Cases, cases, casing

1. Cases, cases, casing Nick Emmel HSRN Winter meeting: Cases for change - organisational case study methods seminar

2. Overview • My case study—the introduction of public health measures and the widening of health inequalities. • Considering cases: • What is going on here • The typical or critical case • Casing as a methodology • Casing and a realist research agenda for inequalities in health

3. Widening health inequalities: three cases • General case: Buck and Frosini (2012) report that unhealthy behaviours has declined significantly, from around 33 per cent of the population in 2003 to around 25 per cent by 2008. These reductions have been seen mainly among those in higher socio-economic and educational groups. A clustering of unhealthy behaviour: people with no qualifications were more than five times as likely as those with higher education to engage in smoking, excess alcohol consumption, low consumption of fruit and vegetables, and inadequate physical activity in 2008, compared with only three times as likely in 2003.

4. Specific case 1: Individuals with cystic fibrosis and classified in the highest socioeconomic group are more likely to die at an older age than those in the lowest socioeconomic group (Barr et al., 2011). • Specific case 2: The rate of sudden infant death syndrome (SIDS) declined throughout Scotland in the early 1990s. This decline had a later onset and was slower among women living in areas of high deprivation. The effect was to create a strong independent association between deprivation and SIDS when one did not exist before (Wood et al., 2012).

5. All three cases are descriptive epidemiological studies used to mobilise particular theoretical (causal) explanations • General case: holistic approach to policy and practice … move beyond siloed approaches to public health … focus on individual lifestyle factors … • Specific case 1 (cystic fibrosis): increased environmental exposure to tobacco smoke, inadequate nutrition, and poor treatment adherence, … higher socioeconomic groups better informed and hence obtain better healthcare when attending clinic.

6. Specific case 2 (SIDS): ‘We believe that the earlier onset of the reduction in rates (of SIDS) among women living in areas of low socioeconomic deprivation is probably explained by dissemination of information on sleeping position from research studies, before the public health campaign … articles reporting findings in the Times, the Independent, and the Guardian’

7. Treating these three as case studies in case study research • Three approaches to case study research: • Empirical (Stake, 2008) • Analytic induction (Yin, 2009) • Casing (Ragin, 1992; Emmel and Hughes, 2009)

8. As empirical cases • As the three cases stand they are rich empirical cases. • Each can be extended. Indeed the authors of each case suggest ways in which descriptive scope might be extended (for instance adding confounders like smoking to SIDS data, if it were available). • Better description lies in the studied accumulation of empirical data.

9. The empirical case • To answer the question ‘What is going on here?’ • My examples today are epidemiological cases, but could be qualitative, or mixed method. • Mixed method has the potential to provide better elaboration of what is going on here, but generalisation becomes increasingly challenging.

10. The analytic inductive case • For Yin (2009:38): ‘… cases are not “sampling units” and should not be chosen for this reason. Rather individual case studies are to be selected as a laboratory investigator selects the topic of a new experiment’ • Cases are selected, Yin goes on to observe, because they are: • Critical—confirm, extend, challenge theory • Unique—a one-off incident to be recorded • Typical—everyday or commonplace • Discovering the condition under which causal relations operate: revising the thing to be explained

11. What is this a case of? • Closing down the boundaries of the cases to make claims to representativeness (the universe it represents). • General case (risk factors): clustered individual lifestyle factors • Specific case 1 (cystic fibrosis): inverse care law • Specific case 2 (SIDS): inverse equity hypothesis • The inductive myth—bridging the gap between facts and theory and facts

12. Casing: resolving difficult issues in linking ideas and evidence • The question what is this a case of is asked over and over again throughout the research and never fully answered. • Taxonomies of case (e.g. data, theoretical, historically specific, or substantive categories) give way to the use of casing as a research tactic to interpret and explain causal mechanisms.

13. Casing: system building information rich cases • The move from bold yet naïve (simple, abstract, incomplete) conjectures (Lakatos, 1976; Ragin, 1992). • Through choosing cases that bundle together ideas, context, regularity, outcome to test theories of the middle range (Pawson, 2006). • To new cases become strategic when they challenge and re-specify received causal processes (Walton, 1992). • And recognising that cases are transformed throughout the research (Emmel, 2013).

14. Theories of the middle range to be tested, refined, elaborated, … • General case (risk factors): Relations in networks reinforce adverse and beneficial health behaviours. • Specific case 1 (cystic fibrosis): Relations between health providers and clients are mediated by socioeconomic status leading to different outcomes. • Specific case 2 (SIDS): Consumption of mass media changes health behaviours, habits, and dispositions.

15. Casing as a methodological strategy • The descriptive baseline of the cases increases throughout the research (complexity and the impossibility of representativeness) • Answering the question 'what works for whom in what circumstances and why' (the reconfiguration of cases) • Working out the relation between ideas and evidence (evidence as situation specific wisdom) • Interpretations and explanations are only ever provisional propositions (but seek to represent reality)

16. Barr, H. L., Britton, J., Smyth, A. R., & Fogarty, A. W. 2011, "Association between socioeconomic status, sex, and age at death from cystic fibrosis in England and Wales (1959 to 2008): cross sectional study", BMJ, vol. 343. • Buck D & Frosini F 2012, Clustering of unhealthy behaviors over time: implications for policy Kings Fund, London. • Emmel N 2013, Sampling and choosing cases in qualitative research: a realist approach Sage, London. • Emmel ND & Hughes K 2009, "Small N access cases to refine theories of social exclusion and access to socially excluded individuals and groups," in The Sage Handbook of Case-Based Methods, Byrne D & Ragin C, eds., Sage, London. • Lakatos I 1976, Proofs and refutations: the logic of mathematical discovery Cambridge University Press, Cambridge. • Pawson R 2006, Evidence-based policy: a realist perspective Sage, London. • Ragin C 1992, "Cases of "What is a case?"," in What is a case, Ragin C & Becker H, eds., Cambridge University Press, Cambridge. • Stake R 2008, "Qualitative case studies," in Strategies of qualitative inquiry, Denzin NK & Lincoln YS, eds., Sage, London. • Wood A, Pasupathy D, Pell JP, Fleming M, & Smith GCS 2012, "Trends in socioeconomic inequalities in risk of sudden infant death syndrome, other causes of infant mortality, and stillbirth in Scotland: population based study", British Medical Journal, vol. 344:e1552ddi. • Yin RK 2009, Case study research: design and methods Sage, London.