevant and understandable, and amending the questions if required.

Regardless of the medium of interview, the researcher must consider the setting of the interview. For face-to-face interviews, this could be in the participant's home, in an office or another mutually convenient location. A quiet location is preferable to promote confidentiality, enable the researcher and participant to concentrate on the conversation, and to facilitate accurate audio-recording of the interview. For interviews using digital methods the same principles apply: a quiet, private space where the researcher and participant feel comfortable and confident to participate in an interview.

Box 1: Example of a topic guide

Study focus: Parents' experiences of brushing their child's (aged 0–5) teeth

1. Can you tell me about your experience of cleaning your child's teeth?

How old was your child when you started cleaning their teeth?

Why did you start cleaning their teeth at that point?

How often do you brush their teeth?

What do you use to brush their teeth and why?

2. Could you explain how you find cleaning your child's teeth?

Do you find anything difficult?

What makes cleaning their teeth easier for you?

3. How has your experience of cleaning your child's teeth changed over time?

Has it become easier or harder?

Have you changed how often and how you clean their teeth? If so, why?

4. Could you describe how your child finds having their teeth cleaned?

What do they enjoy about having their teeth cleaned?

Is there anything they find upsetting about having their teeth cleaned?

5. Where do you look for information/advice about cleaning your child's teeth?

What did your health visitor tell you about cleaning your child's teeth? (If anything)

What has the dentist told you about caring for your child's teeth? (If visited)

Have any family members given you advice about how to clean your child's teeth? If so, what did they tell you? Did you follow their advice?

6. Is there anything else you would like to discuss about this?

Focus groups

A focus group is a moderated group discussion on a pre-defined topic, for research purposes. 28 , 29 While not aligned to a particular qualitative methodology (for example, grounded theory or phenomenology) as such, focus groups are used increasingly in healthcare research, as they are useful for exploring collective perspectives, attitudes, behaviours and experiences. Consequently, they can yield rich, in-depth data and illuminate agreement and inconsistencies 28 within and, where appropriate, between groups. Examples include public perceptions of dental implants and subsequent impact on help-seeking and decision making, 30 and general dental practitioners' views on patient safety in dentistry. 31

Focus groups can be used alone or in conjunction with other methods, such as interviews or observations, and can therefore help to confirm, extend or enrich understanding and provide alternative insights. 28 The social interaction between participants often results in lively discussion and can therefore facilitate the collection of rich, meaningful data. However, they are complex to organise and manage, due to the number of participants, and may also be inappropriate for exploring particularly sensitive issues that many participants may feel uncomfortable about discussing in a group environment.

Focus groups are primarily undertaken face-to-face but can now also be undertaken online, using appropriate technologies such as email, bulletin boards, online research communities, chat rooms, discussion forums, social media and video conferencing. 32 Using such technologies, data collection can also be synchronous (for example, online discussions in 'real time') or, unlike traditional face-to-face focus groups, asynchronous (for example, online/email discussions in 'non-real time'). While many of the fundamental principles of focus group research are the same, regardless of how they are conducted, a number of subtle nuances are associated with the online medium. 32 Some of which are discussed further in the following sections.

Focus group considerations

Some key considerations associated with face-to-face focus groups are: how many participants are required; should participants within each group know each other (or not) and how many focus groups are needed within a single study? These issues are much debated and there is no definitive answer. However, the number of focus groups required will largely depend on the topic area, the depth and breadth of data needed, the desired level of participation required 29 and the necessity (or not) for data saturation.

The optimum group size is around six to eight participants (excluding researchers) but can work effectively with between three and 14 participants. 3 If the group is too small, it may limit discussion, but if it is too large, it may become disorganised and difficult to manage. It is, however, prudent to over-recruit for a focus group by approximately two to three participants, to allow for potential non-attenders. For many researchers, particularly novice researchers, group size may also be informed by pragmatic considerations, such as the type of study, resources available and moderator experience. 28 Similar size and mix considerations exist for online focus groups. Typically, synchronous online focus groups will have around three to eight participants but, as the discussion does not happen simultaneously, asynchronous groups may have as many as 10–30 participants. 33

The topic area and potential group interaction should guide group composition considerations. Pre-existing groups, where participants know each other (for example, work colleagues) may be easier to recruit, have shared experiences and may enjoy a familiarity, which facilitates discussion and/or the ability to challenge each other courteously. 3 However, if there is a potential power imbalance within the group or if existing group norms and hierarchies may adversely affect the ability of participants to speak freely, then 'stranger groups' (that is, where participants do not already know each other) may be more appropriate. 34 , 35

Focus group management

Face-to-face focus groups should normally be conducted by two researchers; a moderator and an observer. 28 The moderator facilitates group discussion, while the observer typically monitors group dynamics, behaviours, non-verbal cues, seating arrangements and speaking order, which is essential for transcription and analysis. The same principles of informed consent, as discussed in the interview section, also apply to focus groups, regardless of medium. However, the consent process for online discussions will probably be managed somewhat differently. For example, while an appropriate participant information leaflet (and consent form) would still be required, the process is likely to be managed electronically (for example, via email) and would need to specifically address issues relating to technology (for example, anonymity and use, storage and access to online data). 32

The venue in which a face to face focus group is conducted should be of a suitable size, private, quiet, free from distractions and in a collectively convenient location. It should also be conducted at a time appropriate for participants, 28 as this is likely to promote attendance. As with interviews, the same ethical considerations apply (as discussed earlier). However, online focus groups may present additional ethical challenges associated with issues such as informed consent, appropriate access and secure data storage. Further guidance can be found elsewhere. 8 , 32

Before the focus group commences, the researchers should establish rapport with participants, as this will help to put them at ease and result in a more meaningful discussion. Consequently, researchers should introduce themselves, provide further clarity about the study and how the process will work in practice and outline the 'ground rules'. Ground rules are designed to assist, not hinder, group discussion and typically include: 3 , 28 , 29

Discussions within the group are confidential to the group

Only one person can speak at a time

All participants should have sufficient opportunity to contribute

There should be no unnecessary interruptions while someone is speaking

Everyone can be expected to be listened to and their views respected

Challenging contrary opinions is appropriate, but ridiculing is not.

Moderating a focus group requires considered management and good interpersonal skills to help guide the discussion and, where appropriate, keep it sufficiently focused. Avoid, therefore, participating, leading, expressing personal opinions or correcting participants' knowledge 3 , 28 as this may bias the process. A relaxed, interested demeanour will also help participants to feel comfortable and promote candid discourse. Moderators should also prevent the discussion being dominated by any one person, ensure differences of opinions are discussed fairly and, if required, encourage reticent participants to contribute. 3 Asking open questions, reflecting on significant issues, inviting further debate, probing responses accordingly, and seeking further clarification, as and where appropriate, will help to obtain sufficient depth and insight into the topic area.

Moderating online focus groups requires comparable skills, particularly if the discussion is synchronous, as the discussion may be dominated by those who can type proficiently. 36 It is therefore important that sufficient time and respect is accorded to those who may not be able to type as quickly. Asynchronous discussions are usually less problematic in this respect, as interactions are less instant. However, moderating an asynchronous discussion presents additional challenges, particularly if participants are geographically dispersed, as they may be online at different times. Consequently, the moderator will not always be present and the discussion may therefore need to occur over several days, which can be difficult to manage and facilitate and invariably requires considerable flexibility. 32 It is also worth recognising that establishing rapport with participants via online medium is often more challenging than via face-to-face and may therefore require additional time, skills, effort and consideration.

