bracketing in case study research

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Continuing to enhance the quality of case study methodology in health services research

Shannon l. sibbald.

1 Faculty of Health Sciences, Western University, London, Ontario, Canada.

2 Department of Family Medicine, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada.

3 The Schulich Interfaculty Program in Public Health, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada.

Stefan Paciocco

Meghan fournie, rachelle van asseldonk, tiffany scurr.

Case study methodology has grown in popularity within Health Services Research (HSR). However, its use and merit as a methodology are frequently criticized due to its flexible approach and inconsistent application. Nevertheless, case study methodology is well suited to HSR because it can track and examine complex relationships, contexts, and systems as they evolve. Applied appropriately, it can help generate information on how multiple forms of knowledge come together to inform decision-making within healthcare contexts. In this article, we aim to demystify case study methodology by outlining its philosophical underpinnings and three foundational approaches. We provide literature-based guidance to decision-makers, policy-makers, and health leaders on how to engage in and critically appraise case study design. We advocate that researchers work in collaboration with health leaders to detail their research process with an aim of strengthening the validity and integrity of case study for its continued and advanced use in HSR.

Introduction

The popularity of case study research methodology in Health Services Research (HSR) has grown over the past 40 years. 1 This may be attributed to a shift towards the use of implementation research and a newfound appreciation of contextual factors affecting the uptake of evidence-based interventions within diverse settings. 2 Incorporating context-specific information on the delivery and implementation of programs can increase the likelihood of success. 3 , 4 Case study methodology is particularly well suited for implementation research in health services because it can provide insight into the nuances of diverse contexts. 5 , 6 In 1999, Yin 7 published a paper on how to enhance the quality of case study in HSR, which was foundational for the emergence of case study in this field. Yin 7 maintains case study is an appropriate methodology in HSR because health systems are constantly evolving, and the multiple affiliations and diverse motivations are difficult to track and understand with traditional linear methodologies.

Despite its increased popularity, there is debate whether a case study is a methodology (ie, a principle or process that guides research) or a method (ie, a tool to answer research questions). Some criticize case study for its high level of flexibility, perceiving it as less rigorous, and maintain that it generates inadequate results. 8 Others have noted issues with quality and consistency in how case studies are conducted and reported. 9 Reporting is often varied and inconsistent, using a mix of approaches such as case reports, case findings, and/or case study. Authors sometimes use incongruent methods of data collection and analysis or use the case study as a default when other methodologies do not fit. 9 , 10 Despite these criticisms, case study methodology is becoming more common as a viable approach for HSR. 11 An abundance of articles and textbooks are available to guide researchers through case study research, including field-specific resources for business, 12 , 13 nursing, 14 and family medicine. 15 However, there remains confusion and a lack of clarity on the key tenets of case study methodology.

Several common philosophical underpinnings have contributed to the development of case study research 1 which has led to different approaches to planning, data collection, and analysis. This presents challenges in assessing quality and rigour for researchers conducting case studies and stakeholders reading results.

This article discusses the various approaches and philosophical underpinnings to case study methodology. Our goal is to explain it in a way that provides guidance for decision-makers, policy-makers, and health leaders on how to understand, critically appraise, and engage in case study research and design, as such guidance is largely absent in the literature. This article is by no means exhaustive or authoritative. Instead, we aim to provide guidance and encourage dialogue around case study methodology, facilitating critical thinking around the variety of approaches and ways quality and rigour can be bolstered for its use within HSR.

Purpose of case study methodology

Case study methodology is often used to develop an in-depth, holistic understanding of a specific phenomenon within a specified context. 11 It focuses on studying one or multiple cases over time and uses an in-depth analysis of multiple information sources. 16 , 17 It is ideal for situations including, but not limited to, exploring under-researched and real-life phenomena, 18 especially when the contexts are complex and the researcher has little control over the phenomena. 19 , 20 Case studies can be useful when researchers want to understand how interventions are implemented in different contexts, and how context shapes the phenomenon of interest.

