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

case study of alternative

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

Research question

  • Conceptual framework
  • Conceptual vs. theoretical framework

Data collection

  • Qualitative research methods
  • Focus groups
  • Observational research

What is a case study?

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

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

Case studies

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

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

Definition of a case study

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

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

Characteristics of case studies

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

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

The role of case studies in research

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

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

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

What is the purpose of a case study?

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

Why use case studies in qualitative research?

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

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

The explanatory, exploratory, and descriptive roles of case studies

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

The impact of case studies on knowledge development

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

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

Types of case studies

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

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

Exploratory case studies

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

Descriptive case studies

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

Explanatory case studies

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

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Intrinsic, instrumental, and collective case studies

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

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

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

Critical information systems research

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

Health research

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

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

Asthma research studies

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

Other fields

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

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

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

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


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

Units of analysis

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


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

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

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

Defining the research question

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

Selecting and defining the case

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

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

Developing a detailed case study protocol

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

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

Collecting data

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

Analyzing and interpreting data

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

Writing the case study report

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

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

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

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


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

Documents and artifacts

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

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

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

Ensuring the quality of data collection

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

Data analysis

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

Organizing the data

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

Categorizing and coding the data

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

Identifying patterns and themes

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

Interpreting the data

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

Verification of the data

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

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

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

Benefits include the following:

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

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

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

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

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Organizing Your Social Sciences Research Assignments

  • Annotated Bibliography
  • Analyzing a Scholarly Journal Article
  • Group Presentations
  • Dealing with Nervousness
  • Using Visual Aids
  • Grading Someone Else's Paper
  • Types of Structured Group Activities
  • Group Project Survival Skills
  • Leading a Class Discussion
  • Multiple Book Review Essay
  • Reviewing Collected Works
  • Writing a Case Analysis Paper
  • Writing a Case Study
  • About Informed Consent
  • Writing Field Notes
  • Writing a Policy Memo
  • Writing a Reflective Paper
  • Writing a Research Proposal
  • Generative AI and Writing
  • Acknowledgments

Definition and Introduction

Case analysis is a problem-based teaching and learning method that involves critically analyzing complex scenarios within an organizational setting for the purpose of placing the student in a “real world” situation and applying reflection and critical thinking skills to contemplate appropriate solutions, decisions, or recommended courses of action. It is considered a more effective teaching technique than in-class role playing or simulation activities. The analytical process is often guided by questions provided by the instructor that ask students to contemplate relationships between the facts and critical incidents described in the case.

Cases generally include both descriptive and statistical elements and rely on students applying abductive reasoning to develop and argue for preferred or best outcomes [i.e., case scenarios rarely have a single correct or perfect answer based on the evidence provided]. Rather than emphasizing theories or concepts, case analysis assignments emphasize building a bridge of relevancy between abstract thinking and practical application and, by so doing, teaches the value of both within a specific area of professional practice.

Given this, the purpose of a case analysis paper is to present a structured and logically organized format for analyzing the case situation. It can be assigned to students individually or as a small group assignment and it may include an in-class presentation component. Case analysis is predominately taught in economics and business-related courses, but it is also a method of teaching and learning found in other applied social sciences disciplines, such as, social work, public relations, education, journalism, and public administration.

Ellet, William. The Case Study Handbook: A Student's Guide . Revised Edition. Boston, MA: Harvard Business School Publishing, 2018; Christoph Rasche and Achim Seisreiner. Guidelines for Business Case Analysis . University of Potsdam; Writing a Case Analysis . Writing Center, Baruch College; Volpe, Guglielmo. "Case Teaching in Economics: History, Practice and Evidence." Cogent Economics and Finance 3 (December 2015). doi:

How to Approach Writing a Case Analysis Paper

The organization and structure of a case analysis paper can vary depending on the organizational setting, the situation, and how your professor wants you to approach the assignment. Nevertheless, preparing to write a case analysis paper involves several important steps. As Hawes notes, a case analysis assignment “ useful in developing the ability to get to the heart of a problem, analyze it thoroughly, and to indicate the appropriate solution as well as how it should be implemented” [p.48]. This statement encapsulates how you should approach preparing to write a case analysis paper.

Before you begin to write your paper, consider the following analytical procedures:

  • Review the case to get an overview of the situation . A case can be only a few pages in length, however, it is most often very lengthy and contains a significant amount of detailed background information and statistics, with multilayered descriptions of the scenario, the roles and behaviors of various stakeholder groups, and situational events. Therefore, a quick reading of the case will help you gain an overall sense of the situation and illuminate the types of issues and problems that you will need to address in your paper. If your professor has provided questions intended to help frame your analysis, use them to guide your initial reading of the case.
  • Read the case thoroughly . After gaining a general overview of the case, carefully read the content again with the purpose of understanding key circumstances, events, and behaviors among stakeholder groups. Look for information or data that appears contradictory, extraneous, or misleading. At this point, you should be taking notes as you read because this will help you develop a general outline of your paper. The aim is to obtain a complete understanding of the situation so that you can begin contemplating tentative answers to any questions your professor has provided or, if they have not provided, developing answers to your own questions about the case scenario and its connection to the course readings,lectures, and class discussions.
  • Determine key stakeholder groups, issues, and events and the relationships they all have to each other . As you analyze the content, pay particular attention to identifying individuals, groups, or organizations described in the case and identify evidence of any problems or issues of concern that impact the situation in a negative way. Other things to look for include identifying any assumptions being made by or about each stakeholder, potential biased explanations or actions, explicit demands or ultimatums , and the underlying concerns that motivate these behaviors among stakeholders. The goal at this stage is to develop a comprehensive understanding of the situational and behavioral dynamics of the case and the explicit and implicit consequences of each of these actions.
  • Identify the core problems . The next step in most case analysis assignments is to discern what the core [i.e., most damaging, detrimental, injurious] problems are within the organizational setting and to determine their implications. The purpose at this stage of preparing to write your analysis paper is to distinguish between the symptoms of core problems and the core problems themselves and to decide which of these must be addressed immediately and which problems do not appear critical but may escalate over time. Identify evidence from the case to support your decisions by determining what information or data is essential to addressing the core problems and what information is not relevant or is misleading.
  • Explore alternative solutions . As noted, case analysis scenarios rarely have only one correct answer. Therefore, it is important to keep in mind that the process of analyzing the case and diagnosing core problems, while based on evidence, is a subjective process open to various avenues of interpretation. This means that you must consider alternative solutions or courses of action by critically examining strengths and weaknesses, risk factors, and the differences between short and long-term solutions. For each possible solution or course of action, consider the consequences they may have related to their implementation and how these recommendations might lead to new problems. Also, consider thinking about your recommended solutions or courses of action in relation to issues of fairness, equity, and inclusion.
  • Decide on a final set of recommendations . The last stage in preparing to write a case analysis paper is to assert an opinion or viewpoint about the recommendations needed to help resolve the core problems as you see them and to make a persuasive argument for supporting this point of view. Prepare a clear rationale for your recommendations based on examining each element of your analysis. Anticipate possible obstacles that could derail their implementation. Consider any counter-arguments that could be made concerning the validity of your recommended actions. Finally, describe a set of criteria and measurable indicators that could be applied to evaluating the effectiveness of your implementation plan.

Use these steps as the framework for writing your paper. Remember that the more detailed you are in taking notes as you critically examine each element of the case, the more information you will have to draw from when you begin to write. This will save you time.

NOTE : If the process of preparing to write a case analysis paper is assigned as a student group project, consider having each member of the group analyze a specific element of the case, including drafting answers to the corresponding questions used by your professor to frame the analysis. This will help make the analytical process more efficient and ensure that the distribution of work is equitable. This can also facilitate who is responsible for drafting each part of the final case analysis paper and, if applicable, the in-class presentation.

Framework for Case Analysis . College of Management. University of Massachusetts; Hawes, Jon M. "Teaching is Not Telling: The Case Method as a Form of Interactive Learning." Journal for Advancement of Marketing Education 5 (Winter 2004): 47-54; Rasche, Christoph and Achim Seisreiner. Guidelines for Business Case Analysis . University of Potsdam; Writing a Case Study Analysis . University of Arizona Global Campus Writing Center; Van Ness, Raymond K. A Guide to Case Analysis . School of Business. State University of New York, Albany; Writing a Case Analysis . Business School, University of New South Wales.

Structure and Writing Style

A case analysis paper should be detailed, concise, persuasive, clearly written, and professional in tone and in the use of language . As with other forms of college-level academic writing, declarative statements that convey information, provide a fact, or offer an explanation or any recommended courses of action should be based on evidence. If allowed by your professor, any external sources used to support your analysis, such as course readings, should be properly cited under a list of references. The organization and structure of case analysis papers can vary depending on your professor’s preferred format, but its structure generally follows the steps used for analyzing the case.


The introduction should provide a succinct but thorough descriptive overview of the main facts, issues, and core problems of the case . The introduction should also include a brief summary of the most relevant details about the situation and organizational setting. This includes defining the theoretical framework or conceptual model on which any questions were used to frame your analysis.

Following the rules of most college-level research papers, the introduction should then inform the reader how the paper will be organized. This includes describing the major sections of the paper and the order in which they will be presented. Unless you are told to do so by your professor, you do not need to preview your final recommendations in the introduction. U nlike most college-level research papers , the introduction does not include a statement about the significance of your findings because a case analysis assignment does not involve contributing new knowledge about a research problem.

Background Analysis

Background analysis can vary depending on any guiding questions provided by your professor and the underlying concept or theory that the case is based upon. In general, however, this section of your paper should focus on:

  • Providing an overarching analysis of problems identified from the case scenario, including identifying events that stakeholders find challenging or troublesome,
  • Identifying assumptions made by each stakeholder and any apparent biases they may exhibit,
  • Describing any demands or claims made by or forced upon key stakeholders, and
  • Highlighting any issues of concern or complaints expressed by stakeholders in response to those demands or claims.

These aspects of the case are often in the form of behavioral responses expressed by individuals or groups within the organizational setting. However, note that problems in a case situation can also be reflected in data [or the lack thereof] and in the decision-making, operational, cultural, or institutional structure of the organization. Additionally, demands or claims can be either internal and external to the organization [e.g., a case analysis involving a president considering arms sales to Saudi Arabia could include managing internal demands from White House advisors as well as demands from members of Congress].

Throughout this section, present all relevant evidence from the case that supports your analysis. Do not simply claim there is a problem, an assumption, a demand, or a concern; tell the reader what part of the case informed how you identified these background elements.

Identification of Problems

In most case analysis assignments, there are problems, and then there are problems . Each problem can reflect a multitude of underlying symptoms that are detrimental to the interests of the organization. The purpose of identifying problems is to teach students how to differentiate between problems that vary in severity, impact, and relative importance. Given this, problems can be described in three general forms: those that must be addressed immediately, those that should be addressed but the impact is not severe, and those that do not require immediate attention and can be set aside for the time being.

All of the problems you identify from the case should be identified in this section of your paper, with a description based on evidence explaining the problem variances. If the assignment asks you to conduct research to further support your assessment of the problems, include this in your explanation. Remember to cite those sources in a list of references. Use specific evidence from the case and apply appropriate concepts, theories, and models discussed in class or in relevant course readings to highlight and explain the key problems [or problem] that you believe must be solved immediately and describe the underlying symptoms and why they are so critical.

Alternative Solutions

This section is where you provide specific, realistic, and evidence-based solutions to the problems you have identified and make recommendations about how to alleviate the underlying symptomatic conditions impacting the organizational setting. For each solution, you must explain why it was chosen and provide clear evidence to support your reasoning. This can include, for example, course readings and class discussions as well as research resources, such as, books, journal articles, research reports, or government documents. In some cases, your professor may encourage you to include personal, anecdotal experiences as evidence to support why you chose a particular solution or set of solutions. Using anecdotal evidence helps promote reflective thinking about the process of determining what qualifies as a core problem and relevant solution .

Throughout this part of the paper, keep in mind the entire array of problems that must be addressed and describe in detail the solutions that might be implemented to resolve these problems.

Recommended Courses of Action

In some case analysis assignments, your professor may ask you to combine the alternative solutions section with your recommended courses of action. However, it is important to know the difference between the two. A solution refers to the answer to a problem. A course of action refers to a procedure or deliberate sequence of activities adopted to proactively confront a situation, often in the context of accomplishing a goal. In this context, proposed courses of action are based on your analysis of alternative solutions. Your description and justification for pursuing each course of action should represent the overall plan for implementing your recommendations.

For each course of action, you need to explain the rationale for your recommendation in a way that confronts challenges, explains risks, and anticipates any counter-arguments from stakeholders. Do this by considering the strengths and weaknesses of each course of action framed in relation to how the action is expected to resolve the core problems presented, the possible ways the action may affect remaining problems, and how the recommended action will be perceived by each stakeholder.

In addition, you should describe the criteria needed to measure how well the implementation of these actions is working and explain which individuals or groups are responsible for ensuring your recommendations are successful. In addition, always consider the law of unintended consequences. Outline difficulties that may arise in implementing each course of action and describe how implementing the proposed courses of action [either individually or collectively] may lead to new problems [both large and small].

Throughout this section, you must consider the costs and benefits of recommending your courses of action in relation to uncertainties or missing information and the negative consequences of success.

The conclusion should be brief and introspective. Unlike a research paper, the conclusion in a case analysis paper does not include a summary of key findings and their significance, a statement about how the study contributed to existing knowledge, or indicate opportunities for future research.

Begin by synthesizing the core problems presented in the case and the relevance of your recommended solutions. This can include an explanation of what you have learned about the case in the context of your answers to the questions provided by your professor. The conclusion is also where you link what you learned from analyzing the case with the course readings or class discussions. This can further demonstrate your understanding of the relationships between the practical case situation and the theoretical and abstract content of assigned readings and other course content.

Problems to Avoid

The literature on case analysis assignments often includes examples of difficulties students have with applying methods of critical analysis and effectively reporting the results of their assessment of the situation. A common reason cited by scholars is that the application of this type of teaching and learning method is limited to applied fields of social and behavioral sciences and, as a result, writing a case analysis paper can be unfamiliar to most students entering college.

After you have drafted your paper, proofread the narrative flow and revise any of these common errors:

  • Unnecessary detail in the background section . The background section should highlight the essential elements of the case based on your analysis. Focus on summarizing the facts and highlighting the key factors that become relevant in the other sections of the paper by eliminating any unnecessary information.
  • Analysis relies too much on opinion . Your analysis is interpretive, but the narrative must be connected clearly to evidence from the case and any models and theories discussed in class or in course readings. Any positions or arguments you make should be supported by evidence.
  • Analysis does not focus on the most important elements of the case . Your paper should provide a thorough overview of the case. However, the analysis should focus on providing evidence about what you identify are the key events, stakeholders, issues, and problems. Emphasize what you identify as the most critical aspects of the case to be developed throughout your analysis. Be thorough but succinct.
  • Writing is too descriptive . A paper with too much descriptive information detracts from your analysis of the complexities of the case situation. Questions about what happened, where, when, and by whom should only be included as essential information leading to your examination of questions related to why, how, and for what purpose.
  • Inadequate definition of a core problem and associated symptoms . A common error found in case analysis papers is recommending a solution or course of action without adequately defining or demonstrating that you understand the problem. Make sure you have clearly described the problem and its impact and scope within the organizational setting. Ensure that you have adequately described the root causes w hen describing the symptoms of the problem.
  • Recommendations lack specificity . Identify any use of vague statements and indeterminate terminology, such as, “A particular experience” or “a large increase to the budget.” These statements cannot be measured and, as a result, there is no way to evaluate their successful implementation. Provide specific data and use direct language in describing recommended actions.
  • Unrealistic, exaggerated, or unattainable recommendations . Review your recommendations to ensure that they are based on the situational facts of the case. Your recommended solutions and courses of action must be based on realistic assumptions and fit within the constraints of the situation. Also note that the case scenario has already happened, therefore, any speculation or arguments about what could have occurred if the circumstances were different should be revised or eliminated.

Bee, Lian Song et al. "Business Students' Perspectives on Case Method Coaching for Problem-Based Learning: Impacts on Student Engagement and Learning Performance in Higher Education." Education & Training 64 (2022): 416-432; The Case Analysis . Fred Meijer Center for Writing and Michigan Authors. Grand Valley State University; Georgallis, Panikos and Kayleigh Bruijn. "Sustainability Teaching using Case-Based Debates." Journal of International Education in Business 15 (2022): 147-163; Hawes, Jon M. "Teaching is Not Telling: The Case Method as a Form of Interactive Learning." Journal for Advancement of Marketing Education 5 (Winter 2004): 47-54; Georgallis, Panikos, and Kayleigh Bruijn. "Sustainability Teaching Using Case-based Debates." Journal of International Education in Business 15 (2022): 147-163; .Dean,  Kathy Lund and Charles J. Fornaciari. "How to Create and Use Experiential Case-Based Exercises in a Management Classroom." Journal of Management Education 26 (October 2002): 586-603; Klebba, Joanne M. and Janet G. Hamilton. "Structured Case Analysis: Developing Critical Thinking Skills in a Marketing Case Course." Journal of Marketing Education 29 (August 2007): 132-137, 139; Klein, Norman. "The Case Discussion Method Revisited: Some Questions about Student Skills." Exchange: The Organizational Behavior Teaching Journal 6 (November 1981): 30-32; Mukherjee, Arup. "Effective Use of In-Class Mini Case Analysis for Discovery Learning in an Undergraduate MIS Course." The Journal of Computer Information Systems 40 (Spring 2000): 15-23; Pessoa, Silviaet al. "Scaffolding the Case Analysis in an Organizational Behavior Course: Making Analytical Language Explicit." Journal of Management Education 46 (2022): 226-251: Ramsey, V. J. and L. D. Dodge. "Case Analysis: A Structured Approach." Exchange: The Organizational Behavior Teaching Journal 6 (November 1981): 27-29; Schweitzer, Karen. "How to Write and Format a Business Case Study." ThoughtCo. (accessed December 5, 2022); Reddy, C. D. "Teaching Research Methodology: Everything's a Case." Electronic Journal of Business Research Methods 18 (December 2020): 178-188; Volpe, Guglielmo. "Case Teaching in Economics: History, Practice and Evidence." Cogent Economics and Finance 3 (December 2015). doi:

Writing Tip

Ca se Study and Case Analysis Are Not the Same!