As with research interviews, focus groups should be guided by an appropriate interview schedule, as discussed earlier in the paper. For example, the schedule will usually be informed by the review of the literature and study aims, and will merely provide a topic guide to help inform subsequent discussions. To provide a verbatim account of the discussion, focus groups must be recorded, using an audio-recorder with a good quality multi-directional microphone. While videotaping is possible, some participants may find it obtrusive, 3 which may adversely affect group dynamics. The use (or not) of a video recorder, should therefore be carefully considered.

At the end of the focus group, a few minutes should be spent rounding up and reflecting on the discussion. 28 Depending on the topic area, it is possible that some participants may have revealed deeply personal issues and may therefore require further help and support, such as a constructive debrief or possibly even referral on to a relevant third party. It is also possible that some participants may feel that the discussion did not adequately reflect their views and, consequently, may no longer wish to be associated with the study. 28 Such occurrences are likely to be uncommon, but should they arise, it is important to further discuss any concerns and, if appropriate, offer them the opportunity to withdraw (including any data relating to them) from the study. Immediately after the discussion, researchers should compile notes regarding thoughts and ideas about the focus group, which can assist with data analysis and, if appropriate, any further data collection.

Qualitative research is increasingly being utilised within dental research to explore the experiences, perspectives, motivations and beliefs of participants. The contributions of qualitative research to evidence-based practice are increasingly being recognised, both as standalone research and as part of larger mixed-method studies, including clinical trials. Interviews and focus groups remain commonly used data collection methods in qualitative research, and with the advent of digital technologies, their utilisation continues to evolve. However, digital methods of qualitative data collection present additional methodological, ethical and practical considerations, but also potentially offer considerable flexibility to participants and researchers. Consequently, regardless of format, qualitative methods have significant potential to inform important areas of dental practice, policy and further related research.

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Gill, P., Baillie, J. Interviews and focus groups in qualitative research: an update for the digital age. Br Dent J 225 , 668–672 (2018). https://doi.org/10.1038/sj.bdj.2018.815

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• Market sizing case example video walkthrough  (L.E.K. website)

11. Roland Berger case interview examples

• Transit oriented development case webinar part 1  (Roland Berger website)
• Transit oriented development case webinar part 2   (Roland Berger website)
• 3D printed hip implants case webinar part 1   (Roland Berger website)
• 3D printed hip implants case webinar part 2   (Roland Berger website)
• Roland Berger case interview guide   (by IGotAnOffer)

12. Capital One case interview examples

• Case interview example video walkthrough  (Capital One website)
• Capital One case interview guide (by IGotAnOffer)

13. Consulting clubs case interview examples

• Berkeley case book (2006)
• Columbia case book (2006)
• Darden case book (2012)
• Darden case book (2018)
• Duke case book (2010)
• Duke case book (2014)
• ESADE case book (2011)
• Goizueta case book (2006)
• Illinois case book (2015)
• LBS case book (2006)
• MIT case book (2001)
• Notre Dame case book (2017)
• Ross case book (2010)
• Wharton case book (2010)

Practice with experts

Using case interview examples is a key part of your interview preparation, but it isn’t enough.

At some point you’ll want to practise with friends or family who can give some useful feedback. However, if you really want the best possible preparation for your case interview, you'll also want to work with ex-consultants who have experience running interviews at McKinsey, Bain, BCG, etc.

If you know anyone who fits that description, fantastic! But for most of us, it's tough to find the right connections to make this happen. And it might also be difficult to practice multiple hours with that person unless you know them really well.

Here's the good news. We've already made the connections for you. We’ve created a coaching service where you can do mock case interviews 1-on-1 with ex-interviewers from MBB firms . Start scheduling sessions today!

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Case Interview: Complete Prep Guide

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Welcome to our preparation tips for case interviews!  Whether you are just curious about case interviews or are planning to apply for consulting internships or full-time jobs, these tips and resources will help you feel more prepared and confident.

A case interview is a role playing exercise in which an employer assesses how logically and persuasively you can present a case. Rather than seeing if you get the “correct” answer, the objective is to evaluate your thought process. ( Adapted with permission from Case In Point: Complete Case Interview Preparation by Marc Cosentino). 

Case interviews are very commonly used in the interview process for consulting firms and companies in similar industries. In the case interview, you will typically be given a business problem and then asked to solve it in a structured way. Learning this structure takes preparation and practice. You can learn more and practice using the resources listed below.  

Why are Case Interviews Used?

Case interviews allow employers to test and evaluate the following skills:

• Analytical skills and logical ability to solve problems
• Structure and thought process
• Ability to ask for relevant data/information
• Tolerance for ambiguity and data overload
• Poise and communication skills under pressure and in front of a client

How can I prepare for Case Interviews?

1.) Read Management Consulted’s “Case Interview: Complete Prep Guide (2024)”

Management Consulted is a FREE resource for Tufts students : case and consulting resources such as 500 sample cases, Case Interview Bootcamp,  Market Sizing Drills, Math Drills, case videos, consulting firm directory, and more

2.) Review additional resources:

• Case in Point – This book, by Marc Cosentino, is a comprehensive guide that walks you through the case interview process from beginning to end. This guide has helped many students over the years and can serve as an excellent foundation for how to approach business problems
• Casequestions.com – The companion website to Marc Cosentino’s book listed above offers preparation for case interviews, along with links to top 50 consulting firms
• Management Consulting Case Interviews: Cracking The Case – tips for case interviews from the other side of the table, from Argopoint, a Boston management consulting firm specializing in legal department consulting for Fortune 500 companies
• Preplounge.com – Free case preparation access for to up to 6 practice interviews with peers, selected cases, and video case solutions
• RocketBlocks – Features consulting preparation such as drills and coaching
• Practice sample online cases on consulting firm websites such as McKinsey , BCG , Bain , Deloitte and more!  

3.) Schedule a mock case interview appointment with  Karen Dankers or Kathy Spillane , our advisors for the Finance, Consulting, Entrepreneurship, and Business Career Community.

4.) PRACTICE PRACTICE PRACTICE cases out loud on your own (yes, that can feel odd) or preferably, with another person. See #2 and #3 above for resources and ideas to find partners to practice live cases

5.) Enjoy and have fun solving business problems!

Click through the PLOS taxonomy to find articles in your field.

For more information about PLOS Subject Areas, click here .

