Multiple Embedded Case Study Design Research Articles

A comparative analysis of COVID-19 physical distancing policies in South Africa and Uganda.

COVID-19 responses internationally have depended on physical distancing policies to manage virus transmission, given the initial absence of treatments and limitations on vaccine availability. Different jurisdictions have different contexts affecting their responses such as past epidemic experience, ratings of epidemic preparedness, and income level. COVID-19 responses in African countries have not been well-studied. A qualitative multiple embedded case study design was used to examine the COVID-19 policies in South Africa and Uganda from January 2020 to November 2021. This study included a documentary review using government websites and reports, news articles, and peer-reviewed journal articles to obtain data on policy responses and contextual factors. Epidemiological data were collected from public sources. Key informant interviews with relevant stakeholders were used to confirm findings and cover missing information. A comparative analysis was conducted to explore differences in implementation of different types of physical distancing policies and potential consequences of lifting or prolonging public health measures. South African and Ugandan policy responses included physical distancing measures such as lockdown, international travel bans, school closures, public transportation measures, and curfew, in addition to socioeconomic relief programs and vaccinations. Differences between jurisdiction policy responses existed in terms of overarching strategy, timing, and stringency. This study provided in-depth comparisons of COVID-19 policy responses and relevant contextual factors in South Africa and Uganda. The study showed how contextual factors such as population age, geographic distribution, and recent epidemic response experience can influence COVID-19 transmission and response. The study also showed differences in overall strategy, timing, and strictness of epidemic management policies in these jurisdictions. These findings suggest it may be important to have sustained, strict measures to limit the spread of COVID-19 and manage the course of a pandemic, which need to be further explored alongside other important social and economic pandemic outcomes.

Challenges Facing Enforcement of University Quality Assurance Standards in Fostering Compliance in Tanzania

Compliance with quality assurance standards worldwide requires universities to be strongly enforced by external and internal quality assurance bodies. Tanzania, as in the case of other countries, enforces quality assurance standards through national and institutional quality assurance bodies. Despite such efforts, non-compliance cases are still found at various university stakeholders’ levels. This study explored the challenges in enforcing quality assurance standards to foster universities’ compliance in Tanzania. The qualitative approach and multiple embedded case study design informed the study. Data was collected from the four public and private universities involving 46 participants who were purposively selected. In addition, data was gathered through focus group discussions, individual interviews and documentary reviews and then analyzed by content analysis. The study found that academics' resistance to quality monitoring of teaching, financial challenges, inadequate quality assurance awareness, quality assurance officers acting as police officers, underestimating the quality of tests, and lack of detailed national guidelines for some enforcement initiatives were the challenges encountered in enforcing quality assurance standards. Such challenges impede the successful enforcement of quality assurance standards. Therefore, they contribute to the universities' non-compliance cases. As such, this study recommends that national and institutional quality assurance bodies continue educating and guiding their stakeholders about the essence of quality assurance standards and how to implement each enforcement initiative to foster compliance. Also, universities must keep searching for multiple sources of funds to enhance their financial stability and sustain quality assurance standards.

Implementation of dementia care management in routine care (RoutineDeCM): a study protocol for process evaluation

IntroductionDementia care management is a complex intervention intended to support persons with dementia and their (caring) relatives in home-based care arrangements. Dementia care management was developed in the federal state...

Capacity building of district health management teams in the era of provincial health administration reform in the Democratic Republic of Congo: a realist evaluation protocol

IntroductionIn 2006, the Congolese Ministry of Health developed a health system strengthening strategy focusing on health district development. This strategy called for reforming the provincial health administration in order to...