In addition to demonstrating coherency with the type of questions case study is suited to answer, there are four key tenets to case study methodologies: (1) be transparent in the paradigmatic and theoretical perspectives influencing study design; (2) clearly define the case and phenomenon of interest; (3) clearly define and justify the type of case study design; and (4) use multiple data collection sources and analysis methods to present the findings in ways that are consistent with the methodology and the study’s paradigmatic base. 9 , 16 The goal is to appropriately match the methods to empirical questions and issues and not to universally advocate any single approach for all problems. 21

Approaches to case study methodology

Three authors propose distinct foundational approaches to case study methodology positioned within different paradigms: Yin, 19 , 22 Stake, 5 , 23 and Merriam 24 , 25 ( Table 1 ). Yin is strongly post-positivist whereas Stake and Merriam are grounded in a constructivist paradigm. Researchers should locate their research within a paradigm that explains the philosophies guiding their research 26 and adhere to the underlying paradigmatic assumptions and key tenets of the appropriate author’s methodology. This will enhance the consistency and coherency of the methods and findings. However, researchers often do not report their paradigmatic position, nor do they adhere to one approach. 9 Although deliberately blending methodologies may be defensible and methodologically appropriate, more often it is done in an ad hoc and haphazard way, without consideration for limitations.

Cross-analysis of three case study approaches, adapted from Yazan 2015

The post-positive paradigm postulates there is one reality that can be objectively described and understood by “bracketing” oneself from the research to remove prejudice or bias. 27 Yin focuses on general explanation and prediction, emphasizing the formulation of propositions, akin to hypothesis testing. This approach is best suited for structured and objective data collection 9 , 11 and is often used for mixed-method studies.

Constructivism assumes that the phenomenon of interest is constructed and influenced by local contexts, including the interaction between researchers, individuals, and their environment. 27 It acknowledges multiple interpretations of reality 24 constructed within the context by the researcher and participants which are unlikely to be replicated, should either change. 5 , 20 Stake and Merriam’s constructivist approaches emphasize a story-like rendering of a problem and an iterative process of constructing the case study. 7 This stance values researcher reflexivity and transparency, 28 acknowledging how researchers’ experiences and disciplinary lenses influence their assumptions and beliefs about the nature of the phenomenon and development of the findings.

Defining a case

A key tenet of case study methodology often underemphasized in literature is the importance of defining the case and phenomenon. Researches should clearly describe the case with sufficient detail to allow readers to fully understand the setting and context and determine applicability. Trying to answer a question that is too broad often leads to an unclear definition of the case and phenomenon. 20 Cases should therefore be bound by time and place to ensure rigor and feasibility. 6

Yin 22 defines a case as “a contemporary phenomenon within its real-life context,” (p13) which may contain a single unit of analysis, including individuals, programs, corporations, or clinics 29 (holistic), or be broken into sub-units of analysis, such as projects, meetings, roles, or locations within the case (embedded). 30 Merriam 24 and Stake 5 similarly define a case as a single unit studied within a bounded system. Stake 5 , 23 suggests bounding cases by contexts and experiences where the phenomenon of interest can be a program, process, or experience. However, the line between the case and phenomenon can become muddy. For guidance, Stake 5 , 23 describes the case as the noun or entity and the phenomenon of interest as the verb, functioning, or activity of the case.

Designing the case study approach

Yin’s approach to a case study is rooted in a formal proposition or theory which guides the case and is used to test the outcome. 1 Stake 5 advocates for a flexible design and explicitly states that data collection and analysis may commence at any point. Merriam’s 24 approach blends both Yin and Stake’s, allowing the necessary flexibility in data collection and analysis to meet the needs.

