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Case Study With a Participatory Approach:
Rethinking Pragmatics of Stakeholder
Engagement for Implementation Research
1
Catherine Hudon, MD, PhD ABSTRACT
Maud-Christine Chouinard, RN, The case study design is particularly useful for implementation analysis of com-
2 plex health care innovations in primary care that can be influenced by the con-
PhD
1 text of dynamic environments. Case studies may be combined with participatory
Mathieu Bisson, MA approaches where academics conduct joint research with nonacademic stakehold-
1
Alya Danish, PhD ers, to foster translation of findings results into practice. The aim of this article is
2 to clarify epistemological and methodological considerations of case studies with
Marlène Karam, PhD a participatory approach. It also aims to propose best practice recommendations
1
Ariane Girard, RN, PhD when using this case study approach. We distinguish between the participatory
1 case study with full co-construction and co-governance, and the case study with
Pierre-Luc Bossé, MSW
3 a participatory approach whereby stakeholders are consulted in certain phases of
Mireille Lambert, MA the research. We then compare the epistemological posture of 3 prominent case
1 study methodologists, Yin, Stake, and Merriam, to present the epistemological
Department of Family Medicine and Emer-
gency Medicine, University of Sherbrooke, posture of case studies with a participatory approach. The relevance, applica-
Sherbrooke, Quebec, Canada tions, and procedures of a case study with a participatory approach methodol-
2Faculty of Nursing, University ogy are illustrated through a concrete example of a primary care research pro-
of Montreal, Montreal, Quebec, Canada gram (PriCARE). We propose 12 steps for designing and conducting a case study
3Integrated University Health and Social with a participatory approach that may help guide researchers in the implemen-
Services Centre, Chicoutimi, Quebec, tation analysis of complex health care innovations in primary care.
Canada
Ann Fam Med 2021;19:540-546. https://doi.org/10.1370/afm.2717.
BACKGROUND
ver the last 40 years, case study research has become increasingly
popular and has evolved rapidly in many disciplines. By allowing
1
Oin-depth analysis of complex phenomena in real-world contexts,
the case study design is particularly useful in health services research,2 for
implementation analysis of complex interventions that can be influenced
3
by the context of dynamic environments. Public health and primary
care research encourage a participatory approach because involvement of
4
stakeholders fosters translation of research findings into practice. This
was the case of the PriCARE primary care research program. In this multi-
jurisdictional Canadian study, the research team and stakeholders aimed
to evaluate the implementation of a case management intervention in 10
primary care clinics, for frequent users of health care services with chronic
diseases and complex care needs.5,6 It is important to first distinguish the
Conflicts of interest: authors report none. case study with a participatory approach from the participatory case study
before proceeding with the example of the PriCARE program.
CORRESPONDING AUTHOR
Catherine Hudon Participatory Research and the Case Study
Department of Family Medi- Participatory research is a systematic inquiry whereby academics con-
cine and Emergency Medicine duct joint research with nonacademic partners affected by the issue
University of Sherbrooke, being studied, for purposes of education and taking action or promot-
Pavillon Z7-Rm 3007 7,8
3001, 12e Ave N ing social change. Participatory research conducted for empowerment
Sherbrooke QC, Canada J1H 5N4 or social change relies on the transformative/postmodern interpretative
Catherine.Hudon@USherbrooke.ca paradigm, in which knowledge is not neutral and reflects the power and
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ANNALS OF FAMILY MEDICINE WWW.ANNFAMMED.ORG VOL. 19, NO. 6 NOVEMBER/DECEMBER 2021
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CASE STUDY WITH A PARTICIPATORY APPROACH
social relationships within a society. The purpose of to involvement or consultation in only certain phases
knowledge construction is to help people improve of the research, balancing stakeholder engagement and
society.9 Each phase of the research process is an availability. The participatory case study with a full
opportunity to create knowledge through a col- co-governance structure relies on the transformative/
laborative effort to develop or refine the research postmodern interpretative paradigm, but what are the
questions, select the methodology, develop data col- epistemological assumptions of the case study with a
lection methods and tools, choose outcome measures, participatory approach? What steps should be taken
interpret findings, craft the message, and disseminate to ensure the validity of this approach when applied to
4
the results, feasibility, and outcomes. Rosemary C. the case study? In this article, we aim to clarify episte-
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Reilly, PhD, MEd proposes that a case study may mological and methodological considerations of case
adopt a participatory focus with full co-governance studies with a participatory approach. We also propose
where participants are fully involved as contributing best practice recommendations when applying this
researchers in all phases of the research process, from approach to the case study.
conceptualization of the study to write-up and dis-
semination of the findings. EPISTEMOLOGICAL ASSUMPTIONS
Within the different participatory research OF 3 PROMINENT CASE STUDY
approaches, the transformational intent of stakeholder METHODOLOGISTS
involvement may, however, range from empowerment
to more pragmatic considerations. The case study with Three prominent case study methodologists—Robert
a participatory approach may be adopted to facilitate K. Yin, PhD, Robert E. Stake, PhD, and Sharan B.
knowledge translation and practice changes4 in the Merriam, MEd, EdD—brought differing perspectives
implementation of a complex intervention such as case to move case study knowledge forward in educational
management, where several components interact with and social science research. All 3 provided definitions,
each other and with their context, and where there designs, applications, and procedures to follow when
11 12
are multiple highly adaptable effects. The intensity conducting case study research. Table 1 summarizes
of stakeholder involvement will vary from full co-con- and compares their epistemological positions and
struction and involvement in all stages of the research assumptions, which we discuss in more detail below.