Building Capacity to Apply Citizen Science Approaches in Policy and Practice for Public Health: Protocol for a Developmental Evaluation of Four Stakeholder-Led Projects

Citizen science is gaining attention as an approach to involving communities in gathering data and contributing to decision-making in public health. Stakeholders interested in citizen science have identified a need for support in applying these approaches and in obtaining evidence of their value. However, there have been few attempts to evaluate citizen science approaches within policy and practice contexts in public health. Within this protocol paper, we outline an approach to evaluating stakeholder-led citizen science projects that focuses on fostering innovation and building capacity in the use of citizen science approaches by these stakeholders. We will use developmental evaluation, which focuses on ongoing reflection and adaptation, to guide the development and delivery of four stakeholder-led citizen science projects in public health. We will employ a multiple embedded case study design, using surveys and interviews, observations of project meetings, reflective journaling, and document review to gather perspectives from a range of stakeholders across the four projects. Data will be synthesised to explore how projects using citizen science approaches operate within policy and practice contexts, including the barriers and facilitators to their application, the circumstances under which they are most useful, and the impacts of these approaches. A developmental approach to evaluation will enable us to build capacity in the use of citizen science approaches by sharing insights and learnings as project teams navigate their individual projects. We hope that this paper will stimulate further discussion about the application and evaluation of citizen science approaches in public health and beyond.

Strengthening capacity in hospitals to reduce perinatal morbidity and mortality through a codesigned intervention package: protocol for a realist evaluation as part of a stepped-wedge trial of the Action Leveraging Evidence to Reduce perinatal morTality and morbidity (ALERT) in sub-Saharan Africa project

IntroductionDespite a strong evidence base for developing interventions to reduce child mortality and morbidity related to pregnancy and delivery, major knowledge–implementation gaps remain. The Action Leveraging Evidence to Reduce perinatal...

Case Management Programs for Improving Integrated Care for Frequent Users of Healthcare Services: An Implementation Analysis.

Introduction:Case management programs (CMP) for frequent users of healthcare services presenting complex healthcare needs constitute an effective strategy to improve patient experience of integrated care and to decrease healthcare overuse and cost. This study sought to identify characteristics of these programs, and their implementation contexts, that help to improve patient self-management, experience of integrated care, and healthcare services use.Methods:A mixed methods multiple embedded case study design was conducted, with six CMP implemented in six hospitals of a region of Quebec (Canada).Results:Within-case analysis describes the structural, environmental, organizational, practitioner, patient, and innovation level characteristics of each CMP and their services integration outcomes based on patient experience, self-management and healthcare services use. Cross-case analysis suggests that the skills, leadership and experience of the case manager, providers’ access to the individualized services plan, consideration of the needs of the patient and family members, their participation in decision-making, and the self-management approach, impact integrated care and healthcare services use.Conclusion and discussion:This study underscores the necessity of an experienced, knowledgeable and well-trained case manager with interpersonal skills to optimize CMP implementation such that patients are more proactive in their care and their outcomes improve.

Accelerators as drivers of coopetition among early-stage startups

Business accelerators are a phenomenon of increasing popularity in practice, but their specific value-added for the participating startups has been understudied thus far. Our study addresses this research gap by investigating how participating in a business accelerator program supports startups to forge relationships with other startups, helping them to overcome their early-stage needs. We use an in-depth exploratory qualitative research approach based on a multiple embedded case study design by studying 23 startups within six accelerators in Germany.We find evidence that startups in accelerators forge specific types of relationships, including both cooperative and competitive elements, characterizing their early-stage needs. They cooperate through joint projects and exchange and compete on the firm level for internal and external resources and on the individual level for reputation, which makes these relationships overall coopetitive. Our findings indicate the importance of accelerators in driving the startups’ relationships, as accelerators trigger “coopetitive” behavior among startups through their available tools, including events, communication and the coworking space.This study contributes to literature on business accelerators and coopetition. Additionally, this study offers implications for startups, accelerators and policy makers.