Yin 30 proposed three types of case study approaches—descriptive, explanatory, and exploratory. Each can be designed around single or multiple cases, creating six basic case study methodologies. Descriptive studies provide a rich description of the phenomenon within its context, which can be helpful in developing theories. To test a theory or determine cause and effect relationships, researchers can use an explanatory design. An exploratory model is typically used in the pilot-test phase to develop propositions (eg, Sibbald et al. 31 used this approach to explore interprofessional network complexity). Despite having distinct characteristics, the boundaries between case study types are flexible with significant overlap. 30 Each has five key components: (1) research question; (2) proposition; (3) unit of analysis; (4) logical linking that connects the theory with proposition; and (5) criteria for analyzing findings.

Contrary to Yin, Stake 5 believes the research process cannot be planned in its entirety because research evolves as it is performed. Consequently, researchers can adjust the design of their methods even after data collection has begun. Stake 5 classifies case studies into three categories: intrinsic, instrumental, and collective/multiple. Intrinsic case studies focus on gaining a better understanding of the case. These are often undertaken when the researcher has an interest in a specific case. Instrumental case study is used when the case itself is not of the utmost importance, and the issue or phenomenon (ie, the research question) being explored becomes the focus instead (eg, Paciocco 32 used an instrumental case study to evaluate the implementation of a chronic disease management program). 5 Collective designs are rooted in an instrumental case study and include multiple cases to gain an in-depth understanding of the complexity and particularity of a phenomenon across diverse contexts. 5 , 23 In collective designs, studying similarities and differences between the cases allows the phenomenon to be understood more intimately (for examples of this in the field, see van Zelm et al. 33 and Burrows et al. 34 In addition, Sibbald et al. 35 present an example where a cross-case analysis method is used to compare instrumental cases).

Merriam’s approach is flexible (similar to Stake) as well as stepwise and linear (similar to Yin). She advocates for conducting a literature review before designing the study to better understand the theoretical underpinnings. 24 , 25 Unlike Stake or Yin, Merriam proposes a step-by-step guide for researchers to design a case study. These steps include performing a literature review, creating a theoretical framework, identifying the problem, creating and refining the research question(s), and selecting a study sample that fits the question(s). 24 , 25 , 36

Data collection and analysis

Using multiple data collection methods is a key characteristic of all case study methodology; it enhances the credibility of the findings by allowing different facets and views of the phenomenon to be explored. 23 Common methods include interviews, focus groups, observation, and document analysis. 5 , 37 By seeking patterns within and across data sources, a thick description of the case can be generated to support a greater understanding and interpretation of the whole phenomenon. 5 , 17 , 20 , 23 This technique is called triangulation and is used to explore cases with greater accuracy. 5 Although Stake 5 maintains case study is most often used in qualitative research, Yin 17 supports a mix of both quantitative and qualitative methods to triangulate data. This deliberate convergence of data sources (or mixed methods) allows researchers to find greater depth in their analysis and develop converging lines of inquiry. For example, case studies evaluating interventions commonly use qualitative interviews to describe the implementation process, barriers, and facilitators paired with a quantitative survey of comparative outcomes and effectiveness. 33 , 38 , 39

Yin 30 describes analysis as dependent on the chosen approach, whether it be (1) deductive and rely on theoretical propositions; (2) inductive and analyze data from the “ground up”; (3) organized to create a case description; or (4) used to examine plausible rival explanations. According to Yin’s 40 approach to descriptive case studies, carefully considering theory development is an important part of study design. “Theory” refers to field-relevant propositions, commonly agreed upon assumptions, or fully developed theories. 40 Stake 5 advocates for using the researcher’s intuition and impression to guide analysis through a categorical aggregation and direct interpretation. Merriam 24 uses six different methods to guide the “process of making meaning” (p178) : (1) ethnographic analysis; (2) narrative analysis; (3) phenomenological analysis; (4) constant comparative method; (5) content analysis; and (6) analytic induction.

Drawing upon a theoretical or conceptual framework to inform analysis improves the quality of case study and avoids the risk of description without meaning. 18 Using Stake’s 5 approach, researchers rely on protocols and previous knowledge to help make sense of new ideas; theory can guide the research and assist researchers in understanding how new information fits into existing knowledge.