Confusion often exists between what it means to write a paper that uses a case study research design and writing a paper that analyzes a case; they are two different types of approaches to learning in the social and behavioral sciences. Professors as well as educational researchers contribute to this confusion because they often use the term "case study" when describing the subject of analysis for a case analysis paper. But you are not studying a case for the purpose of generating a comprehensive, multi-faceted understanding of a research problem. R ather, you are critically analyzing a specific scenario to argue logically for recommended solutions and courses of action that lead to optimal outcomes applicable to professional practice.

To avoid any confusion, here are twelve characteristics that delineate the differences between writing a paper using the case study research method and writing a case analysis paper:

  • Case study is a method of in-depth research and rigorous inquiry ; case analysis is a reliable method of teaching and learning . A case study is a modality of research that investigates a phenomenon for the purpose of creating new knowledge, solving a problem, or testing a hypothesis using empirical evidence derived from the case being studied. Often, the results are used to generalize about a larger population or within a wider context. The writing adheres to the traditional standards of a scholarly research study. A case analysis is a pedagogical tool used to teach students how to reflect and think critically about a practical, real-life problem in an organizational setting.
  • The researcher is responsible for identifying the case to study; a case analysis is assigned by your professor . As the researcher, you choose the case study to investigate in support of obtaining new knowledge and understanding about the research problem. The case in a case analysis assignment is almost always provided, and sometimes written, by your professor and either given to every student in class to analyze individually or to a small group of students, or students select a case to analyze from a predetermined list.
  • A case study is indeterminate and boundless; a case analysis is predetermined and confined . A case study can be almost anything [see item 9 below] as long as it relates directly to examining the research problem. This relationship is the only limit to what a researcher can choose as the subject of their case study. The content of a case analysis is determined by your professor and its parameters are well-defined and limited to elucidating insights of practical value applied to practice.
  • Case study is fact-based and describes actual events or situations; case analysis can be entirely fictional or adapted from an actual situation . The entire content of a case study must be grounded in reality to be a valid subject of investigation in an empirical research study. A case analysis only needs to set the stage for critically examining a situation in practice and, therefore, can be entirely fictional or adapted, all or in-part, from an actual situation.
  • Research using a case study method must adhere to principles of intellectual honesty and academic integrity; a case analysis scenario can include misleading or false information . A case study paper must report research objectively and factually to ensure that any findings are understood to be logically correct and trustworthy. A case analysis scenario may include misleading or false information intended to deliberately distract from the central issues of the case. The purpose is to teach students how to sort through conflicting or useless information in order to come up with the preferred solution. Any use of misleading or false information in academic research is considered unethical.
  • Case study is linked to a research problem; case analysis is linked to a practical situation or scenario . In the social sciences, the subject of an investigation is most often framed as a problem that must be researched in order to generate new knowledge leading to a solution. Case analysis narratives are grounded in real life scenarios for the purpose of examining the realities of decision-making behavior and processes within organizational settings. A case analysis assignments include a problem or set of problems to be analyzed. However, the goal is centered around the act of identifying and evaluating courses of action leading to best possible outcomes.
  • The purpose of a case study is to create new knowledge through research; the purpose of a case analysis is to teach new understanding . Case studies are a choice of methodological design intended to create new knowledge about resolving a research problem. A case analysis is a mode of teaching and learning intended to create new understanding and an awareness of uncertainty applied to practice through acts of critical thinking and reflection.
  • A case study seeks to identify the best possible solution to a research problem; case analysis can have an indeterminate set of solutions or outcomes . Your role in studying a case is to discover the most logical, evidence-based ways to address a research problem. A case analysis assignment rarely has a single correct answer because one of the goals is to force students to confront the real life dynamics of uncertainly, ambiguity, and missing or conflicting information within professional practice. Under these conditions, a perfect outcome or solution almost never exists.
  • Case study is unbounded and relies on gathering external information; case analysis is a self-contained subject of analysis . The scope of a case study chosen as a method of research is bounded. However, the researcher is free to gather whatever information and data is necessary to investigate its relevance to understanding the research problem. For a case analysis assignment, your professor will often ask you to examine solutions or recommended courses of action based solely on facts and information from the case.
  • Case study can be a person, place, object, issue, event, condition, or phenomenon; a case analysis is a carefully constructed synopsis of events, situations, and behaviors . The research problem dictates the type of case being studied and, therefore, the design can encompass almost anything tangible as long as it fulfills the objective of generating new knowledge and understanding. A case analysis is in the form of a narrative containing descriptions of facts, situations, processes, rules, and behaviors within a particular setting and under a specific set of circumstances.
  • Case study can represent an open-ended subject of inquiry; a case analysis is a narrative about something that has happened in the past . A case study is not restricted by time and can encompass an event or issue with no temporal limit or end. For example, the current war in Ukraine can be used as a case study of how medical personnel help civilians during a large military conflict, even though circumstances around this event are still evolving. A case analysis can be used to elicit critical thinking about current or future situations in practice, but the case itself is a narrative about something finite and that has taken place in the past.
  • Multiple case studies can be used in a research study; case analysis involves examining a single scenario . Case study research can use two or more cases to examine a problem, often for the purpose of conducting a comparative investigation intended to discover hidden relationships, document emerging trends, or determine variations among different examples. A case analysis assignment typically describes a stand-alone, self-contained situation and any comparisons among cases are conducted during in-class discussions and/or student presentations.

The Case Analysis . Fred Meijer Center for Writing and Michigan Authors. Grand Valley State University; Mills, Albert J. , Gabrielle Durepos, and Eiden Wiebe, editors. Encyclopedia of Case Study Research . Thousand Oaks, CA: SAGE Publications, 2010; Ramsey, V. J. and L. D. Dodge. "Case Analysis: A Structured Approach." Exchange: The Organizational Behavior Teaching Journal 6 (November 1981): 27-29; Yin, Robert K. Case Study Research and Applications: Design and Methods . 6th edition. Thousand Oaks, CA: Sage, 2017; Crowe, Sarah et al. “The Case Study Approach.” BMC Medical Research Methodology 11 (2011):  doi: 10.1186/1471-2288-11-100; Yin, Robert K. Case Study Research: Design and Methods . 4th edition. Thousand Oaks, CA: Sage Publishing; 1994.

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5 Compelling Alternatives to the Traditional Case Study Format

by John Cole | Aug 11, 2021 | Collateral , B2B Copywriting , Lead Generation , Case Studies | 0 comments

Compelling Alternatives to the “Traditional” Case Study

Case studies have long been one of the most popular and influential forms of marketing content.

In Eccolo Media’s annual B2B Technology Collateral Survey Report s (2008 to 2014), for example, technology buyers ranked case studies the second most influential content type – trailing only white papers – seven years in a row . 1 More recently, 60% of marketing influencers told Ascend2 that research and case studies are the content target audiences trust the most. 2

There’s really no surprise here. After all, case studies are short, quick reads. They’re familiar, easy to follow. They give technology buyers the information they need: solid evidence that they can succeed with your solution. And besides… everybody loves a good story.

But the traditional case study format has its drawbacks. It’s not always the perfect fit for every company, objective, audience, or customer story. And there’s a sameness to traditional case studies that makes it easy for them to get lost in the marketing message crowd.

So today, we’ll look at the advantages and disadvantages of a few “alternative” formats you may want to consider for your next success story project. Those I’ve chosen can all work well with technology-purchasing audiences. But before we explore the alternatives, let’s take a brief look at the pros and cons of the traditional case study.

case study of alternative

The Traditional Case Study Format

We all know the traditional case study format. Four distinct sections under four well-known headings: Customer, Challenge (or Problem), Solution, and Results. They’re familiar to every B2B audience, easy to follow, easy to write.

So, what are the drawbacks of this tried-and-true formula?

Well, first of all, when you begin by describing the customer, it’s hard to get off to a compelling start. A good story provides some drama or intrigue right at the beginning to grab readers’ attention and pull them into the narrative. That drama comes from the customer’s challenge , not his background. Starting with a subject profile is not the best choice for some marketing objectives, like lead generation.

Second, the section headings offer no intrigue. They provide structure, but nothing to draw the attention of scanners. There’s no benefit. Besides, we’ve seen them all before.

Lastly, traditional case studies don’t appeal to trade journal editors. Editors want feature articles that resemble news stories, not academic papers or marketing pieces. If you want to get your case study placed in a trade magazine (or appeal to scanners or generate leads), you need a different format.

Five Alternative Case Study Formats

So, what are the alternatives to the traditional case study format? Here are five that can appeal to technology audiences.

1. The Feature Story

The “feature story” case study format is probably the most popular alternative to the traditional one. The reason it’s so popular? It addresses all the deficiencies of the traditional case study format.

As you’ve undoubtedly guessed, this type of case study is written like a feature story in a newspaper or magazine. It can follow the same logical sequence as the traditional form, but the information is not grouped under the standard subheads. Instead, the feature story case study employs techniques journalists use to engage readers, like descriptive subheads and an engaging opening paragraph, or “lead.”

To create drama in the lead, writers will typically start with the challenge, rather than a customer description. Background on the customer can either be sprinkled into the narrative—as a fiction author fleshes out characters—or placed in a sidebar. Descriptive subheads help to both summarize the story and pique the interest of scanners.

The big advantage of the feature story format is its engaging narrative flow. When well written, feature stories are more enjoyable to read and hold our attention better than traditional case studies. This makes them better for lead generation purposes. That’s also why trade editors like them. They look and read like other feature articles they publish.

The downside of the feature story format is that it requires greater writing skill. The writer must know how to handle key elements, like the headline, lead, and subheads. Story elements must be woven together into a cohesive narrative that flows relentlessly to a satisfying ending. If the reader gets lost, your success story will be a failure.

2. The Story-Within-A-Story

What could be better than a compelling, captivating success story? How about two?

The “story-within-a-story” is a variation of the feature story format. Along with describing why the customer chose your solution and how well it solved their problem, this case study format also includes an example of how your customer uses your solution to provide a better product or service to its own customers.

In other words, it contains a second case study that focuses on one of your customer’s customers.

This format can work very well if your market is OEMs, system integrators, or other vendors who incorporate your solution into their own. It’s also great for getting customer approval for your case study project and buy-in on joint marketing ventures; your customer gains publicity for one of their own successes. And like other feature stories, the story-within-a-story is ideal for trade journal placement and lead generation.

But with double the upside, you also get double the downside. This type of case study is more complex to produce. It involves additional interviews and approval cycles with your customer’s customer. Plus, crafting story-within-a-story calls for even greater writing skill than the feature story. Your writer needs to make sure the second story nests comfortably within the first without upsetting the flow of the narrative.

3. The Q&A

If you want a case study that can be created quickly and easily, consider the Q&A .

As the name suggests, a Q&A case study consists of a list of questions and the customer’s answers to each. While not a great lead-gen tool, Q&As can be very useful as website, blog, and newsletter content for nurturing leads and keeping customers engaged.

There are several advantages to the Q&A. The form is simple and doesn’t require great writing skills, so they’re quick and easy to produce. The questions, however, must be well thought out.

Q&A case studies are very appealing to technical audiences. Normally distrustful of marketing collateral, techies tend to like Q&As conducted with engineers or other technicians in roles similar to their own. They like getting no-nonsense information directly from their peers.

The downside here is that success is largely dependent on the quality of your customer’s responses to your questions. You need to pay a lot of attention to selecting the right customer rep for your interview. And your interviewer must be prepared to draw good information out of that person. There’s very little you can do in the editing process.

4. The First-Person Account

If your audience would respond well to a Q&A case study, but you want something you can place in a trade journal or use in lead generation campaigns, a “first-person” case study may fit the bill.

Like the Q&A, a first-person case study tells the story of a customer’s success with your solution in the customer’s own words. But the form is less rigid, more like that of a feature article. First-person case studies gain credibility by letting the reader hear the story “straight from the horse’s mouth” – like an extended testimonial.

First-person case studies are most often used by coaches and consultants who work with individuals. But they can succeed with corporate prospects as well, especially technical audiences. They tend to work best when the protagonist – the storyteller – had a big personal stake in the outcome of the story (had much to lose if the problem was not resolved, made or championed the purchase decision, etc).

What’s more, these individuals will often be more than willing to shepherd your case study through their own corporate approval process. After all, having a success story publicly documented can give a boost to one’s career.

Among the drawbacks of the first-person case study are that they can take longer to prepare, and they are not good for trade journal publication, due to the first-person perspective. They also have a potentially shorter shelf life. If the featured individual leaves the company, the customer might want the story discontinued.

Finally, a word of warning regarding first-person case studies: Don’t ask customers to write them themselves. Most won’t have the necessary writing skills or experience—let alone the time—to pull the project off. To create a story in the customer’s own words, your writer will need to prepare for a longer interview process and draw the full story out of the subject… without putting words in his or her mouth.

5. The Expected Results Story

Sometimes, it’s in a company’s interest to publish a case study before their customer has achieved any measurable results from their solution. This is called an “expected results” case study.

I wrote one of these recently. My client, an IT services company, had recently delivered Phase 1 of a three-phase project for a prestigious American university. We took an “expected results” approach for several reasons.

First, my client wanted to immediately leverage that success and the customer’s marquee name in their lead generation activities. But most of the measurable results of the project would not be realized until after the completion of Phase 3.

Second, Phase 1 had been the most critical phase of the project and held a very compelling story. It was a prime illustration of my client’s unique selling proposition and the reason the customer had chosen them for the job: the ability to deliver great results, on time and under budget, to an impossible deadline.

Third, while the customer had no problem with their name being used, the participation of a university representative in an interview was subject to a lengthy approval process. There was the possibility that customer participation and measurable results would never become available.

And finally, I would be interviewing members of my client’s technical staff, rather than the customer. Since staff members move quickly to other projects once a job is finished, my client wanted to document this project while it was still fresh in their minds.

Any of these circumstances would have been a good reason to proceed with an expected results story. Plus, there’s another great thing about this type of case study: it can be updated later, once the results are known.

The drawback of the expected results case study, of course, is that it has a weaker impact due to the lack of metrics. It forces you to make a case for your projected results. But if you have a compelling customer story and just lack hard results data, an expected results case study can let you leverage that story right away.

Takeaway Points

1. The traditional case study format (customer-challenge-solution-results) is still effective, but it can get lost in a crowd.

2. Traditional case studies are not always the best choice for every company, story, audience, or marketing objective.

3. Fortunately, you have a wide range of effective alternatives to the traditional case study format, including these five formats which work well with tech audiences:

  • Feature story
  • Story-within-a-story
  • First-person
  • Expected results

If you’d like help interviewing a customer and crafting a case study in any of these formats, including the traditional one, email me at [email protected] .

1   Eccolo Media 2008-2014 B2B Technology Collateral Surveys , .

2 Content Marketing Engagement Survey Summary Report , Ascend2, June 2019.

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Institute for Lifelong Learning

Case study: Alternative Learning Systems (ALS) as a community-based grassroots form of access to basic education


In the Philippines, access to basic education remains a challenge. One in every four Filipinos aged 6-24 years old is considered out-of-school. To reach these marginalized learners, the Philippines government, by means of the Republic Act 9155 or the Governance Act of Basic Education, has improved education access through non-formal and informal education by establishing the Alternative Learning Systems (ALS). These programmes are implemented chiefly by the Department of Education’s (DepEd) Bureau of Alternative Learning System (BALS) and is specifically intended for ‘out-of-school children, youth and adults’ and those who are not able to finish their formal schooling (school leavers) and need basic and functional literacy skills.

The ALS has two components: (1) the Basic Literacy Program (BLP) which teaches basic literacy skills for reading, writing and numeracy; and (2) the Continuing Education Program – Accreditation and Equivalency (CEP A&E) which is a paper pencil test that assesses learner’s competences; successful candidates will receive a certificate from DepEd which is equivalent to that received by pupils graduating from the formal education system. Both programs have their own curriculum which is both modular and flexible so learning sessions can take place anytime and anywhere, depending on the convenience and availability of the learner.

Providers of the programme are of three types: (1) DepEd-Delivered; (2) DepEd-procured (implemented by a contracted service provider such as non-government organizations (NGOs) and literacy volunteers); and (3) DepEd-partners delivered (implemented by non-DepEd contracted organizations). DepEd Delivered ALS programs are implemented by ALS Mobile Teachers (MT) –specialized teachers in the community who teach the BLP – and the District ALS Coordinators (DAC) that harmonizes all ALS activities in the district.

Procedures and processes

Recognition of Prior Learning (RPL), in the context of ALS begins with the Functional Literacy Test (FLT) which all learners must take to gauge prior knowledge and literacy level. Specific to literacy, the FLT emphasizes the following core competences: communication skills, problem-solving and critical thinking, sustainable use of resources/productivity, personal development and raising a sense of community, expanding one’s world vision. The team (composed of the MT, DAC and the learning facilitator) then goes to a specific barangay [1] , brings all the learning materials and conducts learning sessions.

Ideally, the ALS team does not leave the barangay until the learners have become literate according to certain guidelines. However, depending on the need, the team may re-engage in the community for follow-up and visitation. After finishing the basic literacy program, learners may proceed to taking the CPE A&E where they will have the chance to gain a basic education diploma equivalent to that received after formal education.

Outcomes and ways forward

In 2014, the Department of Education Secretary Armin Luistro explained that the department had mapped out 1.2 million Out-of-School Youth (OSYs) in their database and that 76,000 of them had already been enrolled in ALS and other similar government programs. In 2013, 6,135 passed the elementary-level A&E test, while 72,076 passed the secondary school examinations.

  • Department of Education (DepEd). Alternative Learning System . (Accessed 20 May 2015).
  • DepEd. 2014. DepEd releases 2013 ALS A&E test results . (Accessed 20 May 2015).
  • DepEd. 2014. DepEd, NYC launch Abot-Alam program nationwide, target Zero OSY Philippines . (Accessed 20 May 2015).
  • Republic Act 9155: Governance Act of Basic Education. 2001. (Accessed 20 May 2015).

Elmer Talavera Technical Education and Skills Development Authority (TESDA) Manila Philippines

With assistance from:

Christopher Millora Masters in Lifelong Learning: Policy and Management Intern at: UNESCO Institute for Lifelong Learning Hamburg Germany

[1] Barangay is the Filipino term for small community. It is the smallest unit of governance in the country.