The Struggle to Professionalize Teaching: Examining edTPA as a Professionalization and Deprofessionalization Tool

Background/Context:In the United States, strengthening the professionalization of teaching and teacher education has received extensive attention. Notably, the educative Teacher Performance Assessment (edTPA) has gained traction. Developed by the Stanford Center for Assessment, Learning, & Equity (SCALE) in 2009, edTPA requires teacher candidates to videotape their teaching and reflect via three different tasks: planning, instructing, and assessing. More than one third (900+) of all teacher preparation programs (TPPs) across 41 states are now using edTPA, making it the most widely used licensure assessment in the field.Objective:In this study, we examine differences in how stakeholders (i.e., administrators, faculty, and staff) within and across TPPs are making sense of edTPA. We then examine why such differences in edTPA sensemaking have transpired, including varying policy designs, organizational contexts, and individual attitudes/values. Finally, we illustrate how these differences reflect a deeper historical dilemma in teacher education between those supporting professionalism (i.e., program-specific attitudes/beliefs) and those supporting the professionalization of teaching (i.e., structural or systemic characteristics across programs).Participants:Through purposive and snowball sampling, we interviewed 69 stakeholders across eight TPPs in two states, Illinois and Iowa. These stakeholders were interviewed between 2015 and 2018, approximately 1 year after their TPP adopted edTPA (via mandate or voluntarily).Research Design:We employed a multiple embedded case study design. The first set of cases were the two states selected (Illinois and Iowa) because their policy designs differed (mandated vs. voluntary). The second set of cases were the eight TPPs selected. One-hour interviews were conducted with each of the 69 stakeholders across these case TPPs. Using a sensemaking conceptual framework, instrumental case analysis was then used to examine how stakeholders made sense of edTPA and why.Findings/Results:We found diverse perspectives across our case TPPs as to how stakeholders viewed and implemented edTPA—as either a professionalization or a deprofessionalization tool. Those espousing a view of professionalization supported the assessment as a means to strengthen the profession’s perceived legitimacy and quality, whereas those espousing a view of deprofessionalization believed that it is detrimental in these regards. We argue that this divergence reflects enduring disagreement concerning the mechanisms that define “good” teaching and how best to measure it.Conclusions:We found that structural changes, such as edTPA adoption, may move a field toward being more or less professionalized, but those changes do not guarantee alignment or agreement among the professionals within that workforce. Improving this dilemma within teacher education therefore begins with coming to some reasonable consensus on how best to balance professionalization and professionalism.

How medical dominance and interprofessional conflicts undermine patient-centred care in hospitals: historical analysis and multiple embedded case study in Morocco

BackgroundIn Morocco’s health systems, reforms were accompanied by increased tensions among doctors, nurses and health managers, poor interprofessional collaboration and counterproductive power struggles. However, little attention has focused on the...

Learning Lessons for Evaluating Complexity Across the Nexus: A Meta-Evaluation of Environmental Projects

Background: A major gap in environmental policy making is learning lessons from past interventions and in integrating the lessons from evaluations that have been undertaken. Institutional memory of such evaluations often resides externally to government, in evaluation practitioner contractors who undertake commissioned evaluations on behalf of government departments.
 Purpose: The aims were to learn the lessons from past policy evaluations, understand the barriers and enablers to successful evaluations, to explore the value of different types of approaches and methods used for evaluating complexity, and how evaluations were used in practice. 
 Setting: A meta-evaluation of 23 environmental evaluations undertaken by Collingwood Environmental Planning Ltd (CEP), London, UK was undertaken by CEP staff under the auspices of CECAN (the Centre for Evaluation of Complexity Across the Nexus – a UK Research Councils funded centre, coordinated by the University of Surrey, UK). The research covered water, environment and climate change nexus issues, including evaluations of flood risk, biodiversity, landscape, land use, climate change, catchment management, community resilience, bioenergy, and European Union (EU) Directives.
 Intervention: Not applicable.
 Research design: A multiple embedded case study design was adopted, selecting 23 CEP evaluation cases from across a 10-year period (2006-2016). Four overarching research questions were posed by the meta-evaluation and formed the basis for more specific evaluation questions, answered on the basis of documented project final reports and supplemented by interviews with CEP project managers. Thematic analysis was used to draw out common themes from across the case categories.
 Findings: Policy context invariably framed the complex evaluations; as environmental policy has been spread beyond the responsibility of government to encompass multiple stakeholders, so policy around nexus issues was often found to be in a state of constant flux. Furthermore, an explicit theory of change was only often first elaborated as part of the evaluation process, long after the policy intervention had already been initiated. A better understanding of the policy context, its state of flux or stability as well as clarity of policy intervention’s objectives (and theory of change) could help significantly in designing policy evaluations that can deliver real value for policy makers. Evaluations have other valuable uses aside from immediate instrumental use in revising policy and can be tailored to maximise those values where such potential impact is recognised. We suggest a series of questions that practitioners and commissioners could usefully ask themselves when starting out on a new complex policy evaluation.
 Keywords: evaluation; complexity; policy use; natural environment