Table 1. Comparison of Epistemological Assumptions of Yin, Stake, Merriam, and Reilly (Inspired by
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Patton )
Epistemological Knowledge Methodological
Methodologist Position Reality Assumptions Assumptions Assumptions
Robert K. Yin, PhD Postpositivism Reality exists, but we can- Knowledge is the result of the All methods have their limits, so
not know it perfectly. combination of experimen- both quantitative and qualita-
Reality is governed by tations leading to a closer tive methods are needed to
natural, causal, or other approximation of actual generate empirical evidence
laws, but they cannot be mechanisms. and test plausible rival
absolutely known. hypotheses.
Robert E. Stake, PhD Constructivism Multiple socially con- Human experience can be Qualitative methods need
structed realities are built known, and each human to capture the diversity of
through interactions with knows his/her own experi- realities through a deep
others and human lived ence of the real. understanding of peoples’
experiences. perspectives and experiences
regarding a specific situation
or phenomenon.
Sharan B. Merriam, Constructivist Reality is constructed Human experience can be All methods are considered.
MEd, EdD pragmatism through meanings known, and each human What is important is to guide
and understandings knows his/her own experi- the research process by the
developed socially and ence of the real. The finality principles of ethical and sci-
experientially. of knowledge is to address entific rigor, and to clarify
concrete problems and pro- hypotheses.
vide answers or direction to
progress. The truth will be
what works in practice.
Rosemary C. Reilly, Transformative Reality is the product of The knowledge is ideo- Qualitative method is privileged.
PhD, MEd paradigm critical interpretation that logically oriented, and the Participants to the research
aims to transform the focus is empowering in its are experts into the underly-
social world in order to goal. ing causes of the issues within
emancipate marginalized their social world.
groups or communities.
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CASE STUDY WITH A PARTICIPATORY APPROACH
Yin: Postpositivism for example, that sample selection may occur before
1,13 16
Yin’s realist–postpositivist epistemological posture or in conjunction with data collection. As it is the
defines a case study as “an empirical inquiry that unit of analysis that defines the case, other types of
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investigates a contemporary phenomenon (the ‘case’) approaches can be combined with the case study.
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within its real-life context.” Although reality cannot The design will depend on the theoretical framework
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be entirely apprehended, the knowledge generated of the study, its purpose, and the research questions.
from the case study is the result of the combination of In Merriam’s constructivist pragmatism, participatory
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experimentations leading to a closer approximation of research is an approach to enhance internal validity.
15
actual mechanisms. Yin suggests combining quantita- This epistemological posture is compatible with a par-
tive and qualitative sources, viewing them as equally ticipatory approach to case study research.
instrumental. He places considerable emphasis on pre-
paring a detailed design at the outset of the research THE WHY AND HOW OF USING A CASE
and advises that investigators make only minor changes
16 STUDY WITH A PARTICIPATORY APPROACH
in the design after they begin data collection. Interac- IN IMPLEMENTATION RESEARCH
tion with research participants therefore needs to be
minimized and subjectivity managed to avoid biasing Which case study approach should be used in imple-
16
the results. mentation research? The answer will depend on the
epistemological assumptions on which the methods
Stake: Constructivism will rely. On one hand, a research team adopting a
Stake’s epistemological commitment is to construc- postpositivist standpoint (as proposed by Yin) will
tivism, which leads him to define the case study as want to maintain independence from stakeholders
the “study of the particularity and complexity of a and will conduct the implementation analysis from
single case, coming to understand its activity within an external/objective point of view that precludes a
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important circumstances.” Unlike Yin, Stake con- participatory approach. On the other hand, a team
siders knowledge as a construction rather than the adopting a constructivist perspective (as proposed
result of an empiric inquiry developed within a logical by Stake) will plan qualitative methods to shed light
sequence. He argues that reality is multiple and subjec- on the multiple perspectives of stakeholders without
17
tive. This assertion implies that human experiences involving them as co-researchers in the study. Then
can be known through every perspective of a given again, researchers who adopt a transformative posture
situation, all of which are equally valuable. While (as proposed by Reilly) will work closely with commu-
suggesting that every viewpoint of a situation be rep- nity or organizational partners in the co-construction
resented in the case study, he recommends minimal of the implementation using a participatory case study
20
interaction between the researchers and the context of approach. Finally, a “middle ground” approach may
18
the case or the involved individuals. be to adopt a pragmatic posture (as proposed by
Merriam), where researchers use a case study with a
Merriam: Constructivist Pragmatism participatory approach to conduct an implementation
Merriam’s constructivist pragmatism appears similar analysis of a health care innovation while consulting
to Stake’s at the outset. Reality is an intersubjec- community or organizational stakeholders in certain
19
tive construction. Where she diverges from Stake phases of the research. Adopting this epistemological
is mostly in the finality of knowledge, which is to posture, we will present the example of the PriCARE
address concrete problems and give answers or direc- program5,6 in the next section.