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How To Make Recommendation in Case Study (With Examples)

How To Make Recommendation in Case Study (With Examples)

After analyzing your case study’s problem and suggesting possible courses of action , you’re now ready to conclude it on a high note. 

But first, you need to write your recommendation to address the problem. In this article, we will guide you on how to make a recommendation in a case study. 

Table of Contents

What is recommendation in case study, what is the purpose of recommendation in the case study, 1. review your case study’s problem, 2. assess your case study’s alternative courses of action, 3. pick your case study’s best alternative course of action, 4. explain in detail why you recommend your preferred course of action, examples of recommendations in case study, tips and warnings.

example of recommendation in case study 1

The Recommendation details your most preferred solution for your case study’s problem.

After identifying and analyzing the problem, your next step is to suggest potential solutions. You did this in the Alternative Courses of Action (ACA) section. Once you’re done writing your ACAs, you need to pick which among these ACAs is the best. The chosen course of action will be the one you’re writing in the recommendation section. 

The Recommendation portion also provides a thorough justification for selecting your most preferred solution. 

Notice how a recommendation in a case study differs from a recommendation in a research paper . In the latter, the recommendation tells your reader some potential studies that can be performed in the future to support your findings or to explore factors that you’re unable to cover. 

example of recommendation in case study 2

Your main goal in writing a case study is not only to understand the case at hand but also to think of a feasible solution. However, there are multiple ways to approach an issue. Since it’s impossible to implement all these solutions at once, you only need to pick the best one. 

The Recommendation portion tells the readers which among the potential solutions is best to implement given the constraints of an organization or business. This section allows you to introduce, defend, and explain this optimal solution. 

How To Write Recommendation in Case Study

example of recommendation in case study 3

You cannot recommend a solution if you are unable to grasp your case study’s issue. Make sure that you’re aware of the problem as well as the viewpoint from which you want to analyze it . 

example of recommendation in case study 4

Once you’ve fully grasped your case study’s problem, it’s time to suggest some feasible solutions to address it. A separate section of your manuscript called the Alternative Courses of Action (ACA) is dedicated to discussing these potential solutions. 

Afterward, you need to evaluate each ACA by identifying its respective advantages and disadvantages. 

example of recommendation in case study 5

After evaluating each proposed ACA, pick the one you’ll recommend to address the problem. All alternatives have their pros and cons so you must use your discretion in picking the best among these ACAs.

To help you decide which ACA to pick, here are some factors to consider:

  • Realistic : The organization must have sufficient knowledge, expertise, resources, and manpower to execute the recommended solution. 
  • Economical: The recommended solution must be cost-effective.
  • Legal: The recommended solution must adhere to applicable laws.
  • Ethical: The recommended solution must not have moral repercussions. 
  • Timely: The recommended solution can be executed within the expected timeframe. 

You may also use a decision matrix to assist you in picking the best ACA 1 .  This matrix allows you to rank the ACAs based on your criteria. Please refer to our examples in the next section for an example of a Recommendation formed using a decision matrix. 

example of recommendation in case study 6

Provide your justifications for why you recommend your preferred solution. You can also explain why other alternatives are not chosen 2 .  

example of recommendation in case study 7

To help you understand how to make recommendations in a case study, let’s take a look at some examples below.

Case Study Problem : Lemongate Hotel is facing an overwhelming increase in the number of reservations due to a sudden implementation of a Local Government policy that boosts the city’s tourism. Although Lemongate Hotel has a sufficient area to accommodate the influx of tourists, the management is wary of the potential decline in the hotel’s quality of service while striving to meet the sudden increase in reservations. 

Alternative Courses of Action:

  • ACA 1: Relax hiring qualifications to employ more hotel employees to ensure that sufficient human resources can provide quality hotel service
  • ACA 2: Increase hotel reservation fees and other costs as a response to the influx of tourists demanding hotel accommodation
  • ACA 3: Reduce privileges and hotel services enjoyed by each customer so that hotel employees will not be overwhelmed by the increase in accommodations.


Upon analysis of the problem, it is recommended to implement ACA 1. Among all suggested ACAs, this option is the easiest to execute with the minimal cost required. It will not also impact potential profits and customers’ satisfaction with hotel service.

Meanwhile, implementing ACA 2 might discourage customers from making reservations due to higher fees and look for other hotels as substitutes. It is also not recommended to do ACA 3 because reducing hotel services and privileges offered to customers might harm the hotel’s public reputation in the long run. 

The first paragraph of our sample recommendation specifies what ACA is best to implement and why.

Meanwhile, the succeeding paragraphs explain that ACA 2 and ACA 3 are not optimal solutions due to some of their limitations and potential negative impacts on the organization. 

Example 2 (with Decision Matrix)

Case Study: Last week, Pristine Footwear released its newest sneakers model for women – “Flightless.” However, the management noticed that “Flightless” had a mediocre sales performance in the previous week. For this reason, “Flightless” might be pulled out in the next few months.  The management must decide on the fate of “Flightless” with Pristine Footwear’s financial performance in mind. 

  • ACA 1: Revamp “Flightless” marketing by hiring celebrities/social media influencers to promote the product
  • ACA 2: Improve the “Flightless” current model by tweaking some features to fit current style trends
  • ACA 3: Sell “Flightless” at a lower price to encourage more customers
  • ACA 4: Stop production of “Flightless” after a couple of weeks to cut losses

Decision Matrix


Based on the decision matrix above 3 , the best course of action that Pristine Wear, Inc. must employ is ACA 3 or selling “Flightless” shoes at lower prices to encourage more customers. This solution can be implemented immediately without the need for an excessive amount of financial resources. Since lower prices entice customers to purchase more, “Flightless” sales might perform better given a reduction in its price.

In this example, the recommendation was formed with the help of a decision matrix. Each ACA was given a score of between 1 – 4 for each criterion. Note that the criterion used depends on the priorities of an organization, so there’s no standardized way to make this matrix. 

Meanwhile, the recommendation we’ve made here consists of only one paragraph. Although the matrix already revealed that ACA 3 tops the selection, we still provided a clear explanation of why it is the best. 

  • Recommend with persuasion 4 . You may use data and statistics to back up your claim. Another option is to show that your preferred solution fits your theoretical knowledge about the case. For instance, if your recommendation involves reducing prices to entice customers to buy higher quantities of your products, you may invoke the “law of demand” 5 as a theoretical foundation of your recommendation. 
  • Be prepared to make an implementation plan. Some case study formats require an implementation plan integrated with your recommendation. Basically, the implementation plan provides a thorough guide on how to execute your chosen solution (e.g., a step-by-step plan with a schedule).
  • Manalili, K. (2021 – 2022). Selection of Best Applicant (Unpublished master’s thesis). Bulacan Agricultural State College. Retrieved September 23, 2022, from
  • How to Analyze a Case Study. (n.d.). Retrieved September 23, 2022, from
  • Nguyen, C. (2022, April 13). How to Use a Decision Matrix to Assist Business Decision Making. Retrieved September 23, 2022, from
  • Case Study Analysis: Examples + How-to Guide & Writing Tips. (n.d.). Retrieved September 23, 2022, from
  • Hayes, A. (2022, January O8). Law of demand. Retrieved September 23, 2022, from

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Jewel Kyle Fabula

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Case Study Scenario

Search databases for evidence-based information on fenugreek used for diabetes..

  • Citing Sources

 Mrs. Hernandez, a 45 year-old Spanish speaking woman, has been recently diagnosed with Diabetes Type 2.

  • She is admitted to UWMC with uncontrolled hypertension
  • She takes fenugreek
  • Prescribed medications include Lisinopril, Clonidine, and Metformin

Search the databases below for evidence-based information on fenugreek used for diabetes.

For more information on each database, see Find Articles/Databases.

Filter to Article Type

Case Study example:

  • In the PubMed Search box, type:  (fenugreek OR trigonella) AND diabetes
  • Then filter from left sidebar to:  English, Human
  • For evidence-based articles, filter by Article Type to:  Randomized controlled trial, meta-analysis, clinical trial

Filter to Subject

  • In the PubMed Search box, type:   Diabetes Mellitus, Type 2/th
  • Then filter to:   Complementary Medicine  and/or  Dietary Supplements  under Subjects.
  • This strategy will produce results about alternative treatments for diabetes.
  • For evidence-based articles, filter under Article Type to:  Randomized controlled trial, meta-analysis, clinical trial

Search  PubMed Clinical Queries

Search By Clinical Study Category

  • Type:  (fenugreek OR trigonella) AND diabetes
  • Select  Therapy  and  Narrow  (specific) search.

Find Systematic Reviews

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Limit to Research Article

  • Type in the Search box:  (fenugreek OR trigonella) and diabetes
  • Click on  Research Article  under Limit your Results.

Limit by Publication Type

  • Type in Search box:  (fenugreek OR trigonella) and diabetes
  • In Limit your Results, select  Clinical Trial  or  Systematic Review  or  Research  under Publication Type.

Limit by Clinical Query

  • Select any of the choices under Clinical Queries limits.

Limit by Journal Subset

  • In Limit your Results, select  Alternative/Complementary Therapies  under Journal Subset.

Limit by Evidence-Based Practice

  • Click on  Evidence-Based Practice  under Limit your Results.
  • In the Search box, type:  fenugreek AND diabetes
  • In this case, there are no systematic reviews on this topic. You do retrieve, however, some citations to clinical trials.
  • Type  fenugreek  in Search box and then click on Professional Monograph: Fenugreek.
  • Note the diabetes evidence grade under Clinical Bottom Line/Effectiveness.

IBIDS (International Bibliographic Information on Dietary Supplements)

  • Type in Search box: +fenugreek +diabetes
  • Change drop-down menu to Peer-reviewed References instead of All IBIDS References .
  • look under Treatment>Diet for use of fenugreek
  • OR, click on Search Within Text link and follow directions to find fenugreek
  • Type in Search box:  fenugreek and diabetes and ('clinical trial'/exp or 'controlled study'/exp or 'controlled clinical trial' or 'randomized controlled trial')
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Masterful Decision-Making: Identifying the Right Alternatives

by Logapps LLC June 17, 2020

case study of alternative

Proper planning and research are the foundation of alternatives analysis. The first step is to establish the problem and define the decisions that will be made. The client may come to you with an initial problem or a problem with a solution that has already been implemented. Apart from the system itself, stakeholders and decision makers may have disagreements amongst themselves. Planning involves comprehensive research and meetings with team members and stakeholders in the process to outline objectives, designate efforts, and estimate costs. Evaluating the time and resources available is important to ensure that the project itself can be carried out. These initial steps give the project direction and set goals for completion. 

Many decision makers do not know where to start when gathering information about the market. One approach is to study the competition: research if competitors have encountered a comparable problem in the past and learn from their successes and failures. Case studies are excellent sources of information, because they are real-world examples of implemented solutions.  Alternatively, reaching out to the consumers may be equally as effective. Surveys and focus groups are a direct method of obtaining feedback on past projects or proposals for new technologies. An external perspective may be the key to a solution.

Deciding on alternatives should be a team effort to incorporate a variety of perspectives. Having an open discussion or multiple “brainstorming sessions” with team members may highlight options not considered before. This allows for input from legal, economic, and technological perspectives as well as various levels of experience. The aim of identifying alternatives could be to resolve a problem with an initially proposed decision or simply have a backup plan in case a decision goes awry. These may include modification, elimination, developing a new system, delaying a decision, or maintaining the “status quo”- keeping the current system in place. Depending on the given situation, some alternatives may be more beneficial than others. While adjusting the system, removing a part of the system, or creating a new system altogether may seem more progressive, sometimes delaying the decision or keeping the system in place may be the “right” alternative at the moment. Decision delayal, if implemented with set goals, allows for more time to research and identify the correct approach to an issue. Keeping the status quo is a method that allows for continued experimentation with the current system, considering modifications later on.

There may be many more alternatives available than the ones detailed above. It is important to evaluate multiple alternatives, because the decision-making process may require more than one. There must be set criteria to evaluate each alternative and compare them to one another. This will provide a method of elimination for ineffective alternatives. This process can be time-consuming but is worthwhile in the end. According to a report on the Analysis of Alternatives in Defense Acquisitions from the Government Accountability Office (GAO), “programs that considered a broad range of alternatives tended to have better cost and schedule outcomes than the programs that looked at a narrow scope of alternatives” [1]. A robust assessment of alternatives will help to develop working solutions better fit to the client’s needs. 

The presentation of results to stakeholders and decision-makers is an opportunity to showcase the information generated so far. Whether the presentation is a PowerPoint, a report, an infographic, or an open discussion, presenting the results of the alternatives analysis as clearly, consistently, and accurately as possible is the priority. This will let major stakeholders know how the project is going and if more resources are needed. The team must also provide a detailed analysis of the systematic and engineering risks. This will help plan for future implementation, make accurate cost estimates, and ensure that the project is completed on schedule. Direct and honest communication with stakeholders throughout the process will result in a better outcome.

Meticulously researching the contexts of the problem, analyzing and comparing various alternatives, and consulting the findings will help foster successful solutions. It may take time to identify the correct alternatives and it may take multiple trials to implement them. However, the key to establishing successful alternatives is organization and a continued effort toward a specific goal. If the time frame, team, and costs are planned in detail, the decision-making process will become much more manageable.

[1]  “Defense Acquisitions:  Many Analyses of Alternatives Have Not Provided a Robust Assessment of Weapon System Options,” United States Government Accountability Office, Report to the Chairman, Subcommittee on National Security and Foreign Affairs, Committee on Oversight and Government Reform, House of Representatives, Sep. 2009.

Additional Resources

“Analyses of Alternatives,”  The MITRE Corporation , Aug. 2013.

S. Bauer, “The Art of Decision Making – Part 4: Identifying Alternatives,”  Product Anonymous , 15-Sep-2013.



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CrowdStrike’s rivals stand to benefit from its update fail debacle

case study of alternative

The CrowdStrike debacle — a bug in the company’s Windows software that had the disastrous effect of rendering PCs unusable — has disrupted flights , canceled elective medical treatments, and left many an office worker twiddling their thumbs for hours. Unsurprisingly, it’s also tanked CrowdStrike’s stock price , even as the company’s CEO, George Kurtz, promises a fix and systems begin to crawl back online.

Rivals stand to gain.

While it’s difficult to assess at present the business fallout from what’s being called the worst IT outage in history, investors appear to be sensing opportunity. Stocks in CrowdStrike competitors SentinelOne and Palo Alto Networks climbed by as much as 10% this afternoon.

CrowdStrike competes with a number of vendors, including SentinelOne and Palo Alto Networks but also Microsoft, Trellix, Trend Micro and Sophos, in the endpoint security market. Endpoint security tools detect malware on laptops, mobile phones and other devices that have access to corporate networks.

As of year-end 2023, CrowdStrike had an estimated 14.74% share of global revenue from security software sales, raking in roughly $2.01 billion, according to data from Gartner. That’s second only to Microsoft, which had a 40.16% share ($5.49 billion) last year; CrowdStrike’s next-largest competitor is Trellix, with a 6.62% share ($906 million) as of 2023.

Eric Grenier, cybersecurity threat detection and exposure analyst at Gartner, cautioned that it’s too early to say who the “winners” are in the ongoing CrowdStrike saga. But he told TechCrunch that he often sees Microsoft and SentinelOne shortlisted by the clients he speaks with, and it wouldn’t surprise him if Friday’s events cemented a few C-suite decisions in favor of CrowdStrike alternatives.

“I think that there will be some orgs that have zero tolerance for what happened and will look to alternative solutions,” Grenier said. “Every time a competitor’s sales team is in front of a potential customer and competing against CrowdStrike, they can point to this incident as to why you should choose them over CrowdStrike. Long term, I expect CrowdStrike to suffer some loss in business.”

Not everyone agrees.

Mike Jude, research director at IDC, notes that competitors face essentially the same risks as CrowdStrike in that they’re forced to constantly adjust to a changing threat environment and that this rapid response can lead to critical mistakes. The CrowdStrike bug stemmed from a routine update to the company’s flagship Falcon Sensor product , which conflicted with many Windows installations.

“I don’t believe we should think of this outage as a win/lose situation; I don’t think you will find many of CrowdStrike’s competitors celebrating over this outage,” Jude said. “I do think this outage illustrates just how dependent we have become on cybersecurity solutions.”

Chirag Mehta, VP and principal analyst at Constellation Research, echoed Jude’s sentiment that rivals dodged a bullet by luck. “Other vendors are fortunate that they were not affected this time,” Mehta told TechCrunch. “They now have the opportunity to evaluate the depth of their integration with operating systems, the methods of air-gapping their updates and their deployment processes. Overconfidence can be dangerous.”

In a memo to investors Friday morning, analysts at Goldman Sachs said that it expects to see “minimal share shifts” in the endpoint security market as a result of the CrowdStrike bug. Customers generally understand that it’s a question of when — not if — these incidents will happen, the analysts write, and so they care more about a fix and transparent communication.

“In our view, cybersecurity products have to clear a higher bar of reliability and security in customer deployments than other technology products because they are mission critical and actively attacked by adversaries,” the Goldman analysts wrote. “In some ways, we believe this [outage] will reinforce the barrier to entry in the industry and the need for best-in-class update, outage and customer service protocols, ultimately favoring companies with scale.”

The analysts cite a case study: the Okta breach.

In October 2023, hackers accessed data on all of Okta’s thousands of identity and access management customers. While the hack elongated the deal cycle for some organizations as they looked to ascertain whether Okta’s security protocols had improved (and evaluated other products), it didn’t lead to massive churn. For the most part, Okta customers stayed Okta customers.

If anything, says Raj Joshi, SVP for Moody’s Ratings, the wide-ranging effect of the CrowdStrike outage illustrates the precariousness of IT infrastructure today. “This incident calls into question CrowdStrike’s software engineering practices,” Joshi said, “[but] it also underscores growing vulnerabilities in global cloud infrastructure from increasing points of failure.”

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Enhancing inventory management through safety-stock strategies—a case study.

case study of alternative

1. Introduction

2. literature review, 2.1. safety-stock-setting literature, 2.2. abc–xyz analysis approach, 2.3. number-of-days method, 2.4. toc replenishment method, 2.5. service level approach, 3. materials and methods, 5. discussion.