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Open Access

Peer-reviewed

Research Article

Professional regulation in the digital era: A qualitative case study of three professions in Ontario, Canada

Roles Conceptualization, Formal analysis, Funding acquisition, Methodology, Project administration, Supervision, Writing – original draft, Writing – review & editing

* E-mail: [email protected]

Affiliation Faculty of Health Disciplines, Athabasca University, Athabasca, Alberta, Canada

Roles Data curation, Formal analysis, Writing – original draft, Writing – review & editing

Affiliations Faculty of Health Disciplines, Athabasca University, Athabasca, Alberta, Canada, School of Sociological and Anthropological Studies, University of Ottawa, Ottawa, Ontario, Canada

Roles Data curation, Formal analysis, Writing – review & editing

Roles Formal analysis, Writing – original draft, Writing – review & editing

Affiliation Faculty of Nursing, University of Alberta, Edmonton, Alberta, Canada

Roles Validation, Writing – review & editing

Affiliation School of Nursing, University of Northern British Columbia, Prince George, British Columbia, Canada

Roles Conceptualization, Visualization, Writing – review & editing

Affiliation Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada

Roles Conceptualization, Formal analysis, Validation, Writing – review & editing

Affiliation Department of Sociology, Western University, London, Ontario, Canada

• Kathleen Leslie, 
• Sophia Myles, 
• Abeer A. Alraja, 
• Patrick Chiu, 
• Catharine J. Schiller, 
• Sioban Nelson, 
• Tracey L. Adams

• Published: May 10, 2024
• https://doi.org/10.1371/journal.pone.0303192
• Reader Comments

Technology is transforming service delivery and practice in many regulated professions, altering required skills, scopes of practice, and the organization of professional work. Professional regulators face considerable pressure to facilitate technology-enabled work while adapting to digital changes in their practices and procedures. However, our understanding of how regulators are responding to technology-driven risks and the impact of technology on regulatory policy is limited. To examine the impact of technology and digitalization on regulation, we conducted an exploratory case study of the regulatory bodies for nursing, law, and social work in Ontario, Canada. Data were collected over two phases. First, we collected documents from the regulators’ websites and regulatory consortiums. Second, we conducted key informant interviews with two representatives from each regulator. Data were thematically analyzed to explore the impact of technological change on regulatory activities and policies and to compare how regulatory structure and field shape this impact. Five themes were identified in our analysis: balancing efficiency potential with risks of certain technological advances; the potential for improving regulation through data analytics; considering how to regulate a technologically competent workforce; recalibrating pandemic emergency measures involving technology; and contemplating the future of technology on regulatory policy and practice. Regulators face ongoing challenges with providing equity-based approaches to regulating virtual practice, ensuring practitioners are technologically competent, and leveraging regulatory data to inform decision-making. Policymakers and regulators across Canada and internationally should prioritize risk-balanced policies, guidelines, and practice standards to support professional practice in the digital era.

Citation: Leslie K, Myles S, Alraja AA, Chiu P, Schiller CJ, Nelson S, et al. (2024) Professional regulation in the digital era: A qualitative case study of three professions in Ontario, Canada. PLoS ONE 19(5): e0303192. https://doi.org/10.1371/journal.pone.0303192

Editor: Sascha Köpke, University Hospital Cologne: Uniklinik Koln, GERMANY

Received: December 15, 2023; Accepted: April 20, 2024; Published: May 10, 2024

Copyright: © 2024 Leslie et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: The minimum data needed to replicate the study are within the paper and its Supporting information files. However, the raw interview transcripts cannot be made publicly available for ethical reasons because they may contain identifiable or sensitive data. Excerpts from interviews are presented in the paper and additional excerpts can be made available upon reasonable request to the Athabasca University Research Ethics Board (email: [email protected] , phone: 780.213.2033).

Funding: This project was funded by an Insight Development Grant (File # 430-2021-00407) from the Social Sciences and Humanities Research Council of Canada (Principal Investigator KL). The funder had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Funder URL: https://www.sshrc-crsh.gc.ca/ .

Competing interests: The authors have declared that no competing interests exist.

Introduction

Technology is rapidly transforming service delivery across regulated professions, altering required skills, scopes of practice, and the organization of professional work [ 1 – 5 ]. Regulatory bodies that govern these professions are under immense pressure to adapt their practices and procedures to facilitate technology-enabled work, while also upholding their mandate to protect the public interest. This urgency has been magnified by the COVID-19 pandemic, which expedited the shift towards virtual practice [ 6 – 8 ] and the scrutiny of professionals’ social media behaviour [ 9 , 10 ]. Regulators must evolve alongside technological advancements to mitigate emerging risks and ensure that new technologies do not negatively impact professional practice or services provided to the public.

Research exploring the impact of digitalization, artificial intelligence (AI), and other technological changes on professional work is emerging [ 11 – 15 ]. This literature has explored the interplay between traditional professional practice and digital innovation [ 16 , 17 ], the organizational changes induced by digital development [ 13 , 15 , 18 , 19 ], and the emerging digital competencies required by professionals [ 20 , 21 ]. Our previous research has also identified challenges that accompany the expansion of virtual practice, including uncertainty about professional standards, breaches of privacy law and other legal requirements, and concerns about equity and professional ethics [ 6 , 22 , 23 ]. Furthermore, while AI technology has the potential to deliver more efficient and data-driven professional services, the associated risks are just beginning to be explored [ 24 , 25 ]. Notably, the burgeoning use of AI raises issues around privacy, equity, and the integrity of professional practice, all of which have implications for professional regulators. Already there are cases where regulators have needed to respond to the inappropriate use of AI in professional practice [ 26 ]. Technology with the potential to profoundly affect professional practice calls for regulatory practices that are responsive to the changing sociotechnical landscape, including the associated risks, inequities, and uncertainties.

Despite emerging research on digitalization’s impact on professional work, our understanding of how regulatory bodies are responding to technology-driven risks and opportunities remains limited. Responses to these challenges have varied, with some regulators imposing a duty of technological competence [ 27 ], while others have refrained from setting formal tech-centric standards. Standards for virtual practice also vary significantly between regulators, even for the same profession [ 6 ]. In addition to how regulators are working to support registrants in the digital era, regulators may be adopting technology to improve their own regulatory practices. To varying extents, professional regulators are digitizing processes related to registration, complaints management, continuing competence, and discipline. However, the way that professional regulators may be using technology to enhance their own work has received little research attention.

This research aims to address these research gaps by examining how regulatory practices and policies are evolving in response to digitalization, and how regulators can support professionals through significant workplace changes while upholding the public interest. Building on our team’s recent work, including a knowledge synthesis of existing academic and grey literature [ 22 , 23 ] and a review of regulatory guidance around virtual care [ 6 ], this study provides foundational insights into the challenges and opportunities of regulating in a digital era. Understanding these challenges and opportunities can inform professional regulators across various sectors and jurisdictions and guide the development of risk-appropriate policies, guidelines, and standards for modern professional regulation.

We aimed to examine the impact of technology and digitalization on three regulatory bodies in Ontario, Canada through a qualitative comparative case study approach. Our specific objectives were to:

• Explore approaches and policies that these regulators have enacted to address the challenges and opportunities presented by the digital era;
• Describe the effects of technological change on regulatory activities at these regulatory bodies; and
• Compare the regulatory responses to technological change across these regulators.

Our study was guided by Yin’s [ 28 ] structured approach to exploratory case study research, which is well suited to understanding new or less studied areas where the researcher has little or no control over the phenomenon of interest. Case study designs in professional regulatory research can produce comprehensive analyses for examining regulatory reforms and innovations [ 29 ]. In this study, we compared how three professional regulators in Ontario, Canada approached regulating in the public interest in the digital era.