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tion to progress. In this perspective, the truth is what
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works in practice. Merriam’s approach to case study TWELVE STEPS FOR CONDUCTING
design combines elements of Yin’s positivist standpoint CASE STUDIES WITH A PARTICIPATORY
with Stake’s constructivism. For her, a case study is APPROACH IN HEALTH CARE
essentially an in-depth description and analysis of a
19 IMPLEMENTATION RESEARCH
bounded system. Merriam proposes a structured
approach to designing research in a step-by-step pro- Building on Merriam’s previously mentioned step-by-
19
cess: conducting a literature review; constructing a step process, we propose 12 steps for conducting
theoretical framework; identifying a research problem; case studies with a participatory approach in health
crafting and sharpening research questions; and select- care implementation research. Figure 1 illustrates the
19
ing the sample (purposeful sampling). proposed research process. Steps 1 through 10 are
Yet, Merriam recommends that the study design sequential and iterative, whereas steps 11 and 12 are
remain flexible to a certain degree, which means, concurrent and ongoing.
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ANNALS OF FAMILY MEDICINE WWW.ANNFAMMED.ORG VOL. 19, NO. 6 NOVEMBER/DECEMBER 2021
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CASE STUDY WITH A PARTICIPATORY APPROACH
Figure 1. Twelve steps to conduct a case study with a participatory approach.
Participatory
approach
2. Identify 3. Consult Consult and engage stakeholders according 10. Refl ect on
stakeholders and stakeholders to agreement and governance structure the impact of
determine a gov- about the the participa-
ernance structure research tory approach
for consultation problem on the results
1. Think about 4. Conduct 5. Sharpen 6. Choose 7. Defi ne the 8. Design
what a prag- a literature research or construct case and its the methods 9. Do the
matic posture review questions or a theoretical boundaries and collect analysis
means objectives framework the data
Case study
11. Plan strategies to ensure rigor
12. Elaborate and apply a knowledge transfer plan
(1) Think About What a Pragmatic Posture at https://www.AnnFamMed.org/lookup/suppl/
Means doi:10.1370/afm.2717/-/DC1) identifies the committees
Disagreements during the project within the academic and roles of stakeholders within the PriCARE program.
research team, or between the academic research team Four types of stakeholders were involved corre-
and stakeholders, may be related to differences of epis- sponding to the categories proposed by Damschroder
temological posture or values. Being aware of and shar- et al21 in their Consolidated Framework for Imple-
ing this posture from the beginning of the project will mentation Research (Supplemental Figure 1, avail-
help maintain the coherence of methodological choices able at https://www.AnnFamMed.org/lookup/suppl/
throughout the project. For the PriCARE program, in doi:10.1370/afm.2717/-/DC1). Their roles and contribu-
accordance with the pragmatic posture of Merriam, tions are detailed below.
the academic research team decided on consultation of Opinion leaders. Decision makers, who are referred to
varying intensity, rather than full partnership, depend- as opinion leaders,21 are in a good position to inform
ing on the category of stakeholders. the team regarding the broad context of implementa-
tion and to play a role in disseminating results and
(2) Identify Stakeholders and Determine applying new knowledge. In the PriCARE program,
a Governance Structure for Consultation decision makers were health center chief executive
To optimize the implementation process and practice officers, primary care services directors, and representa-
changes, various stakeholders—decision makers, clini- tives of health ministries. The academic research team
cians, and patient partners—may collaborate with the consulted decision makers from each participating prov-
academic research team according to their interest, ince while writing the grant request to ensure consider-
availability, and expertise. In PriCARE, decision makers ation of the global context in which the project would
and clinicians were consulted based on the relevance of be implemented. Decision makers were consulted for
their expertise to certain phases of the project, and to strategic decisions and for knowledge transfer activities.
accommodate time constraints, whereas most patient Champions. As champions,21 clinicians working on
partners were engaged as co-researchers in all steps of the ground are usually aware of the specific dynam-
the project. Many stakeholders were involved before ics in their setting and can give useful advice to the
the grant was obtained and in a pragmatic context research team regarding feasibility, potential chal-
(people changing jobs or people expressing interest lenges, or adaptation required before implementation.
in being involved), whereas other stakeholders joined Champions can be helpful in convincing their col-
the team during the project (new patient partners, new leagues to participate in the project and in encourag-
case managers, etc). Supplemental Table 1 (available ing them toward change. The academic research team
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ANNALS OF FAMILY MEDICINE WWW.ANNFAMMED.ORG VOL. 19, NO. 6 NOVEMBER/DECEMBER 2021ANNALS OF FAMILY MEDICINE WWW.ANNFAMMED.ORG VOL. 19, NO. 6 NOVEMBER/DECEMBER 2021
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