  • The TOC replenishment model and its combination with the ABC–XYZ analysis approach consistently resulted in the highest total inventory costs across all scenarios. The number-of-days method ranked third in terms of the total inventory costs. The service level approach showed a noticeable reduction in total inventory costs compared to these three methods. The second proposed hybrid methodology demonstrated the lowest total inventory costs among all methodologies and scenarios.
  • In the first scenario, where the USC was 500% of the UHC , for the TIC for all products, the second hybrid approach had 30% lower costs than the existing methodology, 55% lower costs than the TOC replenishment model, 24% lower costs than the service-level approach, and 32% lower costs than the first hybrid approach.
  • In the second scenario, where the USC was 1000% of UHC , for the TIC for all products, the second hybrid approach had 28% lower costs than the existing methodology, 74% lower costs than the TOC replenishment model, 37% lower costs than the service-level approach, and 38% lower costs than the first hybrid approach.
  • In the third scenario, where the USC was 1500% of UHC , for the TIC for all products, the second hybrid approach had 27% lower costs than the existing methodology, 82% lower costs than the TOC replenishment model, 42% lower costs than the service-level approach, and 41% lower costs than the first hybrid approach.
  • In the fourth scenario, where the USC was 2000% of UHC , for the TIC for all products, the second hybrid approach had 27% lower costs than the existing methodology, 87% lower costs than the TOC replenishment model, 46% lower costs than the service-level approach, and 42% lower costs than the first hybrid approach.
  • Combining TOC with ABC–XYZ analysis improves cost compared to the pure TOC replenishment model; in all four scenarios, the combination provides lower inventory costs compared with the pure model in the literature.
  • The hybrid method of service-level approach and ABC–XYZ analysis approach provides lower inventory costs compared with the pure service-level approach application in all scenarios.

6. Conclusions

Author contributions, data availability statement, conflicts of interest.

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Click here to enlarge figure

ProductsLead Time
Product 116
Product 220
Product 36
Product 410
Product 515
MethodModelsParameters under ConsiderationCalculation
Existing ModelNumber-of-days methodLead time, demand
First alternative model from the literatureTOC replenishment modelLead time, demand
Second alternative model from the literatureService-level approachLead time, demand variation, desired service level
First developed hybrid modelTOC replenishment model and ABC–XYZ analysisLead time, demand, annual sales value%, COV
Second developed hybrid modelService level approach and ABC–XYZ analysisLead time, demand variation, desired service level, annual sales value%, COV
High value,
high predictability
Medium value,
high predictability
Low value,
high predictability
High value,
medium predictability
Medium value,
medium predictability
Low value,
medium predictability
High value,
low predictability
Medium value,
low predictability
Low value,
low predictability
Low inventoryLow inventoryLow inventory
Low inventoryMedium inventoryHigh inventory
Medium inventoryMedium inventoryHigh inventory
DOH = Lt*25%DOH = Lt*25%DOH = Lt*25%
DOH = Lt*25%DOH = Lt*50%DOH = Lt*100%
DOH = Lt*50%DOH = Lt*50%DOH = Lt*100%
ClassCriteria Limitation (Annual Sales Value Percentage of the Product (%))
Product 1JanFebMarAprMayJunJulAugSepOctNovDecJan*COV
2022 actual sales (ton)129412751771136713981529117218061536172919481185 17.39
2023 actual sales (ton)1277127614711401126912671098141115171095926903
2023 sales forecast (ton)11831149139814101180113191811831245114311277251175
Standard deviation261262262248247253259267240239231172
Unit holding cost (USD/ton)3.363.563.703.883.353.213.253.303.303.313.273.28
Lead time (month)0.530.530.530.530.530.530.530.530.530.530.530.53
2022 actual sales (ton)204421061969193320862015186917441993204519551733 6.21
2023 actual sales (ton)2010199816701718199518931749149616051841191719432062
2023 sales forecast (ton)193419311269172419501899160920222200180019401639
Standard deviation122119108219222213207217223243236236
Unit holding cost (USD/ton)1.771.751.691.741.721.802.922.852.932.932.932.93
Lead time (month)0.670.670.670.670.670.670.670.670.670.670.670.67
2022 actual sales (ton)292945575760896162745743 31.00
2023 actual sales (ton)583412210772607414361841278144
2023 sales forecast (ton)71451018960765011975106106101
Standard deviation171613171818181723232526
Unit holding cost (USD/ton)0.820.720.840.690.790.730.870.680.720.750.890.91
Lead time (month)
2022 actual sales (ton)447529366547621314486466332797517359 28.48
2023 actual sales (ton)477412475561578414402434516532562577450
2023 sales forecast (ton)405411470593474335310391464479540490
Standard deviation1371391391351381311291361381338183
Unit holding cost (USD/ton)
Lead time (month)0.330.330.330.330.330.330.330.330.330.330.330.33
2022 actual sales (ton)289295269270291285270293276278253276 4.44
2023 actual sales (ton)214294234207269214240270220280258259223
2023 sales forecast (ton)297288178100285220287257150250232292
Standard deviation121313325959595958646363
Unit holding cost (USD/ton)0.530.510.620.680.650.590.580.600.620.630.620.63
Lead time (month)0.500.500.500.500.500.500.500.500.500.500.500.50
Product 2 − DOH = 5 daysProduct 5 − DOH = 3.75 days
Product 1 − DOH = 4 days
Product 4 − DOH = 5 days Product 3 − DOH = 6 days
First scenario
Second scenario
Third scenario
Fourth scenario
Serial No.MethodUSC ScenariosTotal Inventory Cost (k USD)
Product 1Product 2Product 3Product 4Product 5Total
1The existing modelFirst scenario48,66531,46558232,103864113,679
Second scenario89,93531,465109763,0291262186,788
Third scenario131,20531,465161193,9561660259,898
Fourth scenario172,47531,4652126124,8832058333,007
2First alternative model from the literatureFirst scenario77,01318,21483737,9461362135,373
Second scenario152,34321,833162675,7252471253,998
Third scenario227,67325,4512415113,5043581372,623
Fourth scenario303,00329,0693203151,2844690491,249
3Second alternative model from the literatureFirst scenario59,86720,22344127,210586108,326
Second scenario115,70129,75579052,552887199,683
Third scenario171,53539,287113977,8931187291,041
Fourth scenario227,36948,8191488103,2351488382,398
4The first developed hybrid modelFirst scenario62,36622,36144028,841938114,946
Second scenario120,26322,36176756,4991508201,398
Third scenario178,15922,361109384,1582078287,849
Fourth scenario236,05522,3611420111,8162648374,300
5The second developed hybrid modelFirst scenario48,12418,09929420,13848587,140
Second scenario88,94518,78838837,054515145,690
Third scenario129,76619,47748353,969545204,240
Fourth scenario170,58720,16657870,885575262,791
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Unlocking potential: a qualitative exploration guiding the implementation and evaluation of professional role substitution models in healthcare

  • Rumbidzai N. Mutsekwa   ORCID: 1 , 2 , 3 ,
  • Katrina L. Campbell   ORCID: 3 , 4 , 5 ,
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As role substitution models gain prominence in healthcare, understanding the factors shaping their effectiveness is paramount. This study aimed to investigate factors that impact the implementation and performance evaluation of professional role substitution models in healthcare, with a focus on understanding the variables that determine their success or failure in adoption, execution, continuity, and outcomes.

The exploratory qualitative study used semi-structured interviews with key opinion leaders, decision makers, facilitators, recipients, and frontline implementers, who had influence and involvement in the implementation of professional role substitution models. Data analysis was guided by the Consolidated Framework for Implementation Research (CFIR).

Between November 2022 and April 2023, 39 stakeholders were interviewed. Factors influencing implementation and evaluation of allied health professional role substitution models of care aligned with the five core CFIR domains (innovation, outer setting, inner setting, individuals, implementation process) and outcome domain incorporating implementation and innovation outcomes. The six themes identified within these CFIR domains were, respectively; i) Examining the dynamics of innovation catalysts, evidence, advantages, and disadvantages; ii) Navigating the complex landscape of external factors that influence implementation and evaluation; iii) Impact of internal structural, political, and cultural contexts; iv) The roles and contributions of individuals in the process; v) Essential phases and strategies for effective implementation; and vi) The assessment of outcomes derived from allied health professional role substitution models.


The study highlights the complex interplay of contextual and individual factors that influence the implementation and performance evaluation of professional role substitution models. It emphasises the need for collaboration among diverse stakeholders to navigate the challenges and leverage the opportunities presented by expanded healthcare roles. Understanding these multifaceted factors can contribute to the development of an empowered workforce and a healthcare system that is more efficient, effective, safe, and sustainable, ultimately benefiting patients.

Peer Review reports

Contributions to literature

• There is limited understanding of the complex interplay of contextual and individual factors that influence implementation and performance evaluation of professional role substitution models of care.

• This study provides comprehensive guidance on successful implementation and evaluation of new models of care which influences efficient use of resources in healthcare.

• This study contributes to recognised gaps in literature, seeking to demonstrate value proposition of professional role substitution models of care. This study has identified outcome measures that can determine the successful implementation and impact of these models of care

The healthcare sector plays a crucial role in ensuring the well-being of individuals and society, but it is facing challenges due to a growing and ageing population. The demand for high-quality healthcare has increased significantly, while the shortage of healthcare workers has become a pressing concern [ 1 , 2 ]. Workforce reforms are now being prioritised in healthcare to shape the future of healthcare delivery. These reforms include initiatives to increase the number of healthcare workers, enhance the quality and duration of healthcare education and training, and diversify the healthcare workforce.

One key strategy to address healthcare challenges is the expanded scope of practice for non-medical healthcare professionals [ 3 ]. This expansion entails a discrete knowledge and skill base beyond the recognised scope of practice within a specific jurisdiction's regulatory framework [ 4 ]. It empowers healthcare practitioners such as nurse practitioners, allied health professionals, and physician assistants to practice to the full extent of their training and education, or to extend their scope of practice beyond traditional boundaries [ 5 , 6 , 7 ]. Consequently, they can perform a broader range of tasks, including those previously reserved for medical doctors.

Professional role substitution models have improved patients' access to healthcare services [ 8 , 9 , 10 ]. Moreover, there is a growing body of evidence suggesting that these alternative healthcare delivery models can provide safe and effective care that patients find acceptable. Nurse practitioners and advanced nurses in the US, Canada, the UK, and Australia expand primary care roles, including diagnosis, prescribing, patient education, managing long-term conditions, and minor surgeries [ 9 , 11 , 12 , 13 ]. Physician assistants (PAs) in countries like the US, Canada, and the Netherlands work closely with physicians, conducting assessments, diagnosing, treating common illnesses, and providing patient education. PAs improve healthcare access, especially in underserved and rural areas with physician shortages [ 14 , 15 , 16 ].

In developing countries with limited healthcare resources, professional role substitution models are vital for addressing shortages of skilled healthcare providers and improving access to essential services. For instance, in sub-Saharan Africa, task shifting from physicians to nurses and community health workers addresses the scarcity of skilled providers [ 17 , 18 ]. Community health workers, trained to deliver basic healthcare services and education, play crucial roles in preventive and promotive interventions, particularly in rural and underserved areas [ 18 ]. Nurse-led clinics have also proven successful in delivering comprehensive primary care services, such as antenatal care and family planning, alleviating pressure on strained healthcare systems [ 19 , 20 , 21 ].

Allied health professionals, encompassing disciplines such as speech pathology, pharmacy, dietetics, physiotherapy, occupational therapy, radiography, sonography, psychology, and social work, are increasingly vital in diverse healthcare settings. Supported by mounting evidence of their effectiveness, their role continues to expand [ 10 , 22 ]. Despite substantial growth, particularly notable in Australia where they rank as the second-largest healthcare group, [ 23 ] the implementation of professional role substitution within allied health is relatively new compared to fields like nursing and physician assistants [ 24 ].

The successful implementation of all professional role substitution models including allied health is complex and contingent on various factors which are not currently well understood or defined [ 10 , 22 , 25 ]. To ensure success, it is essential to consider the impact on patients, healthcare professionals, and the healthcare system [ 25 ]. This must be approached from a multi-stakeholder perspective, involving experts in the field, key opinion leaders, healthcare leaders, decision makers, policy makers, recipients, and frontline implementers.

Research into the expanded scope of practice within allied health disciplines, including implementation and performance evaluation, is crucial [ 6 , 23 , 25 , 26 ]. Previous studies have highlighted patients' perceptions and experiences of healthcare quality in role substitution models [ 27 , 28 ]. While clinicians express support for performance evaluation, there's a gap between support and effective implementation [ 29 ]. There's also a lack of agreed-upon approaches for measuring performance [ 25 , 29 ]. Collaborative efforts involving multiple stakeholders are essential for understanding robust evaluation methods and optimising alternative models of care for healthcare transformation and sustainability [ 25 ].

To address this gap in knowledge and practice, this study aimed to describe the individual and contextual factors that influence the implementation and performance evaluation of allied health professional role substitution models from a multi-stakeholder perspective. Furthermore, the study aimed to identify outcome measures that can demonstrate the successful implementation and impact of these models of care.

Study approach and design

An exploratory qualitative approach was used to explore expectations, perceptions, and experiences of stakeholders involved in the implementation and performance evaluation of professional role substitution models of care. Semi-structured interviews were chosen as the primary method of data collection to allow for flexible exploration of specific topics and issues, maximising the richness of the data [ 30 ]. The study adhered to the Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines [ 31 ]. Please see Additional file 1

Study setting

This study was conducted within the public healthcare system of the State of Queensland, Australia. This comprises 16 hospital and health services and approximately 35,000 allied health professionals [ 32 ]. Queensland initiated an allied health strategy in 2014 to expand professionals' scope of practice, resulting in the establishment of 133 distinct models of care by 2019 [ 24 , 33 , 34 ]. Examining this system offers valuable insights into implementing and evaluating professional role substitution models, providing practical understanding within a specific healthcare context.

Study participants and recruitment

A purposeful sampling strategy was employed to recruit key stakeholders at various levels of the healthcare system who were involved in some way in the implementation and performance evaluation of allied health professional role substitution models of care. Participants included experts in the field, key opinion leaders, decision makers, recipients, and frontline implementers, implementation facilitators and support teams. A sampling matrix was used to consider factors such as location, affiliation, organisational role, tenure, and profession ensuring diversity and representation across the different dimension of the healthcare system. While a specific target number of participants was not predetermined, our aim was to achieve saturation in the sample, ensuring comprehensive coverage of perspectives and experiences relevant to our research objectives. Email invitations were sent to potential participants/participant groups, along with study information and consent forms. Those who agreed to participate contacted the principal investigator to arrange a suitable interview time.

Positionality of researchers

The research team comprised individuals with diverse backgrounds and roles, including experts in professional role substitution, health services research, economics, qualitative study methodology, and healthcare management.

This study was performed in line with the principles of the Declaration of Helsinki with approval granted by Gold Coast Hospital and Health Service (HREC/2020/QGC/62104) and Griffith University (GU Ref No: 2020/876). All participants provided written informed consent.

Data collection

An interview guide was developed by the research team to ensure coverage of the study aims and objectives (Additional file 2). The guide was pilot tested with three eligible participants, resulting in minor wording adjustments for clarity. Interviews were conducted either face-to-face or via video conferencing with only interviewer and participant present. The semi-structured interviews were designed to elicit open-ended responses from participants, with the interviewer using prompts and probing techniques as needed. Data collection continued until data saturation was reached, indicating that no new themes were emerging [ 35 ]. All interviews were audio-recorded, transcribed, and supplemented with field notes for additional context and consistency. Each participant was allocated an anonymous identifier, comprising their participant number along with a descriptor of their role or professional background. (e.g., P34, Workforce and Education). Participants were offered the opportunity to check their transcript.

Data analysis and interpretation

Descriptive statistics were used to analyse demographic data, such as participants' time in their current role, age, gender, and education level. Exploration of contextual influences on implementation and performance evaluation was guided by the Consolidated Framework for Implementation Research (CFIR) [ 36 ]. The CFIR is a comprehensive framework that focuses on understanding and improving the implementation and evaluation of health innovations. Its adaptability enables integration into various contexts, fostering analysis and facilitating cross-study comparisons. This versatility supports a systematic approach to evaluating implementation processes and outcomes, thereby enriching our understanding of innovation dynamics across diverse settings [ 36 ].

It consists of six domains: 1. Innovation domain (the model of care being implemented), 2. Outer setting (the healthcare system in which the inner setting exists) 3. Inner setting (the site in which the model of care is implemented e.g., hospital) 4. Individuals (the roles and characteristics of individuals involved in the implementation process), 5. Implementation process (the activities and strategies used to implement the model of care), 6. Implementation outcomes (perceptions and measures of implementation success or failure), and Innovation outcomes (outcomes that capture success or failure of model of care) [ 36 , 37 , 38 ].

A reflexive thematic approach was taken for qualitative analysis [ 39 ]. The analysis began deductively with codes derived from the CFIR, followed by inductive coding to identify additional categories. These codes were assigned using CFIR definitions, inclusion/exclusion criteria, and appropriate quote examples. NVivo V10 software (QSR International Ltd.) was used to facilitate data management.

Investigator triangulation was employed, with the principal researcher (R.N.M) coding all interviews and 20% of the interviews coded by a second researcher (R.L.A) to enhance reliability and provide different perspectives [ 40 ]. All authors participated in summarising codes prioritised for analysis and interpreting the results. A matrix was created to compare the ratings of each CFIR construct, focusing on any differences among stakeholders. Data extracts were selected to illustrate themes and subthemes, incorporating multiple perspectives for interpretation.

Study population

A total of 39 stakeholders from various hospital and health services across Queensland were interviewed. The stakeholders represented a broad spectrum of positions and roles within the healthcare system, categorised into eight groups: allied health clinicians, medical practitioners/general practitioners, nursing staff, allied health leadership, hospital and health services/statewide leadership, recipients, implementation support personnel, workforce and education. Table 1 provides demographic details of the participants.

Participants had been in their roles on average 11 years, (range 1-27 years). Interviews had an average duration of 32 minutes (range 15-59 minutes). Five interviews were conducted face to face with the remainder ( n =34) conducted through video conferencing.

Six themes were identified which aligned with the five CFIR domains and the outcomes domain. Twenty-seven underlying constructs and subconstructs of the CFIR were identified as factors influencing implementation of professional role substitution in our analysis. Ten constructs were identified in the implementation and innovation outcome categories. Main domains and constructs are illustrated in Fig. 1 .

figure 1

Key implementation and evaluation constructs for professional role substitution models of care

Innovation domain

Examining the dynamics of innovation catalysts, evidence, advantages, and disadvantages in allied health professional role substitution models of care.