Participants

Participating regulators were the Ontario College of Social Workers and Social Service Workers (OCSW), the Law Society of Ontario (LSO), and the College of Nurses of Ontario (CNO). As an exploratory case study, we sought a variety of professional sectors; law, nursing, and social work offered a diversity of regulatory and professional contexts. These three regulators are each under separate legislative frameworks but share the common context of a single jurisdiction of Ontario. Further, the nature of the professional work being regulated is different, and we expected that technology may be impacting these different work contexts in unique ways. In this way, we could distinguish between issues specific to each regulatory body and cross-cutting themes present across the professional, legislative, and workforce factors that vary between them. Our selection of these three regulatory bodies was thus aimed at achieving what Flyvbjerg [ 30 ] called maximum variation in case study research and is appropriate for exploratory work that can be built upon by examining other professions in more jurisdictions in future projects. A brief description of these regulatory bodies is provided in Table 1 .

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https://doi.org/10.1371/journal.pone.0303192.t001

Data collection

We conducted data collection over two phases. The first phase involved gathering publicly available documents relevant to our research objectives and the second phase involved semi-structured interviews. We started with documents to gain a foundational understanding of how technology intersected with regulatory policy and practice for these three professions, and our interviews provided further insight and contextualization to deepen our understanding.

In the first phase, we identified relevant documents by searching regulators’ websites. We conducted our initial searches between May 2022 and September 2022, reviewing documents back to 2015. The date of 2015 was chosen to capture pre-COVID responses while being feasible given our research funding timeline. We also anticipated limited applicability and availability of older regulatory documents given the rapid change of technology in the past decade. The search was updated in January 2023.

We searched each regulator’s website for keywords based on concepts that fit with our research objectives (e.g., digital, tele*, virtual, tech*) and then specific documents were reviewed in full, including minutes from council meetings, regulatory publications for registrants and the public such as newsletters, and strategic plans. We reviewed each retrieved document for references to other regulatory documents, webpages, or resources that were directly relevant to the impact of technology on the regulator’s policies or practices. In this iterative way, we retrieved regulatory updates and news releases; frequently-asked-questions; policies and policy briefs; council briefing reports and minutes; and practice statements, standards, directives, guidance, and guidelines. We identified 34 documents (nine from the CNO, 15 from the LSO, and ten from the OCSW; see S1 File ) that met our inclusion criteria of relating to our research objectives and being published between 2015 and 2022. Document information was organized in a spreadsheet and copies of all included documents were saved as PDFs to keep a record in case websites changed during analysis. These documents allowed us to identify pivotal milestones and policies related to regulatory responses to technology that were used to inform the development of our interview guide. All documents were publicly available.

In the second phase, we emailed the executive director or registrar from each of the three regulators to explain the study and request an interview with individuals familiar with the regulator’s response to technology and relevant policies and practices. Each executive director agreed to an interview and designated two individuals (total n = 6) from their regulatory body to participate and with whom the research team communicated directly by email. Our sampling strategy was purposive and required study participants to have knowledge about the impact of technology on regulatory practice and policy at their organization, appropriate for our case study research design.

We developed a semi-structured interview guide and shared this with our participants prior to the interview (see S2 File ). The semi-structured interview guide was developed collaboratively by the research team based on our previous research in the field, our recent scoping review on a similar topic, and our preliminary analysis of the Phase 1 documents. The first author (KL, she/her) is an early career researcher with experience conducting qualitative interviews in regulatory research who was supported by senior career qualitative researchers (TLA, SN). Interviews were conducted between 1 January 2023 and 31 March 2023 by the first author (KL), and at least one other research team member attended and took detailed notes (TLA, AA, SM). At the beginning of each interview, the first author (KL) provided participants with background information and reiterated the study purpose and objectives. Interviews were conducted by videoconference software (Microsoft Teams) and lasted approximately 60 minutes. Each interview was recorded and transcribed verbatim.

Data analysis

Following data collection, we analyzed all data (documents, interview transcripts, and field notes) using thematic data analysis [ 31 , 32 ]. In this flexible but rigourous approach to data analysis, the researchers play a key role in knowledge production through prolonged engagement with the data [ 32 ]. Three research team members (KL, AA, SM) independently read all documents, transcripts, and field notes to develop a coding framework, using the categories and concepts from the documents and semi-structured interview guide as a basis. Two research team members (KL, PC) with experience in qualitative data analysis and regulatory research then coded all transcripts independently by hand using colour-coded highlighting. KL and PC collaborated throughout regular discussions to develop themes. Extracts from transcripts were brought together for each theme as it was developed, and information from the documents was used to augment and triangulate these findings. As results were developed for each regulator, we compared and contrasted findings across the cases to identify themes and develop rich descriptions. Finally, we returned to the original transcripts and audio recordings to ensure the identified themes and selected quotes accurately reflected the data. We also identified documentary data from Phase 1 that could be included to support the findings and add context, depth, and breadth to the interview data. Findings were regularly reviewed and refined with the research team throughout the analysis.

Trustworthiness

To ensure the credibility of our findings, we used a multifaceted approach. Data collection and analysis were carried out in a systematic way, including extensive engagement with the transcripts and generating a careful audit trail. Using multiple data sources provides enhanced validity with our findings supported by more than one source of evidence [ 28 , 33 ]. We met regularly as a research team to discuss and verify our analysis; we included thick descriptions of our findings and verbatim quotes to support each theme. The diversity of our team, which includes research and clinical backgrounds in professional regulation, political science, nursing, law, and sociology, provided a range of analytical perspectives to aid in interpreting results. We followed the Consolidated Criteria for Reporting Qualitative Research (COREQ) [ 34 ] to guide the transparent reporting of our methods and findings (see S3 File ).

Ethical considerations

The Athabasca University Research Ethics Board approved the study (File #24794). Each regulatory body contacted agreed to participate and informed written consent was obtained from all interview participants. No one withdrew their participation and only participants and research team members were present during the interviews. The study posed minimal risk to participants as they provided information in their professional capacity and no personal information was collected. To protect participant confidentiality, quotes in the findings are attributed to the regulatory bodies and the professions they represent without using names or position titles. As each regulator represents a single case, we have not differentiated between participants representing the same regulator.

While some research team members are members of the profession of participating regulators, they do not have established relationships with interviewees (prior to study commencement or since study completion), and interviewees were aware of the principal investigator’s (KL) background as a registered nurse and lawyer.

We identified five themes in our analysis of the interview and document data: 1) balancing efficiency potential with risks of certain technological advances; 2) the potential for improving regulation through data analytics; 3) considering how to regulate a technologically competent workforce; 4) recalibrating pandemic emergency measures involving technology; and 5) contemplating the future of technology on regulatory policy and practice. Descriptions of these themes, along with illustrative regulatory responses and quotes, are provided in Table 2 . We also review these themes in detail below, providing context from regulatory documents and quotes from interview transcripts. Quotations have been very lightly edited for grammar.

https://doi.org/10.1371/journal.pone.0303192.t002

Theme 1: Balancing efficiency potential with risks of technological advances

Participants recognized that technological advances may enable regulators to work more efficiently; however, they believed the risks associated with new technologies necessitated a cautious approach. This caution meant that many changes were incorporated slowly, and participants emphasized that even seemingly simple changes, such as online registration processes, were being approached carefully. A participant from the LSO noted that “historically, we’ve been very paper-based, so people would fill out paper applications and they would mail those into us” but the pandemic “accelerated changes that were being considered prior to that, and certainly desired prior to that, and so the application process has moved online.” Similarly, a participant from OCSW described their desire to move away from printing out physical certificates for all registrants, noting “we’re hoping we can transition out of it because it’s a very manual, expensive process that we do across the board for everyone.” However, the potential efficiency gain of digital certificates also came with risk, with the participant noting “then technology comes into play, because how do we ensure that it’s not fraudulent? … There’s always the ability to tamper with it” (OCSW).

