A CASE STUDY APPROACH

According to Yin (2014:4), a case study approach is used when one needs to conduct an in-depth analysis in order to understand a particular social phenomenon such as the analysis of communication dynamics at a specific clinic. According to Yin (2014:17), a case study adds value to the overall study for the following reasons:

• It copes with the technically distinctive situation in which there are many more variables of interest than data points.

• It relies on multiple sources of evidence, with data needing to converge in a triangulation fashion.

• It benefits from the prior development of theoretical propositions to guide data collection and analysis.

A case study approach therefore enables the researcher to study a phenomenon in in depth in its real-world context. According to Rowley (2004:211), “an important strength of case study research is that it investigates a phenomenon in its context.

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This is why it recommends itself for use in professional research.” This allows the HCP’s and patients’ relationships to be studied in their real-world (medical setting) context. According to Yin (1999):

“for case studies, data collection may-and-should-involve a broad variety of techniques, not just a single technique such as conducting a site visit ... In using multiple sources of evidence, the goal during the data collection process is to amass converging evidence and to triangulate over a given fact.”

Multiple data collection methods, which included a semi-structured interview schedule and a non-participant observation schedule and documentation were used to collect data at the clinic. The semi-structured interview schedule was guided by theoretical propositions which guided the data collection and data analysis phases.

As the fieldwork proceeded, documentation emerged as a third data collection method to further triangulate data collected in the field.

According to Yin (2014:51–52), the selection of a single case study design is appropriate under several circumstances, which include five rationales that can assist researchers. These include the following:

• A critical case. This involves clear circumstances in which propositions are believed true, which allows for the determination of whether propositions are true or correct or if other explanations are more relevant.

• Unusual. This entails a specific case deviating from everyday norms. It is worth documenting findings in this case since it reveals insight about processes.

• Common. These cases capture circumstances and conditions of everyday situations and provide insight about social processes.

• Revelatory. Such cases provide the opportunity to observe and analyse a phenomenon previously inaccessible to inquiry.

• Longitudinal case. This involves studying the same case at two or more points in time, to analyse how conditions and processes change over time.

The following reasons were used to justify the selection of a single case for this research: unusual, common case and revelatory.

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The unusual case is beneficial in clinical research where findings can assist with analysing and gaining insight into disorders or processes that deviate from the norm.

Regarding diabetes, research findings are worth documenting in order to reveal insight into aspects of health communication for this illness.

With regard to common case, this study was conducted at a single clinic which provided an in-depth approach to understanding HCP-patient communication for diabetes care and treatment. The data provided explanations for understanding communication dynamics and its ability to either facilitate or hamper treatment adherence patterns for diabetic patients in a provincial health-care setting that occur on a daily basis. The social context at this specific clinic and its geographical area were analysed in relation to diabetes health-care and patient adherence patterns.

Regarding the question of revelatory, no previous research had been conducted at Stanger Hospital’s diabetes clinic as the clinic had been previously inaccessible for research owing to the fact that no separate diabetes clinic had existed. Instead, diabetes patients were consulted at the hospital’s out-patient department. Hence the revelatory reason or rationale further justified the single clinic selection in order to conduct an in-depth analysis. In the past, diabetes-specific activities could only be accessed with difficulty as diabetic patients were mixed with other patients using out-patient facilities. The remaining reasons for using a critical and longitudinal case did not apply here because the study was not intended to test propositions for truth or to analyse the case in a longitudinal manner in order to judge how conditions or processes change over time.

Rowley (2004:211) emphasises the point that “case study research starts with an analysis and description of the situation in one organization”. This justifies that a case study approach can be conducted at single site organisations, such as a diabetes clinic in the case of this research study.

Yin (2014:29) identifies the following five components that a case study approach should include:

• Its research questions. These refer to the actual research questions to be answered in the form of “who, what, where, when, how and why”

(Yin 2014:29) (see chapter 1). Yin (2014:9, 14) states that a case study’s research questions are more specifically how and why. These

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relate to contemporary events over which the researcher has no control.