Advancing integrated care evaluation in shifting contexts: blending implementation research with case study design in project SUSTAIN

BackgroundDespite many studies evaluating the effectiveness of integrated care, evidence remains inconsistent. There is increasing commentary pointing out the mismatch between the ability to capture the somewhat ‘illusive’ impact of integrated care initiatives and programmes, and the most appropriate way to do this. Focusing on methodology, this paper describes and critically reviews the experiences of SUSTAIN, a Horizon 2020 funded project (2015–2019) with the purpose of advancing knowledge and understanding of cross-European integrated care evaluation. SUSTAIN sought to improve integrated care initiatives for older people in seven countries, and to maximise the potential for knowledge transfer and application across Europe. The methods approach drew from implementation research, employing the participative Evidence Integration Triangle (EIT) and incorporating a mixed method, multiple embedded case study design. A core set of qualitative and quantitative indicators, alongside context and process data, were created and tested within four key project domains (person-centredness, prevention-orientation, safety and efficiency). The paper critically discusses the overall approach, highlighting the value of the EIT and case study design, and signalling the challenges of data collection with frail older people and stakeholder involvement at the sites, as well as difficulties developing the core set of indicators.ConclusionsLessons learned and recommendations for advancing integrated care evaluation are put forward that focus on the status of integrated care as a complex intervention and a process. The use of implementation research methods and case study design are recommended as an additional evaluation approach for researchers to consider, alongside suggested ways of improving methods of data collection with frail populations and cost analysis.

Improving Person-Centredness in Integrated Care for Older People: Experiences from Thirteen Integrated Care Sites in Europe.

Introduction:Although person-centredness is a key principle of integrated care, successfully embedding and improving person-centred care for older people remains a challenge. In the context of a cross-European project on integrated care for older people living at home, the objective of this paper is to provide insight at an overarching level, into activities aimed at improving person-centredness within the participating integrated care sites. The paper describes experiences with these activities from the service providers’ and service users’ perspectives.Methods:A multiple embedded case study design was conducted that included thirteen integrated care sites for older people living at home.Results:Service providers were positive about the activities that aimed to promote person-centred care and thought that most activities (e.g. comprehensive needs assessment) positively influenced person-centredness. Experiences of service users were mixed. For some activities (e.g. enablement services), discrepancies were identified between the views of service providers and those of service users.Discussion and conclusion:Evaluating activities aimed at promoting person-centredness from both the service providers’ and service users’ perspectives showed that not all efforts were successful or had the intended consequences for older people. Involvement of older people in designing improvement activities could ensure that care and support reflect their needs and preferences, and build positive experiences of care and support.

Opening the 'implementation black-box' of the user fee exemption policy for caesarean section in Benin: a realist evaluation.

To improve access to maternal health services, Benin introduced in 2009 a user fee exemption policy for caesarean sections. Similar to other low- and middle-income countries, its implementation showed mixed results. Our study aimed at understanding why and in which circumstances the implementation of this policy in hospitals succeeded or failed. We adopted the realist evaluation approach and tested the initial programme theory through a multiple embedded case study design. We selected two hospitals with contrastive outcomes. We used data from 52 semi-structured interviews, a patient exit survey, a costing study of caesarean section and an analysis of financial flows. In the analysis, we used the intervention-context-actor-mechanism-outcome configuration heuristic. We identified two main causal pathways. First, in the state-owned hospital, which has a public-oriented but administrative management system, and where citizens demand accountability through various channels, the implementation process was effective. In the non-state-owned hospital, managers were guided by organizational financial interests more than by the inherent social value of the policy, there was a perceived lack of enforcement and the implementation was poor. We found that trust, perceived coercion, adherence to policy goals, perceived financial incentives and fairness in their allocation drive compliance, persuasion, positive responses to incentives and self-efficacy at the operational level to generate the policy implementation outcomes. Compliance with the policy depended on enforcement by hierarchical authority and bottom-up pressure. Persuasion depended on the alignment of the policy with personal and organizational values. Incentives may determine the adoption if they influence the local stakeholder’s revenue are trustworthy and perceived as fairly allocated. Failure to anticipate the differential responses of implementers will prevent the proper implementation of user fee exemption policies and similar universal health coverage reforms.