Participants also discussed the importance of carefully considering the contexts in which technology should be used to facilitate regulatory operations. Participants from all three regulatory bodies discussed opportunities to automate tasks to free up staff and to improve their response times to registrants, especially for low-risk activities. For example, inquiries related to registration renewals are often straightforward and may not require human interaction. Participants from the CNO and OCSW discussed how technology can create opportunities for registrants to better engage with regulatory bodies and increase the accessibility of standards and guidelines at the point of care.

At the same time, all participants emphasized the need to consider the full context of each situation to assess the appropriate use of technology. One commonality between regulators was the recognition that not everything should be digitalized because regulation also involves a relational component. This requirement for human interaction is especially relevant when dealing with registrants and the public in higher-stakes situations (e.g., investigations and discipline processes). A participant from OCSW noted that technological interactions were appropriate for the “benign stuff” such as registration renewals, but that “there is a balance and if a regulator wants to be sort of relevant, they have to ensure that they are meeting that sort of human need.” A participant from the LSO responded similarly:

I think , probably the answer is that where processes that don’t really require a human touch , so for instance , handing an application in–we can eliminate the human touch there and move those types of things increasingly online . But I think maintaining those sorts of areas where having someone to talk to where you’re having an ethical issue , having a CPD program that you can attend that speaks specifically to your practice area and there are other colleagues there as well , those types of things . I think , that’s probably–to my mind at least–where the balance is . You beef up those areas where [human interaction] is important , and you try to gain those efficiencies in areas where perhaps it’s not so important that you do something in person ( LSO )

Participants’ responses highlighted the value regulators place on using a risk-based approach to carefully assess the suitability and feasibility of integrating technology into regulatory processes: “I think increasingly, as we try to move into new areas with technology, that ensuring that we’re approaching things from a risk-based perspective is very important” (LSO).

The potential of technology to improve efficiency was valued by participants who noted the complexity and resource-intensity of regulatory processes were increasing; however, the risk-adverse nature of regulation meant currently these gains have not yet been fully realized as participants focused more on the potential efficiency gains, should risks be appropriately managed.

Theme 2: The potential for improving regulation through data analytics

In addition to potential efficiency gains, participants highlighted where data could be leveraged to guide decision-making and potentially improve regulatory processes and outcomes. Similar to the cautious approach regulators were taking to the incorporation of new technologies more generally, the discussion of data analytics focused primarily on potential, rather than realized, benefits.

Participants from the CNO discussed the development of a new Insights Engine [ 35 ] that focused on data analytics but was in the very early stages of being used. This new system is meant to provide “more real-time data” that would allow the regulator to “specifically tag pieces of information…where they are coming from, from whom, and that informs how we also develop resources for members” (CNO). A CNO participant noted that the regulator had “lots and lots of data inputs” but these were “not accessible in a way that is as meaningful as we would like them to be in order to drive…our projects or the things that we need to improve or change.” The CNO participant described this as important not only to inform decision-making but to “prioritize our projects, where we kind of put our resources and our people, kind of focus our work so I think that will make us more efficient.”

A participant from the OCSW also noted a change in their current data systems that could, in the future, support data analytics for decision-making:

We’re changing over from our current legacy software into a new CRM [customer relationship management system] this year…we are hoping [the new CRM] will be able to mine the data in that way and be able to identify trends . So even when we’re looking at complaints , registrants , investigations or even something simple like [continuing competence program] completion rates . We have a pretty high completion rate , but let’s say we do have a situation where we have lower completion rates , we can look to see if there are certain regions that have individuals that are not participating as much or things like that . Currently , we can’t do that as simply , but in a future state , we’d want to . So , we have the questions we want to ask . ( OCSW )

In addition to regulators’ plans to use data analytics to improve regulation, we also heard that regulators were using existing data to identify practitioners at risk. As a participant from the LSO noted, “I think we always use data that’s available to us to sort of assess risk and try to get ahead of things and understand where problems exist”. For example, existing data have “clearly shown for many years that the sole practitioners are at the highest risk of being the subject of complaints” and “the causes of this are usually skills-related, not knowledge of the law” (LSO). Using this data, the regulator developed a new competence framework to support the implementation of a practice essentials course to support sole practitioners; at the time of our data collection, this was almost ready to be rolled out.

Theme 3: Considering how to regulate a technologically competent workforce

Beyond considering how to incorporate technology to improve regulatory operations, participants also discussed how to support and regulate their registrants in an increasingly digitalized world. Participants from all three regulatory bodies discussed the factors that have influenced their regulatory approaches as technology changes how their registrants practiced. Participants discussed the importance of assessing the most appropriate level of regulation to balance their mandate of protecting the public while ensuring that they do not create barriers in practice. This is sometimes termed right touch or risk-based regulation.

One key consideration was the legislative framework under which regulatory bodies operate and how this impacted regulators’ ability to respond nimbly. A participant from the LSO described their broad bylaw-making power under the Law Society Act and the way it allowed the regulator “quite a bit of flexibility…[to] be fairly nimble when we need to be…basically to allow access to justice to continue when no one could meet in person” during the pandemic. For example, the LSO facilitated emergency Orders in Council to allow virtual execution and witnessing of wills [ 36 ] provided legislative interpretation regarding virtual client identification [ 37 ], and guided registrants about requirements for virtual notarizing and commissioning [ 38 ].

Other factors influencing regulators’ decision-making included their existing strategies for modernizing standards and the influence of collaborative work between regulators. Participants from the CNO highlighted pre-pandemic work that was done in collaboration with other regulators to develop guidelines and competencies for compassion in the digital healthcare age. This work informed their ongoing reforms for technology-enabled practice and virtual care as the regulator worked to modernize practice standards [ 39 ].

Similarly, a participant from the LSO spoke about the influence of the Federation of Law Societies of Canada on discussions around technological competence. In 2019, this Federation added commentary to the duty of competency in its Model Code of Professional Conduct; this commentary required lawyers to have an understanding of and ability to use technology relevant to the nature and area of the lawyer’s practice and responsibility [ 40 ]. The commentary further required that lawyers understand the risks and benefits associated with relevant technology. Different legal regulators across Canada began to adopt this duty of technological competence, and the LSO adopted it in 2022. As one LSO participant described:

In general , we try and stay fairly close to [the model code] , certainly with the basics , because , you know , that’s what a national model code is supposed to do . And in this one , we were actually slow to adopt it because we had a technological taskforce…And then we also had a competence taskforce—the competence taskforce was intended to look at if our competence standards and programs were suitable for the next 20 years…the tech competence requirement was part of that report…So that was the impetus for this particular change to our rules . ( LSO )

An important element of this commentary to the competence rule is that legal professionals must understand technology relevant to their area of practice. One participant from the LSO discussed the importance of this approach given the nuances in different law practice areas. This participant noted that the regulator was not assessing technological competence because “depending on practice area, it’s often not entirely clear how we would assess it anyway” since some areas of legal practice required uses of very specific technologies (e.g., the Ontario Teranet system to transfer title in real estate law) “whereas there are other areas of law where, in theory at least, you could probably still get by with a typewriter and dictaphone” (LSO).