The following section delineates the three primary constructs aligning with CFIR domains and an additional domain, namely "relative disadvantage." These constructs were identified from the perspectives of participants regarding professional role substitution models of care as an innovative approach.

Innovation source

Participants recognised healthcare system strain due to workforce shortages, rising costs, and increased needs with policies now prioritising workforce reform as a key healthcare strategy. The 2006 Australian Productivity Commission review, focusing on optimising scope, competencies, and job redesign was frequently cited by interviewees as the catalyst for change. The Ministerial Taskforce on Health Practitioner Expanded Scope of Practice (Queensland), alongside similar taskforces nationwide, played a vital role in implementing allied-health professional role substitution models of care. “There were a broad range of stakeholders involved in the task force across Queensland Health and external to Queensland in 2014. There was a number of recommendations in the report with overall endorsement from the Minister.” (P34, Workforce and Education)

Furthermore, the Allied Health Professions' Office supported these efforts by funding care models, addressing legislative barriers, developing training, supporting research, monitoring progress, and sharing achievements. A participant explained, ‘The office was charged with implementing the recommendations and to test these models of care. Particularly things like requesting and interpreting forms for diagnostic imaging and requesting pathology.” ( P34, Workforce and Education)

Evidence base

Participants expressed varying perspectives on the evidence base for professional role substitution models of care. Some noted a reliance on grey literature or information from pilots, highlighting the limited evidence supporting certain models. Conversely, others believed the evidence base was robust and questioned the need for further piloting. “It should be business as usual and that’s something we’ve tried to promote where we’ve got evidence from other jurisdictions and internationally. There should then be efforts to implement and try and replicate those results and take it to scale.” (P34, Workforce and Education).

Established services in other countries and professions influenced the implementation in Australia. Clinician leads or facilitators with prior experience in allied health models were identified as key enablers of this process. One participant shared their experience stating, “I was involved with that over there in the UK and so I came with that mentality to Queensland. When I worked as a fellow, I was surprised that there wasn’t that model, and I advocated for it and was told we don’t do that here. So, we ended up running extra clinics as fellows to see the long-wait patients when I knew that back in the UK it would have been [allied health discipline ].” (P19, Medical Specialist)

Relative advantage

Participants, healthcare professional and patients alike identified several advantages of allied health professional role substitution models. These models improved access to care, particularly benefiting underserved areas, and boosted efficiency by “streamlining decision-making and minimising duplication” (P19, Medical specialist). A patient shared their positive experience, stating, “If anything, I thought I was really special. I got pushed ahead really. I didn’t have to wait so long, and I wasn’t made to feel silly for my symptoms and they were investigated. The whole experience was positive.” ( P39, Consumer/Recipient)

While considered cost-effective by those interviewed due to reduced reliance on specialists in resource-limited settings, many highlighted the need for further cost-effectiveness data. One participant mentioned,

“You can get comparable or sometimes a better service at a lower cost using alternate models of care.” (P17, Medical Specialist)

Participants indicated that these models enabled allied health professionals to provide comprehensive, patient-centred care, enhancing overall healthcare experiences and patient satisfaction. Another viewpoint shared was, “ It's about getting patients to clinicians with holistic skill sets rather than just the medical model. Traditionally, patients wait a long time to see a medical professional, only to be referred back to the same clinician “, ( P15, Implementation Support). Additionally, clinicians working in these roles noted , “So, they’re kind of getting that one stop assessment, where the speech pathologist looks at the functional component, as well as pathology or organic disease” (P13, Allied Health Clinician). Moreover, they promoted professional growth, job satisfaction, and workforce retention through expanded roles and skill development opportunities, fostering collaboration among healthcare professionals from various disciplines for improved patient outcomes. One individual expressed “That responsibility and that extra challenge for me is where I get the buzz. (P 12, Allied Health Clinician )

Relative disadvantage

In addition to the benefits of professional role substitution in healthcare, participants emphasised other key factors. Patient safety and care quality surfaced as paramount concerns. A participant with workforce and education background stated, “There was a lot of the discussion and particularly the negative media coverage around the model of care. I was quite driven to answer the questions, or the concerns raised by the health professionals around safety .” (P29, Workforce and Education)

The imperative of ensuring skill, competence, and appropriate clinical governance was strongly emphasised. In some settings, participants flagged the potential for resistance and conflicts with traditional providers and organisations, driven by apprehensions about expertise encroachment, de-skilling, and role ambiguity. A Medical Specialist (P19) highlighted this, “The risk is that if you promote therapists from being treating therapists to being screening and treating therapists, you’re on the risk of deskilling your (medical) workers.”

Building public and patient trust, especially in unfamiliar models, highlighted the importance of transparent communication and educational efforts, as noted by both consumers and healthcare professionals. A patient shared, “I really didn’t know what to expect because I hadn’t been to a clinic like that before and I didn’t know what they were going to do”. (P39, Consumer/recipient). A healthcare professional suggested, “ Another barrier is patient perception, especially if they are expecting to see a doctor” but went on to add , “In my experience this has often not been the case with patients often reassured once they have had a thorough assessment ” (P13, Allied Health Clinician) Initial challenges in interaction with General Practitioners (GPs), were also highlighted with one participant noting, “ See the problems at the beginning where the GPs would ring up and say, I wanted a specialist opinion, and I got a physiotherapist. But once they were educated, those complaints dropped off especially when the patient satisfaction scores were high” (P19, Medical Specialist).

The implementation of these models often demands additional investments in training and supervision, with a consideration of their economic and logistical impact on the healthcare system required. Lastly, “striking a delicate balance between expanded scopes and core responsibilities” (P 25, Allied Health Leadership) is essential. Another participant noted, “ It is also worth considering the amount of time it takes for this training and to set up these roles. It is also important to consider the cost. Once you have a model of care set up well, what’s my sustainability plan for this model in relation to, succession planning, leave management, etcetera ? “(P15, Implementation Support)

Outer setting

Navigating the complex landscape of external factors that influence implementation and evaluation of allied health professional role substitution models of care, partnerships and connections.

Collaborative care teams and strong referral networks emerged as crucial elements for successful role substitution practice. Participants emphasised the importance of interdisciplinary collaboration, where professionals from various disciplines worked together to provide holistic patient care. Furthermore, partnerships with specialists, hospitals, community resources, and primary care facilities were highlighted as essential for ensuring seamless transitions and continuity of care. This was articulated by one GP, (P7) “I think for me and my style of medicine, it’s helpful. I really enjoyed that sort of team, that real MDT and holistic approach to patient care.”

Policies and laws

Implementing professional role substitution and scope extension may require legal and regulatory adjustments, including redefining boundaries and establishing standards which participants noted as a challenge. Variations across jurisdictions, were highlighted emphasising the need for a national approach to align state and federal policies. An occupational therapist identified legislative barriers stating, “Legislation prevents us from ordering imaging, but we all have local agreements with our departments that enable us to order basic radiology. But we want to be able to order that radiology in our general role as well and potentially expand that into other forms of the imaging down the road. This role has expanded even further in the UK to some of those therapists prescribing and referring people for MRIs and CT scans.” (P11, Allied Health Clinician)

Both allied health clinicians and medical doctors expressed concerns about legal accountability in the event of adverse events or complications in professional role substitution models. Stakeholders, including allied health clinicians, medical doctors, and healthcare leaders, emphasised the importance of assurance of indemnity through health services. “We’re protected by public indemnity in this system. And ultimately the directors are responsible for all the patients, even the ones we don’t directly treat. So that model protected our junior doctors and subsequently protects the therapists as well ” (P19, Medical Specialist). Participants also acknowledged the need for regular training and re-assessment of knowledge and skills for medical professionals but were uncertain about the lack of similar scrutiny and regulation mechanisms for allied health clinicians in professional role substitution roles.

Participants had differing perspectives on funding for new models of care. Implementing professional role substitution models of care often relied on short-term funding and grants to pilot services. A participant with an allied health clinician background highlighted complexities in healthcare funding and incentives, pointing out “General practice won’t make money unless the patient sees the GP. They would need to look at some sort of MBS (Medicare Benefits Schedule) item number so that the practice or hospital and health service can generate money from those expanded roles.” (P10, Allied Health Clinician)

Suggestions were made to review Medicare and activity-based funding structures to provide support for professional role substitution models ensuring their viability. A participant who has supported implementation of a professional role substitution model noted, “That’s also based on the fact that with Activity-Based Funding framework, we have to demonstrate that the model can generate enough activity to be viable and valuable.” (P15, Implementation Support).

Additionally, participants emphasised the importance of funding models that prioritise outcomes rather than specific care delivery mechanisms. A healthcare executive highlighted, “W e don’t purchase models of care. I would like to think that we purchase outcomes, and we are quite agnostic in how health services go about achieving those outcomes. We’ve wanted to make sure that the funding model is enabled and that it’s not a barrier to people trying alternative ways using new and different models to achieve those outcomes that we’re interested in.” (P32, Hospital and Health Services/ State-wide Leadership).

Performance management pressure

Participants acknowledged the challenge of meeting patient waiting time targets set by federal and state governments. This was an enabling factor, with professional role substitution models of care implemented as strategies to reduce specialist outpatient waitlists and improve access to services, aligning with performance targets. “There was a wait list issue for the specialty area. There was a big project to see who else could help see patients and try and reduce the waitlists. They highlighted that the [allied health specialist area clinician] might be something that could help with that.” (P8, Allied Health Clinician).

Inner setting

Impact of internal structural, political, and cultural contexts on the implementation and performance evaluation of allied health professional role substitution models in healthcare, work infrastructure.

Implementing role substitution models had workforce implications, including assessing skills availability and workload management. Sustainability relied on individual commitment, posing threats to the longevity of these models of care. An allied health leader, (P22) noted, “Often the first people you get in are personally passionate about it. It’s hard to find those people all the time, but a succession plan is important for sustainability of extended scope roles.“ These sentiments were echoed by a physician who mentioned, “Workforce and sourcing the right resources and clinicians is something that is a bit of a challenge for the health services moving forward.” (P17, Medical specialist)

Relational connections

Participants identified strong relationships and networks as vital for implementing and sustaining professional role substitution models. Trust between medical doctors and allied health clinicians was essential. As one participant noted: “Most of the time when these models fall down, it’s because the relationships between the allied health and the multidisciplinary team, including the doctors, have broken down. The doctor’s left or there’s been an issue that they couldn’t resolve and then everything falls to pieces.” (P23, Allied Health Leadership) Key roles of advocates and clinical leads were emphasised, but overreliance on individuals was a concern. Building resilience in these models across all levels of leadership was an important consideration as are clear governance structures which include supervision and escalation pathways.


Effective communication was necessary for high-quality care, patient safety, and collaborative relationships in both implementing and sustaining professional role substitution models. Iterative modifications and a willingness to learn were recognised as important. Collaboration involved shared decision-making, regular communication, and joint management of complex cases. Specialist doctors provided guidance and medical expertise, while allied health professionals contributed their specialised skills including ability to provide holistic care. “We still needed to iron out all of the kinks, so each side still needs to continue to learn from each other. So, I would say it probably took a good 12 to 18 months before we felt like we had a system that was working well for both sides and streamlining the process.” (P11, Allied Health Clinician). Additionally, some participants emphasised transitioning from “substitution-focused to team-based approaches” (P27, General Practitioner and Healthcare Executive), promoting interdisciplinary and transdisciplinary care.

For some participants, professional role substitution raised concerns about autonomy with potential for conflicts among healthcare professionals. Cultivating a collaborative culture, renegotiating traditional hierarchies, and addressing professional dynamics were identified as strategies to enable interprofessional collaboration, promoting innovation and excellence in patient care. However, despite the progress made, some participants expressed reservations about barriers that still exist, even in allied health practitioners performing tasks that were within their scope of practice. One executive leader expressed frustration at the slow pace of change stating, “ It’s an imperative at the moment that we actively promote full scope of practice and give more support for our allied health staff to do extended scope of practice qualifications. So, we have a role to ensure that we have a culture that encourages the new models of care, because just to have the old models of care, it’s not simply sustainable, it’s not sustainable, at all. “ (P36, Hospital and Health Services/ State-wide Leadership)

Another participant, an allied health leader (P22), highlighted the positive impact of professional role substitution on organisational culture and the morale of younger professionals, stating, “It’s good for our culture and gives some sort of energy to the younger professionals. It also flows through to junior doctors particularly working alongside a consultant that already holds these clinicians and models of care in high standard.”

Mission alignment and tension for change

In many organisations, clinical demand drove professional role substitution adoption, facilitated by change management teams and frameworks. Professional role substitution models aligned with healthcare organisational goals and objectives, promoting innovation, equity, and sustainable use of resources. As articulated by a Medical Specialist (P19) “We have a limited number of specialists, and training for medical students and junior doctors hasn't significantly increased to meet demand. With advanced technology and reduced working hours, we need to expand services. Having other clinicians who can treat patients without surgery is invaluable.”

Additionally, participants acknowledged their role in healthcare delivery to underserved communities and advancing health equity in First Nations, rural, and regional areas, “ improving access and preventing, fragmented care ,” (P33, Nursing Health Professional). Furthermore, participants discussed the impact of population growth on surgical waitlists, revealing the pressing need for effective solutions to address increasing demand. An allied health clinician (P11) highlighted the challenges posed by population growth, stating, “ There's been a significant increase in people moving to Queensland now for many years and our surgical wait lists were continuing to grow. So, when I started in this role… the waitlist was almost four years long.”

Participants stressed the strategic importance of expanded scope in advancing organisational objectives. An Allied health leadership participant (P25), emphasised the multifaceted benefits of expanded scope, highlighting its alignment with strategic goals and the need to reassess care delivery models: “Expanded scope hits all the strategic goals really. We need to disinvest in some of the low value care because we know that we’re not getting any outcomes. We also need to look at the impact of these models of care.”

Available resources

Funding for professional role substitution models varied, with some implemented without dedicated funding which posed challenges in attracting skilled clinicians. Stakeholders recognised the benefits of co-locating allied health clinicians and medical doctors for interdisciplinary case discussions but sometimes faced challenges due to high demand for limited space. An allied health clinician (P8) highlighted the impact of dedicated funding on the feasibility and efficiency of implementing such models “They had a certain amount of funding for this project to set it all up. And I think that really made it feasible. So, then we got the right equipment, the right time to set it up. It was a very set process with money attached to it that got it off the ground quicker.”

Access to knowledge and information

Clinicians in extended scope roles actively sought professional development opportunities to expand their skills. Local credentialing and on-the-job training were the norm. A workforce development officer highlighted the rigorous process of credentialing for clinicians in such roles. “Our credentialling package is fairly intense. It takes months and months and months to become credentialed in a first point of contact clinic like this and needs [Health Service] approval before a clinician can work in a space like this.” (P29, Workforce and Education). In contrast to nurse practitioner programs offered by universities and specialised training institutions, formal education programs for allied health professionals were scarce. Many participants recommended development of formalised training and credentialing programs to ensure high quality and safe care. “We’re now in the process of developing our own course here in Australia in collaboration with the university in New South Wales so that we can provide that level of education that we need in these advanced scope roles ” (P11, Allied Health Clinician).

Individuals domain

The roles and contributions of individuals in the implementation of allied health professional role substitution models of care.

The implementation of allied health professional role substitution models of care heavily relies on the engagement of various individuals who play pivotal roles in the process. Through our interviews, participants identified nine key roles integral to the implementation and evaluation of these alternative healthcare delivery models. These roles, aligned with those in the individuals’ domain of the CFIR, encompassed high-level leaders, mid-level leaders, opinion leaders, implementation facilitators, implementation leads, implementation team members, other implementation support, innovation deliverers, and innovation recipients. Our analysis revealed representation across these roles within our study population, demonstrating the diverse range of contributions.

Participants described the characteristics of these individuals, which we analysed based on the Capability, Opportunity, Motivation-Behaviour (COM-B) theoretical behaviour change model integrated into the CFIR framework. This system evaluates individuals' influence on the implementation process across four constructs: Need, Capability, Opportunity, and Motivation. These constructs assess individuals' deficits addressed by the models of care, their interpersonal competence, availability and power, and commitment and motivation in fulfilling their roles respectively.

Participants emphasised the critical role of medical and executive buy-in for the success of these models. Without their support and commitment, implementation efforts often faced significant hurdles. As one participant stated, " Medical and executive buy-in, if they are not supportive, it doesn’t happen " (P34, Workforce and Education). Furthermore, participants highlighted the importance of strong endorsement from medical professionals and the need for active engagement from allied health clinicians and managers to ensure the sustainability of these models. As articulated by another participant, " Allied health clinicians and even up into the level of our managers, there's certain spheres of influence that we have, but to make something like this come together and to be able to make it sustainable, you really need strong medical endorsement and that real commitment to push it " (P12, Allied Health Clinician).

Moreover, participants identified the Allied Health Office as having a crucial role in facilitating implementation. However, they also expressed the need for greater visibility and recognition of successful implementation efforts. As one participant suggested, " The Allied Health Office has a role to play in that. I think we should certainly see more things up in lights, you know, presentations, success stories et cetera and opportunities for these models to be shared and celebrated more widely across the state " (P15, Implementation Support).

A matrix analysis (Table 2 ) provides detailed insights into the roles and characteristics of individuals within different groups/roles. This elucidates their contributions to the successful implementation of professional role substitution models of care, as perceived by the study participants.

Implementation process

Essential phases and strategies for effective implementation of allied professional role substitution healthcare models.

Participants in our study provided insights into key stages necessary for implementing allied health professional role substitution models of care. We analysed their responses and mapped them to constructs in the implementation process domain of the CFIR, finding alignment with five out of the nine constructs. In the planning phase, participants emphasised the importance of conducting needs assessments and developing comprehensive implementation plans to identify gaps, set objectives, and consider resources and stakeholders' roles. One participant described, "At the start-up of our model of care, we had a series of meetings involving all stakeholders... to develop very clear guidance and pathways for how patients would move through these services " (P13, Allied Health Clinician).

Engaging was highlighted as crucial focused on involving diverse stakeholders, from healthcare providers to patients, forming multi-stakeholder teams to ensure a variety of perspectives and support for long-term sustainability. " There were a broad range of stakeholders involved in the task force across Queensland Health and external to Queensland ." (P34, Workforce and Education) In the doing phase models of care often started as pilot projects, with services developing iteratively.