Practical applications of case study research

Columbia University has recently demonstrated how case studies can help train future health leaders. 41 Case studies encompass components of systems thinking—considering connections and interactions between components of a system, alongside the implications and consequences of those relationships—to equip health leaders with tools to tackle global health issues. 41 Greenwood 42 evaluated Indigenous peoples’ relationship with the healthcare system in British Columbia and used a case study to challenge and educate health leaders across the country to enhance culturally sensitive health service environments.

An important but often omitted step in case study research is an assessment of quality and rigour. We recommend using a framework or set of criteria to assess the rigour of the qualitative research. Suitable resources include Caelli et al., 43 Houghten et al., 44 Ravenek and Rudman, 45 and Tracy. 46

New directions in case study

Although “pragmatic” case studies (ie, utilizing practical and applicable methods) have existed within psychotherapy for some time, 47 , 48 only recently has the applicability of pragmatism as an underlying paradigmatic perspective been considered in HSR. 49 This is marked by uptake of pragmatism in Randomized Control Trials, recognizing that “gold standard” testing conditions do not reflect the reality of clinical settings 50 , 51 nor do a handful of epistemologically guided methodologies suit every research inquiry.

Pragmatism positions the research question as the basis for methodological choices, rather than a theory or epistemology, allowing researchers to pursue the most practical approach to understanding a problem or discovering an actionable solution. 52 Mixed methods are commonly used to create a deeper understanding of the case through converging qualitative and quantitative data. 52 Pragmatic case study is suited to HSR because its flexibility throughout the research process accommodates complexity, ever-changing systems, and disruptions to research plans. 49 , 50 Much like case study, pragmatism has been criticized for its flexibility and use when other approaches are seemingly ill-fit. 53 , 54 Similarly, authors argue that this results from a lack of investigation and proper application rather than a reflection of validity, legitimizing the need for more exploration and conversation among researchers and practitioners. 55

Although occasionally misunderstood as a less rigourous research methodology, 8 case study research is highly flexible and allows for contextual nuances. 5 , 6 Its use is valuable when the researcher desires a thorough understanding of a phenomenon or case bound by context. 11 If needed, multiple similar cases can be studied simultaneously, or one case within another. 16 , 17 There are currently three main approaches to case study, 5 , 17 , 24 each with their own definitions of a case, ontological and epistemological paradigms, methodologies, and data collection and analysis procedures. 37

Individuals’ experiences within health systems are influenced heavily by contextual factors, participant experience, and intricate relationships between different organizations and actors. 55 Case study research is well suited for HSR because it can track and examine these complex relationships and systems as they evolve over time. 6 , 7 It is important that researchers and health leaders using this methodology understand its key tenets and how to conduct a proper case study. Although there are many examples of case study in action, they are often under-reported and, when reported, not rigorously conducted. 9 Thus, decision-makers and health leaders should use these examples with caution. The proper reporting of case studies is necessary to bolster their credibility in HSR literature and provide readers sufficient information to critically assess the methodology. We also call on health leaders who frequently use case studies 56 – 58 to report them in the primary research literature.

The purpose of this article is to advocate for the continued and advanced use of case study in HSR and to provide literature-based guidance for decision-makers, policy-makers, and health leaders on how to engage in, read, and interpret findings from case study research. As health systems progress and evolve, the application of case study research will continue to increase as researchers and health leaders aim to capture the inherent complexities, nuances, and contextual factors. 7

Reflexive Bracketing

• First Online: 02 January 2023

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The term “bracketing” was first used by Husserl, in his published work in phenomenology (Husserl, 1950, as cited in Schwandt 2015 . The Sage dictionary of qualitative inquiry (4th ed.). Sage Publications.). The term means that researchers should suspend judgment and set aside their assumptions and prior notions, with regard to their object of study.

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Squires, V. (2023). Reflexive Bracketing. In: Okoko, J.M., Tunison, S., Walker, K.D. (eds) Varieties of Qualitative Research Methods. Springer Texts in Education. Springer, Cham. https://doi.org/10.1007/978-3-031-04394-9_66

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Understanding Bracketing in Qualitative Research

Introduction

Subjectivity in qualitative research, phenomenology, what does bracketing research mean, where does bracketing occur in research, why do we use bracketing in research, how to use bracketing in qualitative research.