In contrast to the LSO’s specific inclusion of technology in its commentary to the duty of competence, the OCSW and CNO described how their current standards were broad enough to generally cover technological competence. The Council of the OCSW specifically decided not to adopt the model technology guidelines for social work published by the Association of Social Work Boards in 2015 [ 41 ], opting “instead to produce resources to help support members in their practice and to apply those standards to technology or any other issue” (OCSW). One participant from the OCSW described how this decision was made:

I think one of the convincing reasons for that was the current edition of our standards of practice refers to diskettes , which is such a great example of why you don’t want standards of practice to be too specific , because they’ll be out of date before the ink dries , I guess . And so I think that has been the approach that our college has taken—that technology competence and technology really doesn’t warrant its own standalone standard because it applies to other standards such as record keeping boundaries , competence and integrity , and confidentiality . ( OCSW )

Despite differences in approaches to technological competence, participants from all three regulatory bodies spoke about their role in supporting their registrants’ professional practice by developing guidance around technology and virtual practice. In deciding what practice resources were needed, regulators responded based on registrant inquiries and the level of perceived risk. For example, a participant from the LSO discussed how they use inquiries from their practice management helpline to inform their continuing professional development offerings and regulatory resources.

Participants from the OCSW discussed how they encourage registrants to identify learning needs associated with technology when completing their continuing professional development program. Our review of OCSW newsletters showed ongoing encouragement of members to review resources on topics such as using communication technology in practice, selecting online platforms for virtual services, and practice standard considerations for navigating COVID-19 [ 42 – 46 ]. Participants from the OCSW also highlighted measures they took to ensure social workers from other Canadian jurisdictions were registered with OCSW before providing virtual services to clients in Ontario. This enabled the regulator to address issues related to professional conduct since “we can’t minimize the risks involved in electronic practice—they’re huge…so it is probably extra important that those people be registered in Ontario” (OCSW).

In developing practice support and guidance, participants discussed whether they had a role in providing guidance on specific technologies. There were differences in perspectives between regulators. For example, participants from the CNO discussed that it was not within their mandate to endorse or provide guidance on specific technologies:

Questions about which [technology platform] I should be using—we don’t regulate that , right ? We don’t say one thing is better than the other . We don’t endorse certain products . So that also becomes a challenge as well , what do we tell them in order to assess what is appropriate ? It goes back to your accountabilities . Does it meet those standards that you’re obligated to follow in order to assess whether this application or technology is appropriate and is safe for you to use ? ( CNO )

Participants from the LSO spoke about their technology resource centre [ 47 ] that provided guidance on selecting technology for practice, technology use, data protection, cybersecurity, cloud computing, and working remotely. While this was a departure from the level of guidance provided historically, this participant felt it was necessary to guide legal professionals on what was required to meet the standard of professional competence.

We’ve also tried to sort of help people along , in terms of what was created at the Technology Resource Centre…that was sort of a bit of a departure for us , because we got into really looking at specific products and…even suggesting to people that these are products that you can use in certain areas to help facilitate your practice . And traditionally , that hadn’t been our approach . Our approach was much more of satisfy yourself—go out there and see what’s out there kind of approach . So , we’ve tried to help nudge people in the right direction and give them a better idea of what we mean by technological competence . But that has certainly been a challenge . ( LSO )

Thus, while all three regulators operate within the same province, their approach to regulating a technologically competent workforce differed, creating differences in standards and resources provided to registrants regarding technology.

Theme 4: Recalibrating pandemic emergency measures involving technology

In many ways, the COVID-19 pandemic accelerated the use of virtual technologies and impacted various aspects of regulatory operations, including entry-to-practice, registration, continuing competence, and complaints and discipline proceedings. Different perspectives emerged about whether specific regulatory functions should remain virtual or return to pre-pandemic in-person norms. A recurring theme was the need to strike a balance between both modalities.

I think through all of this , whether it’s hearings or discipline or entry to practice , I think there’s increasingly this feeling that… some form of hybrid is probably where the sweet spot is , and I think we need to figure out where that is , and figure out what’s going to stay online , what’s going to stay remote and what should be in-person . And I suspect it’ll take some time to really figure that out . ( LSO )

Since a core function of regulatory bodies is to ensure that applicants meet the required entry-to-practice competencies, regulators found themselves grappling with the consequences of changes to the delivery of education and practicums during the pandemic. Participants from the CNO discussed how the lack of evidence on the outcomes of simulated clinical experiences created challenges for ensuring graduates were prepared competently:

Is there a break point in terms of safety ? And there is research out there [but] none of it is conclusive . There certainly are some jurisdictions that have gone the route of saying , you know , 50% of your clinical can be simulation . We haven’t designated a percentage yet . ( CNO )

Participants from the LSO also experienced challenges as education, placements and articling shifted online. In some cases, applicants were called to the bar after completing their legal education and training remotely. While these changes were necessary due to the pandemic, participants discussed the need to re-assess to determine the best approach going forward.

The pandemic also meant that some regulators shifted to online entry-to-practice exams, but this raised risks related to the security of exams and the appropriateness of the testing environment. The CNO did not adopt remote proctoring and participants noted they “weren’t comfortable at the time with the kind of research that’s out there in terms of security and the whole process around remote proctoring. And we are well aware that there are other regulators—both nursing and outside of nursing—that are doing it. So it’s something we’re exploring” (CNO). The LSO was one of the regulators that adopted remote proctoring and experienced an “exam cheating scandal…where we received information and materials to suggest that there had been cheating involved in some of our licensing examinations…And we’re now no longer doing testing online.” While the OCSW does not currently require an entry-to-practice exam, participants spoke about their interest in exploring how digitalization might impact future exam requirements that were being considered.

In considering the use of technology to increase efficiencies during the licensure process, one participant from the LSO identified the need to attend to equity considerations:

I think the other place where you really see that tension playing out is in the equity space … for , particularly , students who are going through the licensing process . If you are in one of these marginalized groups , you can … face more barriers , you can become more anxious about dealing with what feels like the behemoth , the impersonal behemoth , of the Law Society … So that’s a tension and because efficiency is highly valued … I think , how we are trying to deal with that is to have a personal engagement as needed . The trick is to determine when it’s needed . I don’t think it’s hard to find a sympathetic ear actually at the Law Society , but to know when that intervention is required—that’s , I think , the real challenge . ( LSO )

In addition to changes to entry-to-practice and registration/licensure, regulators’ investigation, discipline, and conduct processes were significantly disrupted by the pandemic as many of these shifted from in-person to virtual formats. This shift to virtual formats provided some advantages that participants described, such as “levelling the playing field” (CNO) for those who lived far from the regulatory body and potentially easing anxiety to facilitate more open conversations.

Participants from the CNO and LSO highlighted the potential negative consequences of virtual hearings such as increased ‘Zoom fatigue’, perceptions of informality, and barriers for individuals who live in areas with unreliable internet access. A participant from the CNO mentioned concerns about whether virtual hearings would have the same level of seriousness as an in-person meeting. These concerns were shared by those at the LSO:

When you walk into a courtroom , and you see that the judge sitting up there and there’s a sense of formality to it , versus getting on a Zoom call with a bunch of heads from shoulders up . That may not feel like you’re getting the same hearing that you might have in person . So , I think there’s definitely a balance there . ( LSO )

In general, regulators seemed to be striving for a balanced approach to post-pandemic recalibrations. Advantages, disadvantages, and risks associated with in-person and virtual modalities are becoming clearer and are helping inform this recalibration process.

