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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 ...

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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
                                                                                                                      540
                                                                                       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-
                                                    10
                      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 
                                    15
                         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 
                                                                                                                                                                                                           19
                   investigates a contemporary phenomenon (the ‘case’)                                                 approaches can be combined with the case study.  
                                                                 14
                   within its real-life context.”  Although reality cannot                                             The design will depend on the theoretical framework 
                                                                                                                                                                                                                 19
                   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 
                                                                                                                                                                                                                16
                   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 
                                                               17
                   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.
                                               15
                   tion to progress.  In this perspective, the truth is what 
                                                 15
                   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
                                                                                                                   542
                                                                                       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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...Case study with a participatory approach rethinking pragmatics of stakeholder engagement for implementation research catherine hudon md phd abstract maud christine chouinard rn the design is particularly useful analysis com plex health care innovations in primary that can be influenced by con text dynamic environments studies may combined mathieu bisson ma approaches where academics conduct joint nonacademic stakehold alya danish ers to foster translation findings results into practice aim this article clarify epistemological and methodological considerations marlene karam it also aims propose best recommendations ariane girard when using we distinguish between full co construction governance pierre luc bosse msw whereby stakeholders are consulted certain phases mireille lambert then compare posture prominent methodologists yin stake merriam present department family medicine emer gency university sherbrooke relevance applica quebec canada tions procedures methodol faculty nursing ogy ...

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