Qualitative inquiry is an inherently human and, thus, subjective endeavor . The meaning of a particular concept or phenomenon will invariably differ from one person to the next, dismissing any assumptions that the research process is or should be an objective process.

Addressing methodological challenges , researchers employ a concept called bracketing to mitigate or at least address potential critiques of research rigor for the purpose of establishing and determining validity . What bracketing means will depend on the research orientation you adopt and the research methods you employ. In this article, we'll look at bracketing in qualitative research and what considerations you should keep in mind when accounting for subjectivity.

Before we fully talk about bracketing, let's first address where subjectivity comes from. Researchers may come to qualitative research thinking it must be a clinical, almost sterile process more often seen in chemistry, physics, or the other natural sciences. As a result, there is always a sustained push to mitigate or even eliminate any " biases " that can be seen as skewing the qualitative analysis .

In practice, positivist scholars critique the presence of preconceived notions that are formed without any engagement with existing scholarship. Under this paradigm, an analytical lens that is primarily developed from personal beliefs may not be sufficiently rigorous or connected to the overall dialogue in research.

That said, there is a competing school of thought that asserts that assumptions are a natural element of human analysis that can never be completely divorced from the research process, nor should they. Instead of looking to build an impenetrable wall between personal bias and analysis, sociocultural researchers look to develop a nuanced and contextualized understanding of the social world through a transparent accounting of personal subjectivities.

Bracketing is the product of this tension. Its origins lie in phenomenology, but bracketing has since expanded to other qualitative methodologies . While there are competing processes for bracketing interviews , observations , and other kinds of data , the overall goal is to address how the subjectivities that researchers may bring to the process can influence the data and the analysis .

There is no straightforward definition for bracketing, because how we address this subjectivity also depends on the orientation we adopt when conducting research. Most broadly, qualitative researchers can exist on a continuum defined by two approaches to phenomenology, or ways of looking at and interpreting the social world.

Transcendental phenomenology

On the objective side of this continuum, a transcendental approach, in simple terms, asks researchers to look at the world from a sterile lens, like an alien visiting a new world. The goal is to avoid bringing any preconceived judgment of the subject they are examining and to focus on the core essence of the social and cultural practices and customs they observe.

The reasons for this approach stem from a desire to capture how the social world is perceived at the moment of consciousness before any personal beliefs inform and transform how social phenomena are understood. Transcendental phenomenology thus looks for a description of events and practices that are as free of biases as possible.

Interpretive phenomenology

Some researchers look at the challenges presented by transcendental phenomenology and consider them to be all but impossible to meet. After all, ignoring any preconception about a research context, let alone ignoring all preconceptions, seems to be an unrealistic objective.

Indeed, those who take a grounded theory approach , where all data analysis arises from the researcher's interpretation of the data alone, find it more feasible to fully account for, rather than completely disregard, the thought processes that govern the analytical lens of the researcher.

Rather than try to define a research participant's intended meaning, those who take an interpretive approach to understanding phenomena examine how people make sense of the world around them. The goal of an interpretive approach, then, is to view the interaction between a person's subjectivities and the phenomenon that the inquiry focuses on.

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Now that we have an understanding for the different ways through which we can interpret the social world, we can acknowledge how people may address their interpretations in scientific knowledge in different ways. Whatever the research approach, however, the concept of bracketing can be utilized.

Think about written text and how brackets or parentheses set aside additional meaning in a sentence (like this!). A writer uses parentheses to separate words or phrases from the core of the sentence to emphasize the presence of nuances or to allow the reader to separate meaning from the main clause.

The concept of bracketing in the qualitative research process works in a similar fashion. In discourse analysis , interpretations of qualitative interviewing depend significantly on who is interpreting the data .