Does public service motivation matter in Moroccan public hospitals? A multiple embedded case study

BackgroundThe motivation of health workers is a key concern of policy makers, practitioners and researchers. Public Service Motivation (PSM), defined as the altruistic desire to serve the common interest, to serve others and to help patients and their families regardless of financial or external rewards, has been shown to be key to the performance of public servants. Yet, limited attention has been paid to this kind of motivation in health care settings in low- and middle-income countries. Little is known about PSM and its contextual specificity in the Moroccan health system. We set out to qualitatively explore the meaning of PSM and its expression among health workers in four public hospitals.MethodsWe adopted a multiple embedded case study design to explore PSM in two well-performing and two poor-performing hospitals. We carried out 68 individual interviews, eight focus group discussions and 11 group discussions with different cadres (doctors, administrators and nurses). We carried out thematic analysis using NVivo 10.ResultsOur analysis shows that public service motivation is a notion that seems natural to the health workers we interviewed. Daily interactions with patients catalysed health providers’ affective motives (compassion and self- sacrifice), a central element of PSM. It also provided them with job satisfaction aligned with their intrinsic motivation. Managers and administrative personnel express other PSM components: attraction to public policy making and commitment to public values. A striking result is that health workers expressed strong religious beliefs about expected rewards from God when properly serving patients.ConclusionThis study highlights the presence of PSM as a driver of motivation among health workers in four Moroccon hospitals, and the prominence of intrinsic motivation and compassion in the motivation of frontline health workers. Religious beliefs were found to shape the expression of PSM in Morocco.

Designing and evaluating provider results-based financing for tuberculosis care in Georgia: a realist evaluation protocol

IntroductionIn 2016, Georgian researchers and policymakers were developing a policy to improve the performance of the national tuberculosis (TB) control programme. The research programme ‘Designing and Evaluating Provider Results-Based Financing...

Identifying evidence to define community-based rehabilitation practice in China using a case study approach with multiple embedded case study design

BackgroundThis study examined community-based rehabilitation (CBR) practice in China on the basis of the development of an evaluation system using current evidence in a real context.MethodsA multiple embedded case study design was used to interpret both quantitative and qualitative data. In Part 1, a thematic analysis was conducted to identify the different levels of evidence available in CBR programs in China. Identified themes were then associated with the literature to form a system to code, categorise, and rank the obtained evidence. In Part 2, CBR practice was examined in 12 CBR programs by using the developed evaluation system with the CBR matrix and CBR framework.ResultsSix themes under three categorised levels of evidence for demonstrating quality of practice were found. An evaluation system of program practice, based on existing standards to define levels of evidence, was created and used with the CBR matrix and CBR framework to evaluate the quality of practice in 12 CBR programs. The results of a within-case analysis revealed the strengths and areas for improvement in each program. An across-case analysis by using identified correlations revealed the characteristics of CBR practice in China, as demonstrated in the interaction of core CBR components. The content elements of CBR programs were significantly correlated with health outcomes, social development, education, and empowerment. Empowerment was significantly correlated with participant governance and community ownership.ConclusionThe proposed evaluation system, as developed in a real context, is feasible for monitoring and identifying the strengths of and areas for improvement in CBR programs. This study described the characteristics and interaction of different CBR components in CBR practice in China and is pertinent for enhancing the evidence-based practices and quality of CBR programs in China.

The SUSTAIN Project: A European Study on Improving Integrated Care for Older People Living at Home.