• Its propositions, if any. According to Yin (2014:30), “each proposition directs attention to something that should be studied within the scope of the study.” Propositions are viewed as a basis for reasoning or a starting point for further investigation from known facts. Propositions shape the focus of the study together with the specific research questions which help narrow the study’s perspective. This study did not make use of propositions since it followed a qualitative research methodology which was open and flexible. In addition, it did not use a specific basis or any known facts as a starting point for the research.

• Its unit(s) of analysis: The units of analysis refer to “who” or “what” is being studied (Babbie & Mouton 2001; Trochim 2006). The units of analysis in the current study included the HCPs’ staff members (treatment team) and the patients (multiple individuals) who made use of the diabetes clinic for medical treatment and care. According to Brewer and Hunter (2006:88), the units of observation and units of analysis can differ in studies, or they can be the same. For the purposes of this study, the HCPs and the patients were regarded as the units of analysis as well as the units of observation (see table 6.1 below).

• The logic linking the data to the propositions. According to Yin (2014:35), this component assists with the study’s data analysis steps, which include: pattern matching, explanation building, time-series analysis, logic models and cross-case synthesis. The data collected should be assembled or combined with the initial propositions of the study. Even though Yin (2014) makes provision for different data analysis procedures as outlined above, this study made use of Tesch’s eight steps for interpreting and analysing data, which are discussed in section 6.9 below.

• The criteria for interpreting the findings. According to Yin (2014:36), this component arises in case study research when quantitative,

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statistical analyses are used to analyse data collected and it is therefore not applicable to this study.

6.3.1 Types of case studies

Case study research design is distinct from other research methods because it does not include a formal design. However, Yin (2014:50) suggests that having some notion of a formal design can make the study stronger and easier to conduct. Yin (2014:50) identifies different types of case study designs namely, single case and multiple case designs. Each type aims at analysing the context of the case.

However, the boundaries between the case and the context are often blurred and indistinctive. The design for this study was the single case with the units of analysis/units of observation being patients and HCPs.

As opposed to Yin’s four types of case study design, Stake (2000) identifies three types, namely the instrumental, collective and intrinsic case study. The instrumental case study is aimed at providing insight into an issue or revising a generalisation.

The focus is not the actual case, but something else. A collective case study refers to a study that includes a number of cases in order to investigate a general phenomenon (Stake, 2000). In this instance, the study can be categorised as an intrinsic case study where research was conducted to gain an in-depth understanding of the selected case with no intention of generalisations or theory building beyond the single case. This study focused on understanding communication dynamics at the diabetes clinic located at Stanger Hospital. The purpose was to understand how communication in the HCP-patient relationship and the HCP-HCP teamwork relationship contributed to positive or negative patient care and treatment adherence in the context of diabetes.

The table below provides an explanation of case study research (analytical features) as it was applied to this study:

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Table 6.1: Case study analytical features as applied to the study

Case study research: analytical features Applied to the selected case study

Each case has boundaries which must be identified at an early stage of the research.

Case study: Stanger Hospital’s diabetes clinic:

● HCP-patient communication dynamics

● HCP-HCP teamwork relationships

● Patient treatment adherence patterns

● Interactive communication: facilitation or hampering of effective treatment adherence Each case will be something in which the

researcher is interested. The unit of analysis/unit of observation must be defined at the outset in order to clarify the research strategy.

The researcher was interested in conducting research at this specific diabetes clinic since no previous research had been conducted there.

Interest was focused on understanding communication dynamics for diabetes as an illness.

● The units of analysis/units of observation were patients and HCPs

Case studies seek to preserve the wholeness and integrity of the case. In order to achieve some focus, a limited research problem/research goal must be established that is geared to specific features of the case.

Against the background of the rising burden of diabetes, effective management of the disease has become essential to reduce complications and morbidity. Effective communication is central to this.

In this study, a case study research approach was used at Stanger Hospital’s diabetes clinic to assess the quality of HCP-patient and HCP-HCP communication dynamics in disease management.

A health communication model was developed (from a variety of other models) to explain the health communication process at the research site.

(Source: Punch 1998)