Reflecting and evaluation Participants stressed the importance of building evaluation into the model of care to ensure sustainability and strategic outcomes. However, challenges such as limited time and funding were acknowledged, as one participant stated, "We don't get the time or the funding in my experienc e" (P1, Allied Health Clinician). Lastly , in adapting , participants recognised the need for continuous learning and tailored strategies to the local context, acknowledging the necessity for flexibility in response to evolving healthcare systems. Moreover, strategies to enhance evaluation included dedicated funding, external evaluation to reduce bias, development of performance frameworks, and tailored technology and digital systems allowing data collection and analysis at the point of care. Collaboration with universities and the use of research frameworks and grants were also seen by participants as facilitators to enhance performance measurement.

Implementation and innovation outcomes

The assessment of outcomes derived from allied health professional role substitution models.

In our study, participants highlighted the importance of evaluating healthcare models' success and failure, focusing on both implementation process and innovation outcomes. They identified eight key domains, including implementation aspects such as adoptability, implementability, and sustainability, as well as innovation delivery outcomes like effectiveness, safety, patient-centeredness, healthcare provider experience, access, activity, and economic evaluation. One participant stressed the need for thoughtful measurement, stating , “You do need to think about what you need to measure to prove the value of your service .” (P35, Allied Health Leader). Figure 2 summarises these outcomes and provides examples of measures discussed by participants.

figure 2

Recommended outcomes and examples to measure the impact of professional role substitution models of care

Implementation outcomes

Participants shared diverse perspectives on implementation success for allied health professional role substitution models, with factors like regulatory environment, financing, medical acceptance, stakeholder engagement, and individual characteristics playing key roles. Sustainability was particularly highlighted, as expressed by a participant, “ You need to know that a service that has been implemented is still running after several years ” (Participant 1, Allied Health Clinician).

Innovation outcomes

Participants emphasised specific outcomes in evaluating the impact of allied health professional role substitution models of care. One participant stressed the importance of measuring performance and demonstrating improved access and cost saving, saying, " I think it is important to measure performance and to show that there is improved access and economic benefits. You know, to show that the service is doing what it was intended to do" (P5, Allied Health Clinician). They also highlighted the need to track activity data, with another participant mentioning, "We basically keep data on all of the occasions of service, how many patients are seen within the service, and how many patients are discharged." (Participant 8, Allied Health Clinician).

Healthcare provider experience, including clinician and patient satisfaction, emerged as essential, with one participant suggesting : "Surveying the general practitioners would be a good way of doing it as well, asking if they are happy with the service" (P36, Executive Leader). Continuity of care and patient centredness were also emphasised. "It's actually quite heartening hearing what our patients value and to see if our services line up with that " (P29, Allied Health Clinician). Participants in the study also stressed the importance of safety as a crucial outcome measure in evaluating allied health professional role substitution models of care. One general practitioner (P7) highlighted this by stating, "We need to know we are providing great healthcare to patients. You know that we are reducing harm, not causing harm, and hopefully not missing diagnoses”.

Finally, participants perceived effectiveness as paramount for assessing the success and impact of the model on patient care experiences and health outcomes. One executive leader (P36) expressed: "Forgetting about everything else, the patients' view of whether or not they've been treated adequately to me is the most important. If there are no outcomes with the model of care, the patients won't be satisfied, and they will say so."

This study investigated factors influencing the implementation and performance evaluation of allied health professional role substitution models of care using the CFIR framework. We identified six overarching themes aligned with CFIR domains and outcomes. These themes covered dynamics such as innovation catalysts, evidence, advantages, and disadvantages; external factors affecting implementation and evaluation; internal structural, political, and cultural contexts; roles and contributions of individuals; essential implementation phases and strategies; and assessment of model outcomes. Our analysis identified twenty-seven underlying constructs and subconstructs within the CFIR framework that influence professional role substitution implementation. Additionally, we identified ten key constructs across implementation and innovation outcome categories: adoptability, sustainability, implementability, effectiveness, safety, patient-centeredness, accessibility, healthcare provider experiences, service delivery metrics, and economic evaluations. These findings addressed critical questions regarding factors influencing implementation and methods for assessing the impact of care models. Overall, this study provides a robust framework for implementing and evaluating allied health professional role substitution models, effectively addressing gaps in literature and practice.

Priority areas of focus

While prior studies have demonstrated the potential benefits of these models in terms of providing safe, effective, and cost-efficient care, [ 10 , 11 ] the current research goes further by exploring stakeholders' perceptions and experiences in depth. Grounded in the Consolidated Framework for Implementation Research (CFIR), [ 36 , 37 , 38 ] it explores the multifaceted factors influencing the adoption and integration of these models within healthcare systems.

Healthcare organisations play a significant role in either facilitating or impeding the implementation of professional role substitution models of care [ 41 ]. Along with previous research , this work underscores the significance of supportive organisational cultures, adequate resources, leadership commitment, and medical endorsement as critical factors for the successful adoption of such models [ 42 ]. Conversely, factors like resistance to change, resource limitations, and insufficient infrastructure can pose significant barriers that must be addressed to ensure successful implementation.

Traditional healthcare structures were once considered conducive to advancing medical sciences [ 43 ]. However, recent reviews have highlighted how entrenched organisational cultures and long-held traditions within healthcare settings may now act as barriers to alternative models of practice and hinder improvements in healthcare access for the community [ 41 ]. Consequently, healthcare organisations must proactively assess their readiness for new models and develop strategies to overcome these barriers. Leveraging the constructs and principles identified in the inner setting domain of this study is essential for cultivating a culture that fosters role substitution and innovation in healthcare delivery.

Stakeholders' perceptions and attitudes play a significant role in shaping the success of professional role substitution models of care, influenced by factors like medical buy-in, leadership support, and engagement strategies [ 41 , 44 , 45 ]. Effective stakeholder engagement strategies, alongside tailored training, communication programs and ongoing support mechanisms, emerge as crucial tools for addressing individual concerns and fostering buy-in from all involved parties. These findings align with similar studies in physiotherapy and nursing, emphasising the universal importance of considering individual perspectives in healthcare implementation efforts [ 41 , 44 , 45 , 46 ].

This research emphasises the importance of incorporating perspectives from patients and innovation recipients to enhance the success of healthcare interactions. Integrating these viewpoints strengthens the potential for sustainable adoption of evidence-based innovations, promoting patient-centred care [ 47 , 48 , 49 ]. Patient involvement in co-designing and evaluating alternative healthcare models improves trust and acceptance, highlighting the significance of collaboration and patient engagement strategies for optimising implementation and evaluation processes [ 27 , 28 , 47 ].

Performance evaluation plays a pivotal role in assessing the implementation of professional role substitution models of care [ 25 ]. Monitoring various factors, including outcomes, patient satisfaction, quality of care, safety, healthcare professionals’ performance, healthcare system efficiency, and cost-effectiveness, can provide valuable insights for ongoing improvement, optimisation, and sustainability of models of care [ 25 , 50 ]. We address gaps highlighted in previous research, particularly concerning the lack of comprehensive evaluations and guidance on outcome measures [ 10 , 22 , 25 ]. Many current frameworks lack specificity in identifying key metrics relevant to professional role substitution models [ 25 , 26 ]. However, this study delineating eight key outcome measures emphasises a data-driven approach to decision-making. This represents an advancement in the field, providing a structured framework for assessing the impact and value of these models.

Implications for policy, practice and future research

In combination with existing literature in various alternative healthcare delivery models, this study highlights the shared challenges and opportunities across healthcare professions and settings [ 41 , 45 , 46 ]. Our analysis of implementation considerations, stakeholder perspectives, and outcome measures, advances theoretical understanding and also provides practical guidance for real-world implementation and evaluation. These insights can be extended beyond Australia's healthcare system, with implications for policy development, collaboration, knowledge exchange, and healthcare delivery practices in other regions.

In practice, maximising the effectiveness and sustainability of professional role substitution models necessitates comprehensive training and education initiatives for health professionals. Collaborating with professional bodies and universities can standardise training, provide continuous professional development opportunities, and address individual factors that impact implementation readiness for alternative healthcare delivery models.

Adapting regulatory frameworks to the evolving healthcare landscape is paramount, necessitating clear guidelines and legal frameworks to delineate practice boundaries and facilitate the seamless implementation of expanded roles. Adequate funding is critical to support various aspects, including staffing, infrastructure development, establishment of incentivising reimbursement models, research, evaluation, and ensuring ongoing sustainability. Prioritising evidence-based policy development, informed by comprehensive evaluation of care models, is essential to ensure alignment with best practices and standards of care. Integrating standard outcome measures into evaluation frameworks is crucial for accurately assessing the impact and effectiveness of care models, thereby enabling informed decision-making based on evidence. The research we have conducted supports these assertions, emphasising the importance of these factors for the successful implementation and sustainability of alternative healthcare delivery models.

Our findings may therefore serve as a catalyst for discussion and debate on allied health professional role substitution and other alternative healthcare delivery models, guiding future research endeavours. Exploring longitudinal studies to gauge sustainability and long-term impact, conducting comparative analyses across diverse settings and patient populations, and conducting qualitative inquiries to identify implementation and evaluation facilitators and barriers are critical. Additionally, research in health economics, health information technology, policy analysis, and interprofessional collaboration can provide valuable insights to optimise implementation practices and enhance the applicability of these models across different healthcare systems and cultural contexts.

Strengths and limitations

The strengths of this study lie in the diverse range of stakeholders involved, including key opinion leaders, decision makers, allied health clinicians, medical professionals, policymakers, healthcare administrators, university partners, professional bodies, advocates, and patients. The inclusion of participants with varied experiences enhances the robustness of the findings. Purposeful sampling with maximum variation further improves the transferability of the results.

The use of the COREQ-checklist and independent co-coding and discussions among the research team enhance the credibility, trustworthiness, and transparency of the study [ 31 ]. Another notable strength is the use of the Consolidated Framework for Implementation Research (CFIR) to guide the analysis, which helped identify and organise themes into multi-level intervention principles that influence implementation effectiveness. It should be noted that the CFIR was not used to guide data collection, as is often practiced, [ 38 ] as this may have limited the exploration of qualitative themes relevant to the research question but not explicitly aligned with CFIR domains and constructs.

As the study was conducted in Australia, the generalisability of the findings to other stakeholders or healthcare contexts in different countries and settings may be limited. Additionally, as with any research involving human subjects, the possibility of self-selection bias influencing the results cannot be excluded, and the findings should be interpreted with this in mind. Insights gained from this study may also have broader implications for other countries facing similar challenges in healthcare delivery. By examining similarities and differences in healthcare systems and regulatory environments, countries can however learn from Queensland’s experiences adopting strategies to support the implementation of role substitution models.

In conclusion, this study provides a systematic examination of the key elements and principles influencing the implementation and performance evaluation of professional role substitution models of care. By understanding the multifaceted nature of these factors and addressing the challenges and opportunities associated with expanded healthcare roles, healthcare systems can navigate complexities and capitalise on opportunities. This holistic approach, involving collaboration among stakeholders and considering patient safety, quality of care, and optimal healthcare outcomes will contribute to the development of more efficient, equitable, sustainable, and patient-centred models of care and healthcare systems.

Availability of data and materials

Data is available from corresponding author on reasonable request.


Consolidated Framework for Implementation Research

Consolidated Criteria for Reporting Qualitative Research

Physician Assistants

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A special thanks to the participants who gave up their time to share their experiences and perceptions on implementation and performance evaluation of professional role substitution models of care.

This work was supported by the Gold Coast Hospital and Health Service Collaborative Research Grant [grant number RGS20190041].

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Rumbidzai N. Mutsekwa

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RNM, RC, KC, RLA, LJM, JB contributed to conception and design of the study. RM led the data collection and analysis and wrote the initial draft of the manuscript. RNM, KC, RC, RLA, LJM and JB interpreted results, critically revised the manuscript, and approved the final version.

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Across the world, critical businesses and services including airlines, hospitals, train networks and TV stations, were disrupted on Friday by a global tech outage affecting Microsoft users.

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Ethanol is a renewable fuel made from various plant materials collectively known as " biomass ." More than 98% of U.S. gasoline contains ethanol to oxygenate the fuel. Typically, gasoline contains E10 (10% ethanol, 90% gasoline), which reduces air pollution.

Ethanol is also available as E85 (or flex fuel), which can be used in flexible fuel vehicles , designed to operate on any blend of gasoline and ethanol up to 83%. Another blend, E15 , is approved for use in model year 2001 and newer light-duty vehicles.

There are several steps involved in making ethanol available as a vehicle fuel:

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  • E10 is sourced from fuel terminals whereas E85 is sourced from a terminal or directly from an ethanol production facility.
  • E15 is available from fuel terminals or through a blender pump dispenser that draws from E10 and E85 tanks at a station.

Fuel Properties

Ethanol (CH 3 CH 2 OH) is a clear, colorless liquid. It is also known as ethyl alcohol, grain alcohol, and EtOH (see Fuel Properties search .) Ethanol has the same chemical formula regardless of whether it is produced from starch- or sugar-based feedstocks, such as corn grain (as it primarily is in the United States), sugar cane (as it primarily is in Brazil), or from cellulosic feedstocks (such as wood chips or crop residues).

Ethanol has a higher octane number than gasoline, providing premium blending properties. Minimum octane number requirements for gasoline prevent engine knocking and ensure drivability. Lower-octane gasoline is blended with 10% ethanol to attain the standard 87 octane.

Ethanol contains less energy per gallon than gasoline, to varying degrees, depending on the volume percentage of ethanol in the blend. Denatured ethanol (98% ethanol) contains about 30% less energy than gasoline per gallon. Ethanol’s impact on fuel economy is dependent on the ethanol content in the fuel and whether an engine is optimized to run on gasoline or ethanol.

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In the United States, 94% of ethanol is produced from the starch in corn grain. Energy is required to turn any raw feedstock into ethanol. Ethanol produced from corn demonstrates a positive energy balance , meaning that the process of producing ethanol fuel does not require more energy than the amount of energy contained in the fuel itself.

Cellulosic ethanol improves the energy balance of ethanol because the feedstocks are either waste, coproducts of another industry (wood, crop residues), or dedicated crops—such as switchgrass and miscanthus—with lower water and fertilizer requirements compared to corn. When biomass is used to power the process of converting non-food-based feedstocks into cellulosic ethanol, the amount of fossil fuel energy used in production is reduced even further. Another benefit of cellulosic ethanol is that it results in lower levels of life cycle greenhouse gas emissions .

For more information on the energy balance of ethanol, download the following documents:

  • USDA's 2018 – A Life-Cycle Analysis of the Greenhouse Gas Emissions from Corn-Based Ethanol
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Null & Alternative Hypotheses | Definitions, Templates & Examples

Published on May 6, 2022 by Shaun Turney . Revised on June 22, 2023.

The null and alternative hypotheses are two competing claims that researchers weigh evidence for and against using a statistical test :

  • Null hypothesis ( H 0 ): There’s no effect in the population .
  • Alternative hypothesis ( H a or H 1 ) : There’s an effect in the population.

Table of contents

Answering your research question with hypotheses, what is a null hypothesis, what is an alternative hypothesis, similarities and differences between null and alternative hypotheses, how to write null and alternative hypotheses, other interesting articles, frequently asked questions.

The null and alternative hypotheses offer competing answers to your research question . When the research question asks “Does the independent variable affect the dependent variable?”:

  • The null hypothesis ( H 0 ) answers “No, there’s no effect in the population.”
  • The alternative hypothesis ( H a ) answers “Yes, there is an effect in the population.”

The null and alternative are always claims about the population. That’s because the goal of hypothesis testing is to make inferences about a population based on a sample . Often, we infer whether there’s an effect in the population by looking at differences between groups or relationships between variables in the sample. It’s critical for your research to write strong hypotheses .

You can use a statistical test to decide whether the evidence favors the null or alternative hypothesis. Each type of statistical test comes with a specific way of phrasing the null and alternative hypothesis. However, the hypotheses can also be phrased in a general way that applies to any test.

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The null hypothesis is the claim that there’s no effect in the population.

If the sample provides enough evidence against the claim that there’s no effect in the population ( p ≤ α), then we can reject the null hypothesis . Otherwise, we fail to reject the null hypothesis.

Although “fail to reject” may sound awkward, it’s the only wording that statisticians accept . Be careful not to say you “prove” or “accept” the null hypothesis.

Null hypotheses often include phrases such as “no effect,” “no difference,” or “no relationship.” When written in mathematical terms, they always include an equality (usually =, but sometimes ≥ or ≤).

You can never know with complete certainty whether there is an effect in the population. Some percentage of the time, your inference about the population will be incorrect. When you incorrectly reject the null hypothesis, it’s called a type I error . When you incorrectly fail to reject it, it’s a type II error.

Examples of null hypotheses

The table below gives examples of research questions and null hypotheses. There’s always more than one way to answer a research question, but these null hypotheses can help you get started.

( )
Does tooth flossing affect the number of cavities? Tooth flossing has on the number of cavities. test:

The mean number of cavities per person does not differ between the flossing group (µ ) and the non-flossing group (µ ) in the population; µ = µ .

Does the amount of text highlighted in the textbook affect exam scores? The amount of text highlighted in the textbook has on exam scores. :

There is no relationship between the amount of text highlighted and exam scores in the population; β = 0.

Does daily meditation decrease the incidence of depression? Daily meditation the incidence of depression.* test:

The proportion of people with depression in the daily-meditation group ( ) is greater than or equal to the no-meditation group ( ) in the population; ≥ .

*Note that some researchers prefer to always write the null hypothesis in terms of “no effect” and “=”. It would be fine to say that daily meditation has no effect on the incidence of depression and p 1 = p 2 .

The alternative hypothesis ( H a ) is the other answer to your research question . It claims that there’s an effect in the population.

Often, your alternative hypothesis is the same as your research hypothesis. In other words, it’s the claim that you expect or hope will be true.

The alternative hypothesis is the complement to the null hypothesis. Null and alternative hypotheses are exhaustive, meaning that together they cover every possible outcome. They are also mutually exclusive, meaning that only one can be true at a time.