Theme 5: Contemplating the future of technology in regulatory policy and practice

Participants described their curiosity in wanting to learn more about the impact on public protection as technologies like AI continue to evolve and become more commonplace. Participants described specific areas they were watching to learn more about how technology was impacting professional practice, such as how the therapeutic relationship might “look different when practicing in a more technological environment” (CNO). A participant from the LSO was interested in exploring “whether virtual proceedings have impacted incarceration rates, and release versus bail, or other outcomes” and whether digital products such as online “will kits” help people in the way they are intended.

Participants highlighted opportunities for increased collaboration between regulators to streamline and harmonize processes and to share data to support evidence-based regulatory policy across professions. For example, one participant from the CNO said “I think there’s always been that collaboration amongst different regulators, but having data, I think, provides this objective piece as well, which I think will be helpful for sure.” A participant from the OCSW described the importance of working together given the similarities in regulatory functions and services, especially across health profession regulators:

In essence , even though we’re regulating different professions , we’re all regulating . So , when you’re thinking of technology and the use of social media and some of the expectations we have from our professionals , specifically health , it would be good if those regulatory bodies could come together and say , you know , here’s the spectrum of our expectations . Here’s how we’ve been monitoring this spectrum . Let’s talk about it as a unit…We may be regulating different professionals , but we’re all running organizations . The operations of each of these organizations are extremely similar and overlap . ( OCSW )

A participant from OCSW expressed a desire for regulation to become more forward-thinking around technology: “Often regulators are sort of the last ones around the corner with a lot of the updates……there’s no reason the regulator can’t be the cutting edge in some of this.” One more innovative approach to staying on top of technological changes was the LSO’s Access to Innovation program which created a regulatory sandbox for innovative technological legal services [ 48 ]. While, at the time of our interview, this sandbox did not yet have evaluation data available, this way of providing a safe space to support innovative technology is meant to provide insight into new risks and opportunities related to technology.

Technology can potentially revolutionize professional work and the regulation of that work. However, technological change has simultaneously created tensions around the application of AI, data analytics, technological competence, social media use, and other dimensions of professional practice and regulation [ 49 ]. The results of our study have underscored the wide-ranging implications of technology on regulatory practices, with changes to entry-to-practice and registration/licensing, practice standards and guidance, practitioner support, continuing professional development, and disciplinary practices and procedures. Regulators are grappling with how to respond to technological changes in the practice of the professionals they regulate, while simultaneously experiencing technologically mediated changes to internal processes.

Concerns about risk may slow progress

Our findings illustrate that regulators are in the early stages of exploring the opportunities and risks that technology has on daily operations. Although regulators from different sectors have adopted technology at varied paces, the literature suggests that many have begun exploring the potential value of technology, including AI, in supporting regulatory operations and decision-making [ 50 – 55 ]. Regulation is becoming increasingly complex and resource-intensive, and our findings suggest that participants are hopeful that integrating technology into regulatory operations will provide a means to enhance efficiency. While participants noted that there are areas where technology can be integrated more easily, they also highlighted the importance of carefully studying the impacts of technology on functions that carry a greater risk of producing undesirable outcomes. This finding aligns with research by van der Gaag et al. that found regulators were concerned that AI could introduce errors and biases, jeopardize public trust, and perpetuate systemic inequities [ 56 ]. Our participants noted a need to take a risk-based approach to the advantages and disadvantages of adopting technology to support decision-making. While risk aversion may be necessary for higher-stakes regulatory processes, it may slow progress in adopting technological enhancements that could drive needed efficiency gains in increasingly resource-constrained environments.

Ensuring an equity-based approach to virtual practice and processes

The rapid expansion of virtual services influenced our participants’ responses to regulating technology use among professionals. In the context of the health and social care sectors, the pandemic accelerated the proliferation of virtual care options. In the context of law, evidence from before the pandemic suggests that, increasingly, lawyers are operating virtual legal offices rather than those of traditional brick-and-mortar [ 57 ]. Technology use in practice raises important questions about privacy, confidentiality, boundaries, informed consent, continuity of services, and new complexities for addressing malpractice and complaints [ 6 , 57 – 59 ]. While our participants discussed that technology does not necessarily require the development of unique standards of practice, this is an area that regulators will be required to re-evaluate as new risks and challenges emerge.

The introduction of virtual practice also raises unique equity concerns, potentially expanding access but in unequal ways [ 60 ]. Regulators have a role in ensuring that regulatory decisions do not perpetuate systemic inequities [ 61 ]. Our previous research on for-profit virtual care in Canada found that equity has not been adequately considered within standards from medical regulators [ 6 , 22 ]. Equity considerations must be embedded in regulatory decision-making as technology continues to evolve, and many of these considerations apply to regulatory policies and practices (e.g., virtual discipline hearings) as well as regulating virtual practice.

Our participants also described varied approaches to virtual training experiences and entry-to-practice exams, and this was an area where participants noted disparate approaches were common even across regulators in the same field. A growing body of literature across various professions suggests that there are advantages and lessons to be learned from virtual training models, including virtual reality. More evidence is needed to support informed regulatory decision-making in this evolving area of technology-enabled training and assessing entry-to-practice competency. For nursing, social work, and law, training usually requires hands-on, practical experience that may be difficult to gain in a virtual or simulated setting; however, there may be advantages to innovative virtual training models [ 62 ]. There may also be lessons that can be learned from professions, such as paramedicine, that use training via virtual reality to help establish competence [ 63 – 65 ].

Varied approaches to ensuring technologically competent professionals

As regulators work to strike a balanced approach for enabling professionals to deliver virtual services, practitioners themselves must build technological competence. As discussed by our participants, regulators expect registrants to have the required knowledge and skills related to technology but the approaches regulators have taken to ensure that registrants have this competence differed. Scholars have explored the knowledge needs and competencies that members of their professions require to function in an increasingly digitalized world [ 59 , 66 , 67 ]. As discussed by our participants, technological competence will look different depending on each practice setting. However, with growing interprofessional collaboration, regulators within and across sectors have an opportunity to work together to share evidence and explore how competencies can be harmonized to ensure greater consistency amongst professionals.

Aside from being competent in using technology to deliver professional services, social media introduces implications for how regulated professionals interact with the public to maintain public trust. Many professional regulators have developed standards of practice to outline responsibilities and accountabilities due to increased complaints and findings of unprofessional conduct centred on inappropriate social media use [ 9 , 68 – 71 ]. High-profile conduct cases have sparked considerable debate about the need to balance professionals’ freedom of expression and speech with their obligations to maintain public trust. Social media can be a powerful platform for fostering professional networks, continuing education, and advocacy to encourage system improvements. At the same time, it can potentially cause significant social harm. Regulators will continue to need to evaluate how they approach registrants who use social media in ways that push the boundaries of conventional views of professionalism.