Introduction:Integrated care programmes are increasingly being put in place to provide care to older people who live at home. Knowledge of how to further develop integrated care and how to transfer successful initiatives to other contexts is still limited. Therefore, a cross-European research project, called Sustainable Tailored Integrated Care for Older People in Europe (SUSTAIN), has been initiated with a twofold objective: 1. to collaborate with local stakeholders to support and monitor improvements to established integrated care initiatives for older people with multiple health and social care needs. Improvements focus on person-centredness, prevention orientation, safety and efficiency; 2. to make these improvements applicable and adaptable to other health and social care systems, and regions in Europe. This paper presents the overall structure and approach of the SUSTAIN project.Methods:SUSTAIN uses a multiple embedded case study design. In three phases, SUSTAIN partners: (i) conduct interviews and workshops with stakeholders from fourteen established integrated care initiatives to understand where they would prefer improvements to existing ways of working; (ii) collaborate with local stakeholders to support the design and implementation of improvement plans, evaluate implementation progress and outcomes per initiative, and carry out overarching analyses to compare the different initiatives, and; (iii) translate knowledge and experience to an online roadmap.Discussion:SUSTAIN aims to generate evidence on how to improve integrated care, and apply and transfer the knowledge gained to other health and social care systems, and regions. Lessons learned will be brought together in practical tools to inform and support policy-makers and decision-makers, as well as other stakeholders involved in integrated care, to manage and improve care for older people living at home.

Multi-level gaps: a study of intended, actual and experienced human resource practices in a hypermarket chain in India

Multi-level (Multi-level in this paper refers to three levels- intended, actual and experienced- at which HR practices are theorised in the existing strategic human resource management process research) gaps in human resource (HR) practices have not been extensively investigated in the HR literature. Using a multiple embedded case study design within a multi-unit hypermarket chain in India, we identify ‘Intended-Actual-Experienced’ gaps across nine HR practices in seven retail units. We find that these gaps arise from implementers’ adaptation of HR practices due to different understandings of the intent of HR practices, the importance given to their contents and the processes adopted in their implementation. We propose an inductive model for emergence of multi-level gaps in HR practices. Our model depicts the processes and variables that have the potential to enable or disable adaptation, delivery and experience of HR practices, thus creating gaps between intended and experienced HR practices. This paper highlights the need for further research on HR implementation with particular focus on gaps. It also provides a framework for practitioners to take cognisance of the gaps that could impact implementation and experience of corporate-driven HR practices.

A comprehensive grid to evaluate case management’s expected effectiveness for community-dwelling frail older people: results from a multiple, embedded case study

BackgroundCase management is a type of intervention expected to improve the quality of care and therefore the quality of life of frail, community-dwelling older people while delaying institutionalisation in nursing homes. However, the heterogeneity, multidimensionality and complexity of these interventions make their evaluation by the means of classical approaches inadequate. Our objective was twofold: (i) to propose a tool allowing for the identification of the key components that explain the success of case management for this population and (ii) to propose a typology based on the results of this tool.MethodsThe process started with a multiple embedded case study design in order to identify the key components of case management. Based on the results of this first step, data were collected among 22 case management interventions, in order to evaluate their expected effectiveness. Finally, multiple correspondence analyses was conducted to propose a typology of case management. The overall approach was informed by Wagner’s Chronic Care Model and the theory of complexity.ResultsThe study identified a total of 23 interacting key components. Based on the clustering of response patterns of the 22 case management projects included in our study, three types of case management programmes were evidenced, situated on a continuum from a more “socially-oriented” type towards a more “clinically-oriented” type of case management. The type of feedback provided to the general practitioner about both the global geriatric assessment and the result of the intervention turned out to be the most discriminant component between the types.ConclusionThe study design allowed to produce a tool that can be used to distinguish between different types of case management interventions and further evaluate their effect on frail older people in terms of the delaying institutionalisation, functional and cognitive status, quality of life and societal costs.Electronic supplementary materialThe online version of this article (doi:10.1186/s12877-015-0069-1) contains supplementary material, which is available to authorized users.