Alternative hypotheses often include phrases such as “an effect,” “a difference,” or “a relationship.” When alternative hypotheses are written in mathematical terms, they always include an inequality (usually ≠, but sometimes < or >). As with null hypotheses, there are many acceptable ways to phrase an alternative hypothesis.

Examples of alternative hypotheses

The table below gives examples of research questions and alternative hypotheses to help you get started with formulating your own.

Does tooth flossing affect the number of cavities? Tooth flossing has an on the number of cavities. test:

The mean number of cavities per person differs between the flossing group (µ ) and the non-flossing group (µ ) in the population; µ ≠ µ .

Does the amount of text highlighted in a textbook affect exam scores? The amount of text highlighted in the textbook has an on exam scores. :

There is a relationship between the amount of text highlighted and exam scores in the population; β ≠ 0.

Does daily meditation decrease the incidence of depression? Daily meditation the incidence of depression. test:

The proportion of people with depression in the daily-meditation group ( ) is less than the no-meditation group ( ) in the population; < .

Null and alternative hypotheses are similar in some ways:

  • They’re both answers to the research question.
  • They both make claims about the population.
  • They’re both evaluated by statistical tests.

However, there are important differences between the two types of hypotheses, summarized in the following table.

A claim that there is in the population. A claim that there is in the population.

Equality symbol (=, ≥, or ≤) Inequality symbol (≠, <, or >)
Rejected Supported
Failed to reject Not supported

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To help you write your hypotheses, you can use the template sentences below. If you know which statistical test you’re going to use, you can use the test-specific template sentences. Otherwise, you can use the general template sentences.

General template sentences

The only thing you need to know to use these general template sentences are your dependent and independent variables. To write your research question, null hypothesis, and alternative hypothesis, fill in the following sentences with your variables:

Does independent variable affect dependent variable ?

  • Null hypothesis ( H 0 ): Independent variable does not affect dependent variable.
  • Alternative hypothesis ( H a ): Independent variable affects dependent variable.

Test-specific template sentences

Once you know the statistical test you’ll be using, you can write your hypotheses in a more precise and mathematical way specific to the test you chose. The table below provides template sentences for common statistical tests.

( )

with two groups

The mean dependent variable does not differ between group 1 (µ ) and group 2 (µ ) in the population; µ = µ . The mean dependent variable differs between group 1 (µ ) and group 2 (µ ) in the population; µ ≠ µ .
with three groups The mean dependent variable does not differ between group 1 (µ ), group 2 (µ ), and group 3 (µ ) in the population; µ = µ = µ . The mean dependent variable of group 1 (µ ), group 2 (µ ), and group 3 (µ ) are not all equal in the population.
There is no correlation between independent variable and dependent variable in the population; ρ = 0. There is a correlation between independent variable and dependent variable in the population; ρ ≠ 0.
There is no relationship between independent variable and dependent variable in the population; β = 0. There is a relationship between independent variable and dependent variable in the population; β ≠ 0.
Two-proportions test The dependent variable expressed as a proportion does not differ between group 1 ( ) and group 2 ( ) in the population; = . The dependent variable expressed as a proportion differs between group 1 ( ) and group 2 ( ) in the population; ≠ .

Note: The template sentences above assume that you’re performing one-tailed tests . One-tailed tests are appropriate for most studies.

If you want to know more about statistics , methodology , or research bias , make sure to check out some of our other articles with explanations and examples.

  • Normal distribution
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Hypothesis testing is a formal procedure for investigating our ideas about the world using statistics. It is used by scientists to test specific predictions, called hypotheses , by calculating how likely it is that a pattern or relationship between variables could have arisen by chance.

Null and alternative hypotheses are used in statistical hypothesis testing . The null hypothesis of a test always predicts no effect or no relationship between variables, while the alternative hypothesis states your research prediction of an effect or relationship.

The null hypothesis is often abbreviated as H 0 . When the null hypothesis is written using mathematical symbols, it always includes an equality symbol (usually =, but sometimes ≥ or ≤).

The alternative hypothesis is often abbreviated as H a or H 1 . When the alternative hypothesis is written using mathematical symbols, it always includes an inequality symbol (usually ≠, but sometimes < or >).

A research hypothesis is your proposed answer to your research question. The research hypothesis usually includes an explanation (“ x affects y because …”).

A statistical hypothesis, on the other hand, is a mathematical statement about a population parameter. Statistical hypotheses always come in pairs: the null and alternative hypotheses . In a well-designed study , the statistical hypotheses correspond logically to the research hypothesis.

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Costs and cost drivers of comprehensive sexual reproductive health services to female sex workers in Kenya

  • Griffins O. Manguro 1 ,
  • Urbanus Mutuku Kioko 2 ,
  • Gerald Githinji 3 ,
  • Patricia Owira 3 ,
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Comprehensive sexual reproductive health (SRH) programs for female sex workers (FSW) offering clinical, behavioural, and structural interventions have contributed to declining rates of HIV in this population. However, data on costs and cost drivers is needed to support programs and their donors to better allocate resources, make an investment case for continued funding, and to identify areas of improvement in program design and implementation. We aimed to estimate the annual per-FSW costs of comprehensive services for a standalone FSW program in Kenya.

We implemented a top–bottom and activity-based costing study of comprehensive FSW services at two drop-in centres (DICs), Mtwapa and Kilifi town, in Kilifi County, Kenya. Service costs were obtained from routinely collected patient data during FSW scheduled and unscheduled visits using Kenyan Ministry of Health records. Costing data were from the program and organization’s expenditure reports, cross checked against bank documents and supported by information from in-depth interviews. Data were collected retrospectively for the fiscal year 2019. We obtained approval from the AMREF Research Ethics Committee (AMREF-ESRC P862/2020).

In 2019, the unit cost of comprehensive services was 105.93 USD per FSW per year, roughly equivalent to 10,593 Kenya shillings. Costs were higher at Mtwapa DICs compared to Kilifi town DIC; 121.90 USD and 89.90 USD respectively. HIV counselling and testing cost 63.90 USD per person, PrEP was 34.20 USD and family planning was 9.93 USD. Of the total costs, staff salaries accounted for about 60%. Adjusted for inflation, costs in 2024 would be approximately 146.60.

Programs should strive to maximize the number of FSW served to benefit from economies of scale. Given that personnel costs contribute most to the unit costs, programs should consider alternative designs which reduce personnel and other costs.

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In the last decade, many sub-Saharan African (SSA) countries have reported marked progress in reducing new HIV infections, increasing access to antiretroviral treatment (ART), and reducing AIDS-related deaths. Between 2010 and 2015, the Eastern and Central African region reported reductions of 14% and 38% in new HIV infections and AIDS-related deaths respectively, indicating noteworthy progress in the HIV response [ 1 ]. Such progress is attributed to many things including successful prevention programs, early initiation and expanded access to ART, oral pre-exposure prophylaxis (PrEP), and successful programs that target key populations (KP) [ 2 , 3 , 4 , 5 ].

In Kenya, key populations (KP) which include female and male sex workers (FSW/MSW), men who have sex with men (MSM), people who inject drugs (PWID), and transgender persons currently make up about one third of newly infected persons [ 6 ]. Additionally, FSW also contribute significantly to new infections through their general population sexual partners [ 7 ]. Fortunately, many African countries are reporting declining HIV prevalence among FSW. Our 2016 study on sex workers in Mombasa, Kenya, reported a prevalence of 12%, almost half of what was reported in previous national estimates, and modelling showed that prevalence had declined by 30% between 1993 and 2016 [ 8 , 9 ]. Although it is likely that these declines reflect and are linked to similar trends in the general population, FSW-targeted programs have no doubt played a significant role [ 10 ].

Most KP programs in Kenya are donor funded. By 2021, there were about 100 such programs run by non-governmental organizations (NGOs) and KP community-led groups, serving about 207,000 FSW, 51,000 MSM, and 6,000 transgender persons [ 11 ]. The two main sources of funding are the US President's Emergency Plan for AIDS Relief (PEPFAR), and the Global Fund for AIDS, Tuberculosis, and Malaria [ 11 ]. The Kenyan National AIDS and STI Control Program (NASCOP) develops guidelines, monitors and evaluates quality and outcomes, and coordinates funding at the national level [ 11 ]. Although KP programs have always offered HIV prevention and treatment services as well as structural interventions, recent approaches by PEPFAR focus on HIV case identification and linkage to care [ 11 ]. This shift from a comprehensive community-led program offering a balance of biomedical, behavioural and structural interventions to one focused on clinical services and clinical outcomes could undermine the gains made over the years by eliminating activities that get KP interested and engaged in programs [ 12 ] and proven to have a significant impact in reducing the risk of HIV. The shift is mostly due to reductions in overall global funding for HIV and the need to double down on successful interventions [ 12 ].

A significant challenge in securing funding for FSW programs in African countries is the lack of accurate data on the per-person costs of delivering comprehensive services or the cost-effectiveness of HIV programs targeting FSW [ 11 , 13 ]. By comprehensive services, we mean biomedical, behavioural, and structural interventions. Several studies have attempted to estimate these costs to inform FSW program budgets. However, these studies mostly focus on costing HIV care services alone, such as HIV testing, antiretroviral treatment (ART), and oral PrEP and largely overlook other clinical services (such as contraceptives, mental health care, and interventions for alcohol and drug use) behavioural and structural interventions (for example peer education, mapping sex worker locations, and sexual and gender-based violence interventions) [ 14 ]. Because of this lack of completeness FSW implementors, national programs, and donors often rely on incomplete data when making budgets, leading to under-resourced programs.

This study was conducted with the aim of: Estimating the per-person cost of comprehensive services in an ongoing FSW program in Kenya providing a mix of behavioural, biomedical and structural interventions; estimating the cost of specific clinical services (HIV testing, family planning, and oral PrEP), and estimating the contribution of behavioural and structural interventions to the overall per-person costs. By generating such comprehensive cost data, this study will provide FSW program implementers, national programs, and donors with the necessary data to make realistic budgets for more efficient programs. Additionally, implementers and national programs will have more accurate and complete estimates to use when negotiating with donors.

Materials and methods

Program description.

Since 2014, the International Centre for Reproductive Health Kenya (ICRHK), a Kenyan research NGO, has implemented a program targeting to improve access to comprehensive sexual and reproductive health services to FSW in two towns in Kilifi County, Kenya. This program is funded by the United Nations Population Fund (UNFPA). ICRHK has extensive experience conducting research and interventions for FSWs in Kenya and has significantly contributed to building evidence to the national policies and guidelines [ 8 , 15 , 16 , 17 , 18 , 19 ].

Program design

The program follows the national (NASCOP) guidelines for FSW HIV and STI programming which recommend a peer-led approach and a balanced mix of behavioural, biomedical, and structural interventions [ 20 ]. The evidence behind adding behavioural and structural interventions, in addition to biomedical HIV prevention interventions to reduce HIV in FSW and its effectiveness has been published before. In the peer-led approach, peer educators (PEs) are engaged to educate fellow FSWs, promote and distribute condoms, and refer them for clinical services [ 15 , 20 ]. Biomedical services such as HTS, PrEP and ART, and behavioural interventions such as counselling for alcohol addiction are provided through special clinics, drop-in centres (DICs), that are established and run by the program. Structural interventions, which aim to make the environment within which FSW operate, for example holding meetings to engage hotspot owners and the police to prevent and respond to sexual violence are also supported by the program. These have been shown to be effective in reducing FSW risk of infection [ 20 ]. The two ICRHK DICs in Kilifi County are in Mtwapa and Kilifi Townships, which are about an hour apart by car. The DIC in Mtwapa was the first in the region and was established in 2013. The DIC in Kilifi town is smaller, opened in 2017 and offered HIV testing as the only clinical service until 2019. Mtwapa is a cosmopolitan town, with a population of approximately 100,000. Kilifi town is smaller than Mtwapa and is mostly rural with an estimated population of 60,000.

The peer-led approach and the evidence of its effectiveness in FSW programs has been described in various publications [ 15 , 20 , 21 ]. In the ICRHK program, each peer educator was assigned a cohort of 60 to 80 FSWs peers who they contacted at least once a month. They were supervised by Outreach Workers (OW), and each OW supervised 15 peer educators as per the guidelines [ 20 ]. Peer educators underwent a five-day training using a NASCOP curriculum at the time of recruitment, and each year, they underwent a one-day refresher training. Each peer educator received a monthly stipend of approximately 35 USD. Outreach Workers received 75 USD and a further 20 USD (total 95 USD) per month to cover transportation costs. Peer educators and Outreach Workers also received 5 USD transport reimbursement during each outreach. All these were part of the program costs.

For clinical services including HIV testing and STI screening, FSWs were scheduled for visits to the DICs once every quarter. HIV positive FSW on ART were also required to visit the DIC every three months for medication refill, and for clinical and immunological monitoring once every year. At each DIC, two clinical officers were employed full-time. Additional clinicians were engaged to support the full-time clinicians during outreach. The additional clinicians were either nurses or trained HIV testing counsellors. The clinical services offered at both DICs are outlined in Table  1 . The program leased space for DICs. The location was selected by the FSWs themselves, and was required to be safe, accessible even during evening hours, and close to sex work venues. The program obtained a licence for the DICs to operate as private clinics from the Kenya Medical Practitioners and Dentists Council. HIV test kits, ART (including PrEP), family planning commodities, and medications for tuberculosis and STIs were supplied to the DICs by the Kenya Medical Supplies Authority, in the same manner as they were provided to public facilities across Kenya. These services were offered free of charge to FSW at the DICs. For FSWs living with HIV, laboratory testing for ART monitoring and for TB diagnosis was integrated into the county’s HIV and TB program which was supported by PEPFAR throughout Kenya and offered free of charge. Samples were collected at the DICs and sent to the nearby government health facility and results transmitted online.

Data sources

We costed services for the year 2019. For peer educator and clinical service data, we used quantitative data collected routinely through Ministry of Health (MOH)/NASCOP forms. Peer education data was obtained from paper-based forms completed by peer educators each time they encountered FSWs and provided outreach services. Such data included data on the number of condoms and other services FSW received. Clinical data was obtained during enrolment, follow-up routine clinic visits, and unscheduled (sick) visits. During each visit, paper-based clinical forms were completed by clinical officers and subsequently entered into an electronic database in Microsoft Access by a data assistant stationed at each DIC. The same information was used to generate quarterly program reports. To ensure completeness and correctness of the data, quarterly data quality assessments were conducted by the program.

Data analysis

To obtain cost data, program expenditure reports and other expenditure reports from the ICRHK finance department were used. These were cross-checked against bank documents to support the expenditure. The data collectors also conducted interviews with the Finance Manager and Senior Accountant, and with project staff to provide additional information for costing. The interview guide is provided in the supplementary materials.

We summarized the social, demographic, health, and sex work characteristics of all sex workers in the program for each DIC. This data was not used for the costing but is presented to describe the social and demographic characteristics of the FSW group. The mean and standard deviation (SD) of continuous data were presented. Numbers and proportions were used to represent binary or categorical data. To compare categorical and continuous variables between the two DICs, we used a chi-squared test and a T test, respectively.

We used a top–bottom and step-down approach for costing, whereby expenditures and economic costs were allocated to the program, then to each DIC and finally to the various program activities [ 22 , 23 ]. The availability of comprehensive expenditure data for both the program and the organization, time sheets, and staff for interviews made it possible to use this approach. The personnel costs section included the salaries for staff working full-time on the program such as the Project Manager, Clinical Officers, Community Mobilizer and Data Assistants, as well as salaries for staff who only provided limited time to the project such as the Country Director and Finance Manager. The latter’s costs were prorated based on time allocated to the project as per the time sheets and supported by data from the interviews. Peer educator and outreach workers’ stipends and allowances were not included in the salaries costs but were under Peer Educator Stipends, a separate program cost. Rent and utilities’ costs for the DICs were cost under rent and utilities, an independent cost activity, while the costs for ICRHK main offices and utilities were included in Administration costs. The costs associated with program monitoring and evaluation, quality improvement, and reporting were distributed across various activities. For instance, transport for data officers to the DICs for data checks during monitoring and evaluation were categorized under transport and communications. Meeting costs during data reviews were allocated to meetings. Training costs for health workers and peer educators, aimed at enhancing service quality or updating them on revised guidelines as part of quality assurance, were allocated to training. Table 2 below details the cost categories and specific activities included in each category.

Given that the study was carried out in 2019, we adjusted the cost of services in 2019, for inflation between 2019 and 2024 in order to obtain the approximate cost in 2024. Inflation rates were: 2020, 5.4%; 2021, 6.1%; 2022, 7.7%; 2023, 7.0%; 2023, 5.1; 2024, 5.1% (based on preliminary data from early 2024). The average annual inflation rate during this period was 6.8%. The adjusted rate was calculated using the formula:

The cost of HIV test and STI screening kits, ART (including PrEP), family planning (FP) commodities, and laboratory monitoring for HIV and TB were not included. There were several reasons for this: 1) The Kenya Medical Supplies Authority procured HIV and STI test kits, ART, and FP commodities and distributed these to health facilities; patients in public facilities and DICs were not charged 2) Afya Pwani, a PEPFAR-funded project coordinated sample pick-up, testing and ensured individual patient results were available through a central, online portal for all HIV and TB patients in the region at no cost to the patients; 3) The exact prices of these commodities were unavailable, and if we were to use global market prices, our estimates would have been exaggerated as governments purchase in bulk at lower prices; 4) Because these costs were already covered by other national programs and were not routinely included in FSW program budgets or scope, by including them, our estimates of FSW program costs would be exaggerated. We did include the costs of cervical cancer screening through visual inspection using acetic acid and Lugol’s Iodine because this was offered annually to all sex workers but was not covered by the KEMSA supplies and were included in the project’s budget.

The financial costing process adhered to the principles outlined in the Global Health Cost Consortium Reference Case (GHCC) [ 24 ]. The total cost of the program for the year was calculated by adding all the actual costs incurred. The annual per-FSW cost was calculated by dividing the total program cost to the weighted total number of FSW who received services during that time period. The weighting was determined by the number of visits made by each FSW.

Ethical approval

The study obtained approval from the Amref Research Ethics Committee (AMREF-ESRC P862/2020) in Nairobi, Kenya to analyse retrospectively collected program data, costing data from program expenditure, and to conduct interviews with ICRHK staff to get more information on budgeting and cost allocation. Individual FSW data were collected during routine service delivery, so informed consent was not obtained. For ICRHK finance, administration, and program staff who answered interview questions, written informed consent was obtained. All methods were carried out in accordance with relevant guidelines and regulations pertaining to research in human subjects.