Opportunities to leverage regulatory data

Participants discussed the opportunities that technology can bring in facilitating better use of regulatory data to inform decision-making, though many challenges–including adequate knowledge and resources, addressing privacy concerns, and ensuring data platform interoperability–remain to realize this potential. Beyond the use of data analytics to inform internal regulatory policies and processes, regulators have an opportunity to leverage data to inform broader social goals such as workforce planning. Within the health and social care sectors, the importance of standardized health workforce data for integrated workforce planning has been recognized by scholars [ 72 – 74 ] and has become a priority for federal, provincial, and territorial governments in Canada [ 75 – 77 ]. Promising practices exist in other jurisdictions such as the United States and Australia where national databases and datasets are used, and Canada has recently announced pan-Canadian databases for physician and nursing data [ 75 , 78 ]. These data support inter-jurisdictional labour mobility and awareness of registration status and malpractice or disciplinary histories. The collection of standardized data can also provide meaningful input on issues such as the mental health of the workforce, a priority mentioned by all our participants. In addition, equity must be a priority, and the collection of enhanced demographic data could facilitate better understanding of the diversity of the workforce and the inequities that exist to inform policy and research needs.

Limitations and future research

The transferability of these findings should be interpreted carefully when applying to other regulatory contexts within and outside of Canada. Our participant sample was small and meant to provide foundational insights into how regulators are navigating an increasingly digitalized world. Members of our team are currently engaged in two funded research projects that build on this foundational work, one that expands the current study to survey and interview regulators across Canada, and one examining whether ethical codes and guidelines from regulators provide sufficient guidance for practitioners when they encounter challenges related to technology in practice. The implications of technology on professional regulation will require monitoring and evaluation over time to examine how technological innovations impact all facets of regulation and professional work.

Our case study explored how three Ontario professional regulators operating within different legislative frameworks are navigating technology in the digital era. Cross-sectoral participants provided theoretical and pragmatic insights for regulating in the digital era and the role regulators can and should play in digitally enabled professional practice. These insights provided an understanding of how these regulatory bodies are responding to the challenges of upholding their mandate to regulate in the public interest during rapid digital evolution. Our analysis identified five themes: balancing efficiency potential with risks of certain technological advances; the potential for improving regulation through data analytics; considering how to regulate a technologically competent workforce; recalibrating pandemic emergency measures involving technology; and contemplating the future of technology on regulatory policy and practice. Regulators will continue to grapple with considerations about technology used to facilitate regulatory functions, balancing consumer demands amid emerging risks posed by technology, producing technologically competent workforces, and informing workforce planning via regulatory data. Policymakers and regulators across Canada and internationally should prioritize risk-balanced policies, guidelines, and practice standards for modern professional regulation.

Supporting information

S1 file. description of regulatory documents..

https://doi.org/10.1371/journal.pone.0303192.s001

S2 File. Semi-structured interview guide.

https://doi.org/10.1371/journal.pone.0303192.s002

S3 File. COREQ checklist.

Consolidated criteria for reporting qualitative studies (COREQ): 32-item checklist.

https://doi.org/10.1371/journal.pone.0303192.s003

Acknowledgments

We gratefully acknowledge and thank our interview participants for generously sharing their time and insights with us.

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• Open access
• Published: 09 May 2024

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

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

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

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Metrics details

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

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

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

Conclusions

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

Trial registration

NCT05343390. Date of registration: April 25, 2022.

Peer Review reports

Introduction

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

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

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

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

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

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

Study design

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

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

Data collection

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

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

Data analysis

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

Ethical clearance

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

Participant characteristics are described in Table  1 below.

Factors influencing feasibility of assisted ICT: barriers and facilitators

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

Conceptual diagram mapping feasibility barriers and facilitators to the ICT process

Feasibility barriers

Sensitivities around discussing ict with clients.

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

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

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

Privacy concerns

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

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

Limited time for ICT amid high workloads

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

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

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

Poor quality contact information

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

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

Logistical obstacles to tracing

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

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

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

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

Feasibility facilitators

Hcw knowledge about ict.

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

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

HCW interpersonal skills

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

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

HCW non-stigmatizing attitudes and behaviors

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

HCW sense of purpose

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

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

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

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

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

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

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

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

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

Availability of data and materials

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

Abbreviations

Acquired Immunodeficiency Syndrome

Antiretroviral Therapy

Health Care Worker

Human Immunodeficiency Virus

HIV Testing Services

Index Case Testing

In-Depth Interview

Intimate Partner Violence

Institutional Review Board

President’s Emergency Plan for HIV/AIDS Relief

People Living With HIV

Joint United Nations Programme on HIV/AIDS

World Health Organization

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Acknowledgements

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

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

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

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

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Can SVVR Help with Student Engagement in an Online EFL Writing Class? A Chinese Case Study

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• Published: 13 October 2023

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• Bin Shen   ORCID: orcid.org/0000-0001-6233-7328 1 , 2 ,
• Zhijie Wang   ORCID: orcid.org/0000-0002-3516-369X 1 ,
• Xiaowen Zhong 1 , 3 ,
• Michael Yi-Chao Jiang   ORCID: orcid.org/0000-0001-6807-4039 4 &
• Morris Siu-Yung Jong   ORCID: orcid.org/0000-0001-9186-0484 5 , 6  

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Although research into the educational benefits of Spherical Video-based Virtual Reality (SVVR) has gained popularity in traditional face-to-face English-as-a-Foreign-Language (EFL) class, little is known about whether this immersive, interactive, and imaginative teaching-assisted technology could facilitate learning in online EFL settings in the post-pandemic time. The current study explored how students engaged themselves in an online EFL class facilitated by SVVR. To achieve that, one focus group interview and two semi-structured interviews were conducted to collect in-depth data of students’ perceptions of their engagement under the SVVR-supported online learning. Based on the theoretical framework of engagement, the collected data were thematically coded into three categories, namely, behavioral, emotional, and cognitive engagement. The findings suggested that with SVVR affordances, students engaged behaviorally, emotionally, and cognitively in the online EFL writing class, both in an independent and interrelated way. The enhanced emotional engagement of students could then support their behavioral engagement while students’ cognitive engagement could also promote their emotional and behavioral engagement. The present study thereby could not only build our understanding of the dynamic, multifaceted, and interconnected nature of student engagement, but also provide one feasible solution to teachers towards the disengagement issue in online EFL learning in the post-pandemic time.

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Acknowledgements

We would like to express our gratitude to all the anonymous reviews and the editors for their constructive and insightful comments and suggestions on this paper. We are grateful to the teacher and students who participated in this research. This paper would not have been possible finished without their help. Any errors and omissions that remain are our own responsibility.

This work was funded by 2019 Fujian Provincial Education Sciences “Thirteenth Five-Year Plan” Key Project Fund (Grant no. FJJKCGZ19-349) and Fujian Provincial Social Sciences Fund (Grant no. FJ2023B030).

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School of Foreign Languages, Shenzhen Technology University, Shenzhen, China

Michael Yi-Chao Jiang

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Centre for Learning Sciences and Technologies, The Chinese University of Hong Kong, Hong Kong, China

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Shen, B., Wang, Z., Zhong, X. et al. Can SVVR Help with Student Engagement in an Online EFL Writing Class? A Chinese Case Study. Asia-Pacific Edu Res (2023). https://doi.org/10.1007/s40299-023-00774-6

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