Summary of characteristics of services and of FSWs

Between January and December 2019, 1,964 FSW received comprehensive services at the two DICs. Of these, 1,175 were served in Mtwapa and 789 in Kilifi town. There were 4,358 visits in Mtwapa and 1,968 in Kilifi town, an average of 3.7 (Standard deviation [SD] 2.9) and 2.4 (SD 1.8) visits per FSW per year in Mtwapa and Kilifi town respectively. Visits lasted between 15 and 45 min, with an average of 28 min per visit. Fifteen peer educators were engaged to cover sex work venues in Mtwapa and 12 in Kilifi town. In Mtwapa, each PE maintained a cohort of 79 FSW while in Kilifi town, each had a cohort of 65.3.

In brief, the majority of the FSW were aged between 21 and 30 (63.1%; Table  1 )) with a median age of 27 years. HIV prevalence in the total FSW population was 6.3%. There were significant differences in social and demographic characteristics (age, education, marital status), clinical characteristics (HIV and STI prevalence) and sexual characteristics between those served in Mtwapa and Kilifi DICs.

Cost of FSW services

In 2019, the cost of providing HIV and other services to one FSW for the year was 105.93 USD, which is roughly equivalent to 10,593 Kenyan Shillings (Kshs) based on the 2019 exchange rate of 1 USD = 100 Kshs. The annual cost per FSW in Mtwapa was 89.90 USD, and in Kilifi it was 121.90 USD. The cost of HIV testing services (HTS) was 63.90 USD per FSW per year across the program, 65.80 USD in Mtwapa, and 62.00 USD in Kilifi DIC. For oral PrEP services, the cost was 34.20 USD per FSW per year in the overall program, 25.80 USD in Mtwapa and 42.60 USD in Kilifi DIC. FP services cost 9.93 USD across the program, 8.10 USD in Mtwapa and 11.80 USD in Kilifi. Figure  1 presents the cost of services across the program and at the two DICs. Adjusted for inflation between 2019 and 2024, the estimated cost of services per FSW in 2024 would be USD 146.50. In Mtwapa, services would cost USD 120.90, while in Kilifi DIC, they would be USD 162.62. For the individual activities of the program, the adjusted costs for 2024 would be USD 85.90 for HTS, USD 45.98 for PrEP, and USD 13.35 for FP.

figure 1

Unit cost of FSW services in US Dollars. A bar chart representing the cost in US dollars for 1) all SRH services, 2) HIV testing services, 3) Oral Pre exposure prophylaxis services, and 4) family planning services for an individual FSW for one year for the program, and at Mtwapa and Kilifi town DICs

Breakdown of financial costs for different activities

When we looked at how various program activities contributed to the overall costs, personnel costs were the greatest contributor. In Mtwapa, personnel costs accounted for about 60% of the overall costs (USD 53.94) and in Kilifi, it was 55% (USD 67.05). Other significant cost drivers were rent and utilities for the DICs, (11%, USD 9.90 in Mtwapa and 8%, USD 9.75 in Kilifi), PE/Outreach Worker stipend (8%, USD 7.19 in Mtwapa and 8% USD 9.75 in Kilifi.). Figure  2 presents the key program activities and the proportion they contributed to the overall unit costs at each DIC.

figure 2

Key program activities and the proportion (in percentages) they contribute to the unit cost. A colour-coded horizontal stacked bar chart depicting key program activities and the proportion (percentage) they contribute to the per-year unit cost of FSW services at Mtwapa and Kilifi Town DICs

We carried out this study to estimate the unit cost of comprehensive FSW services in two drop-in centres in Mtwapa and Kilifi town, Kenya, funded and implemented as one program and by the same Organization. We estimated the costs of a program that provided comprehensive services using the NASCOP-recommended approach which emphasized on a peer-led implementation with an equal mix of biomedical, behavioural and structural interventions. This research builds on previous research that have demonstrated the success of HIV outcomes in FSW programs. While our previous research demonstrated that FSW-targeted programs as designed effectively reduced HIV incidence and prevalence, our goal here was to provide national programs and implementing partners with an estimate of the per-person cost of service delivery to guide funding allocation and to identify cost drivers. We found that the cost of services was 105.93 USD per FSW per year on average, with personnel accounting for nearly two-thirds of the cost. Furthermore, service costs were lower at the Mtwapa drop-in centre (DIC), compared to Kilifi DIC.

When we compared our unit costs to other studies, we found large variations, ranging from as little as 10.70 USD in India to 1098.00 USD in Burkina Faso [ 25 , 26 , 27 ]. This is not surprising; multiple factors contribute to the per-person costs; FSW programs have complex and different designs, different studies include different costs and studies perform analyses differently. The FSW population reached, services provided, in-country cost of goods, maturity of the program and the organization-level efficiency of the implementing partner all contribute to the per-person costs [ 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 ]. Large programs that serve many FSW benefit from economies of scale which has been shown to result in lower unit costs even when the projects are implemented by the same organization [ 27 , 31 ]. FSW programs that offer comprehensive antiretroviral treatment are more expensive than programs that offer peer education, counselling and testing alone because of the additional service delivery costs. Structural interventions, such as advocacy to decriminalize sex work, and measures to address violence when added to FSW interventions also increase the unit cost of programs [ 28 ]. Community-based organizations, which generally have simpler structures and where salaries for management and other staff are likely lower are also likely to have cheaper running costs than local or international NGOs [ 26 ]. Recently established programs have also been reported to cost more, presumably due to higher administrative costs associated with more intense supervision and coordination, and project overhead costs for FSW projects are likely to reduce over time [ 25 ]. In Burkina Faso, for example, Cianci et al. reported an annual cost of 1098.00 USD per FSW, nearly ten times what we report [ 25 ]. Included in their cost analyses were ART, laboratory testing for HIV monitoring (CD4 and viral load), and treatment for opportunistic infections, which we did not. Their clinic also served 305 FSW per year, roughly one-fifth of our population, and approximately 60% of their FSW population were HIV positive on ART, including second-line ART. Conversely, in Nigeria, Nance et al. sampled 31 community-based organizations and reported a mean cost of services of 22 USD per FSW per year [ 27 ]. Only HIV education, counselling and testing with referral to other facilities were provided. It is worth noting that in our study, the unit cost at Mtwapa DIC was lower than at Kilifi town DIC, much as both DICs were operated by the same ICRHK program which underscores the importance of economies of scale as a cost determinant. This was also reported by the Avahan Program in India [ 25 ].

That Personnel costs contributed most to the per-person cost is consistent not only with FSW studies, but with other HIV service programs such as Prevention of Mother-to-Child Transmission (PMTCT), Voluntary Male Medical Circumcision (VMMC), and Pre-Exposure Prophylaxis (PrEP), and across various geographies [ 30 , 33 , 34 ]. Personnel costs in this study included direct service provider salaries, such as nurses and clinical officers, as well as time and effort compensation for monitoring and evaluation and project management. While we were unable to provide a breakdown of the proportions for each service level (direct service delivery personnel costs versus costs for support project staff), studies such as the Avahan study report that direct service delivery personnel costs can account for up to 65% of unit costs [ 25 ]. There are multiple ways through which FSW programs can improve their efficiency and reduce their costs for service delivery. For example, current Kenyan ART guidelines recommend differentiated service delivery for PLHIV beyond the first six months of ART for patients who are established to be adherent to medication [ 35 ] and such patients can be followed up less frequently, with up to six months between clinical appointments. This means that programs can deliver quality clinical care for more FSW with less clinical staff. The PEPFAR FY2024 technical considerations also recommend that KP programs consider a set of optimized testing approaches that includes social network strategy testing, index testing, risk network testing, self-testing, social media and information communication technology platforms to complement standard venue based HTS [ 36 ]. These approaches could mean that a greater number of FSW can receive HIV services outside the DICs.

Another approach to reduce costs and ensure sustainability, which has been recommended by NASCOP would be to integrate FSW services into the routine services in public and private health facilities instead of stand-alone DICs. Such an approach would mainstream FSW services and reduce stigma and discrimination. Jilinde, Kenya's largest PrEP scale-up program successfully piloted PrEP services for FSW in public and private health facilities [ 37 ]. Similarly, other FSW programs have established "link desks" within public health facilities, whereby a peer educator is assigned to a “link desk” to help FSW visiting the facility navigate through care. Protocols on providing FSW services are available, and these programs ensure strong links between Peer Educators and the facility to minimize referral loss and establish safe spaces for FSWs peer support. The staff at the health facility are also trained to provide non-discriminatory, stigma-free services. One big disadvantage of such an approach of integrating FSW services into available public and private health facilities is that FSWs typically prefer DIC services because of the privacy and tailored services and FSW could engage less with programs and interventions when services are integrated [ 38 ]. Additionally, it is challenging for health facilities already stretched to provide focused care to a single population. It may also counterfactually increase stigma against FSW when the receive preferential care at public and private health facilities.

It is worth noting that family planning (FP) constituted only 10% of the total unit cost. This means that FP services can be easily added without significantly driving up the unit cost. While FP can be considered a cost-effective intervention, many FSW programs do not include FP services into the programs’ design, DICs do not routinely stock FP commodities and clients are often referred elsewhere. Alternatively, FSW pay for FP services in private facilities despite the ease of availing them in public facilities [ 39 ]. One of the major gaps for FSW programs in Africa is the inability to integrate other relevant health issues into HIV services; programs have been criticized for focusing on HIV and ignoring other health issues that contribute to the overall wellbeing of FSW, even when such interventions are inexpensive and easily integrated into whatever is already in place. However, this could be interpreted as inflexibility, which is common in many donor programs; FSW programs are frequently funded by HIV-designated funds, which are frequently ineligible for use to support other health issues.

In summary, this study provides a unit cost estimate for comprehensive FSW SRH programming providing a balance of biomedical, behavioural, and structural interventions, and includes both service delivery and above service costs. FSW programs should consider using these estimates when budgeting and advocating to donors. Our estimates of cost drivers should also guide policy makers in making decisions on how to structure programs and maximize cost efficiency.

Our study has some significant limitations. First, we were unable to conduct a cost-effectiveness analysis to provide robust evidence that the program at this cost “works”. The cost-effectiveness would be a critical piece of evidence for funding justification. However, this was not our objective for this study as we had inadequate data on the program outcomes. Secondly, the cost analysis was from a single FSW program in two DICs in Kenya’s Coast region, and therefore, the findings may be considered not nationally representative. However, we believe that the programs’ design accurately represents the NASCOP model used by most programs in Kenya, and we therefore provide accurate information that can inform advocacy and decision-making at both the program and national levels. Thirdly, our cost estimates did not include the cost of HIV test kits, ART, STI medication, and laboratory tests, which lead to an underestimate. However, it is important to note that these costs are not typically included in FSW program budgets, and our estimates may accurately represent the actual costs incurred by programs. Finally, the data was from 2019, and may not accurately reflect the current cost of services. We have updated the cost based on the present inflation rates however, to provide an estimate for 2024. One major advantage of our study is that it is the first in Kenya to present a unit cost of comprehensive services provided to FSWs, whereas previous studies have only estimated the unit cost of HTS, ART, or PREP separately [ 28 ].

Programs can benefit in multiple ways from understanding the unit cost of comprehensive services provided to FSWs. First, it can assist programs in advocating for increased funding or convincing funders to include the cost of essential program activities, such as structural interventions. Second, cost estimates can help programs identify the primary cost drivers and propose interventions to optimize program design. Finally, these cost estimates can serve as a guide for countries that do not yet have cost estimates.

Availability of data and materials

The datasets containing individual FSW service data generated and/or analysed during the current study are available from the corresponding author on reasonable request.


Sub Saharan Africa

Human Immunodeficiency Virus

Antiretroviral treatment

Key populations

Pre exposure prophylaxis

Men having sex with men

People who inject drugs

  • Female sex workers

Non-governmental organization

President’s Emergency Plan for AIDS Relief

National AIDS and STI Control Program

International Centre for Reproductive Health Kenya

United Nations Population Fund

Sexually Transmitted Infections

Drop-in Centres

Peer Educators

Kenya Medical Supplies Authority


Standard Deviation

Prevention of Mother to child Transmission

Voluntary Male Medical Circumcision

HIV Testing Services

Family Planning

Sexual and Reproductive Health

Sexual and gender based violence

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The authors express their gratitude towards the efforts of the entire staff, peer educators, and outreach workers at the Mtwapa and Kilifi town drop-in centres for their valuable contributions in delivering high-quality services to female sex workers (FSW) and ensuring the provision of accurate and reliable data. The authors would like to express their gratitude for the assistance provided by ICRHK finance, administration, and project staff involved in the data collection process for cost estimations.

The UNFPA Kenya Office provided funding for the sex worker program and this costing study. D.O and L.L from the UNFPA Kenya Office were consulted during the study's conceptualization and both contributed to the manuscript's preparation.

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Griffins O. Manguro, Marleen Temmerman & Stanley Luchters

University of Nairobi School of Economics, Nairobi, Kenya

Urbanus Mutuku Kioko

Monitoring and Evaluation, International Centre for Reproductive Health Kenya, Mombasa, Kenya

Gerald Githinji, Patricia Owira & Marleen Temmerman

UNFPA Kenya Office, Nairobi, Kenya

Lillian Langat & Dan Okoro

Aga Khan University Centre for Excellence in Women and Child Health, Nairobi, Kenya

Marleen Temmerman

Liverpool School of Tropical Medicine (LSTM), Liverpool, UK

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G.O.M, P.O, L.L and D.O conceptualized the study. U.M.K and G.O.M designed the method and carried out the costing analyses. P.O and G.G oversaw data collection for FSW services. G.G prepared the FSW service datasets and carried out analyses for FSW service data.  G.M, U.M.K, M.T, and S.L were major contributors in writing the manuscript. All authors read and approved the final manuscript.

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Manguro, G.O., Kioko, U.M., Githinji, G. et al. Costs and cost drivers of comprehensive sexual reproductive health services to female sex workers in Kenya. BMC Health Serv Res 24 , 822 (2024).

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case study of alternative


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A case study of alternative assessment practices in a ccac graduate primary science classroom, in a community-based school in pakistan.

Sharif Panah , Aga Khan University, Institute for Educational Development, Karachi

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Master of Education (M. Ed.)

Institute for Educational Development, Karachi

It is believed by many educationists that the traditional assessment approaches are less effective in students' learning. The contemporary trend in education favours the practice of alternative forms of assessment for improved students' learning outcomes. However, in the context of Pakistan traditional forms of assessment are being practiced in the classroom, which is considered a hindrance towards the holistic development of the learner and for the overall quality education in the country. The main aim of this study was to explore a science teacher's purposes, practices, challenges and opportunities of implementation of alternative assessment, who has participated in AKU-IED's Certificate in Classroom Assessment Course to contribute towards the understanding of implementation of alternative assessments in developing country context and subsequently to improve students' learning. A qualitative case study approach was used to explore the research topic. A primary level science teacher of a community based high school in Karachi, Pakistan was the primary participant, while the vice principal, section head of primary, a science teacher and a group of students of the school, formed the secondary participants. The data was collected through classroom observation, interviews, document analysis, field notes and reflective journal. The study revealed that, the research participant used alternative assessment for variety of purposes such as to enhance students' learning, providing feedback and grading. Questioning was practiced for getting students' attention and promoting thinking skills. Self assessment was used for giving students responsibility of their own learning and performance assessment was practiced to provide students opportunities to demonstrate variety of skills. The opportunities for implementing alternative assessment included teacher's professional development, which developed her basic understanding and skills for planning and implementation of alternative assessment. The skills included developing open ended questions, designing objectives based assessment tasks, setting clear learning targets and criteria which are aligned with her instructions and the provision of clear criteria and rubric based instructions to the students. Moreover, the features such as supportive school culture and autonomy for teacher to develop own syllabus, were seen to facilitate the process of alternative assessment in the classroom. The alternative assessment practices were also seen to facilitate student learning through their involvement in the activities, motivations towards their work and responsibility of their own learning. However, the study also revealed limited use of alternative assessment, such as lack of provision of opportunity for students to improve their work based on timely feedback. The challenges were limited to school based professional support, lack of follow up support from the professional development institution after the conclusion of the course, increased managerial responsibilities and limited beliefs of colleagues and parents about alternative assessment. The findings of the study suggest that, for effective practice of alternative assessment in the classroom, a teacher has to plan thoroughly, communicate the criteria clearly to the students and provide timely feedback. Furthermore, teachers' professional development and autonomy to develop own curriculum enhances the practice of the implementation of alternative assessments.

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Panah, S. (2008). A case study of alternative assessment practices in a CCAC graduate primary science classroom, in a community-based school in Pakistan (Unpublished master's dissertation). Aga Khan University, Karachi, Pakistan.

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case study of alternative

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A Case Study of Alternative Learning System Graduates Enrolled in Pangasinan State University, Lingayen Campus

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  • Jessica Jacoba
  • Julie Ann Nalanga
  • Claire Tamayo
  • Donabel Sabas

case study of alternative

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Educational for all is the main goal of the Philippine government which encompasses all sectors of the society thus the country has implemented a wide concept of education which involves: outcomes based - rather than input-oriented whether the delivery of this concept is formal, non-formal and informal education; One type of education is the non- formal education which is Alternative Learning System. This type of program caters to those who cannot access formal education but want to pursue their studies as well as those adults who want to study again in order to achieve basic functional literacy. Alternative Learning System is a ladderized, modular non-formal education program in the Philippines for dropouts in elementary and secondary schools, out-of-school youths, non-readers, working Filipinos and even senior citizens. It is part of the education system of the Philippines as an alternative to the regular classroom studies requires students to choose schedules according to their choice and availability. The study used case study as a method in collecting data. Given the qualitative nature of the research, it is deemed to be the best way to capture the details of the study. Coordination with the Guidance Office and Registrar’s Office is properly done before the conduct of the study. In the study 6 out of 40 students listed in the registrar’s office have confirmed that they are graduates of alternative learning system program. Furthermore Aliases are used in order to protect the identity of the respondents since their profile and personal information are gathered.

Authors retain copyright and grant the journal right of first publication with the work simultaneously licensed under a Creative Commons Attribution 4.0 International License that allows others to share the work with an acknowledgment of the work's authorship and initial publication in this journal. 

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