Imagine that a group of people are analyzing the same set of interviews with elementary school teachers. How would a fellow teacher interpret the interview data, and how would their interpretations differ from that of a parent or a school principal?

Whatever the researcher decides when bracketing interviews, it's important for the researcher to consciously take stock of the factors that inform their analysis of the interview data. Once identified, these factors can then be addressed in the research, either by acknowledging their relation to the collected data or by isolating them from the data altogether.

You can find the practice of bracketing in studies that involve examination of cultural practices or interaction with human subjects. Descriptions of such phenomena are subjectively constructed, requiring a transparent accounting of the characteristics and sociocultural identifiers of the researcher collecting and analyzing the data .

In qualitative health research, think about how sensitive topics like bereavement and palliative care touch on people's emotions. In a research setting involving terminal illness and death, accounting for and separating their subjectivities can be difficult for the researcher. Even advanced nursing practitioners would have trouble adopting a clinically neutral stance in the face of terminally ill patience. Asking the same of researchers collecting data for a qualitative study can be similarly challenging.

The ultimate goal of research is to contribute to scientific knowledge, and the extent of that contribution depends significantly on the research being persuasive to scholars within the research community. Researchers need to believe (or at least find credible) the assertions being proposed in an academic journal, a formal essay, or a research presentation before they can consider it to be useful research.

As a result, research should be considered credible before any researcher can accept the findings presented to them as well as the analysis from which those findings are generated. Even among scholars who accept the inevitability of subjective influences, there is an expectation that those influences are presented in a transparent manner that adequately contextualizes the analysis.

Accounting for personal influences that might inform the collection and analysis phases in a study is essential to bracketing regardless of the approach the researcher adopts. Whether one is suspending " bias " or explaining how their subjective lens affects the study, recognition of what makes the inquiry subjective is an essential prerequisite to bracketing.

Researchers should first conscientiously consider their positionality relative to the research context and its participants. Above all, this should bring about a recognition that the human researcher is not an objective collector of information, and anything which may shape their interpretations should be acknowledged and addressed.

Ask yourself how you approach the research study you are conducting. Think about your search history or search results when building your literature review , for example. What scholars or theories have influenced your view of the research context? Are you conducting this research for a grant proposal or to complete a doctoral program? How do these motivations affect how you collect and analyze data?

A full accounting of your positionality and worldview can only enhance, not interfere with, the research in front of you. Be sure to list in your bracketing notes all possible influences that can be relevant to conducting your study and explaining your findings to your research audience.

If you are adopting a transcendental approach to phenomenology, the bracketing notes are your resource that help you suspend your preconceptions when conducting your study. This practice requires constant reflection on your own conduct in the field.

This approach requires an open mind when you engage with the social world. This might involve documenting as much of the concept or phenomenon as objectively as possible without making interpretations or judgments (e.g., describing what something is rather than whether it is "good" vs "bad" or you agree or disagree). Or it might require you to reflect on your observations afterward to determine if you need to adjust your analysis so it captures more of the essence of the object under inquiry.

On the other hand, an approach that acknowledges the necessity of subjective influences is less about suspending preconceptions and more about describing your analysis in the context of your analytical lens. What do you notice or focus on because of your identities? What might you overlook or misinterpret because of any outside status you might have in the field?

Bracketing within an interpretive paradigm requires constant reflection as well as deep engagement with participants in the field to capture as much of their perspectives as possible. A thick description, made possible by a rich understanding of how those in the field see the world, can help the researcher mitigate any misinterpretations and recognize differences in individual characteristics.

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Bracketing as a skill in conducting unstructured qualitative interviews

Affiliation.

• 1 Pirkanmaa Hospital District, Tampere, Finland.
• PMID: 25783146
• DOI: 10.7748/nr.22.4.8.e1317

Aim: To provide an overview of bracketing as a skill in unstructured qualitative research interviews.

Background: Researchers affect the qualitative research process. Bracketing in descriptive phenomenology entails researchers setting aside their pre-understanding and acting non-judgementally. In interpretative phenomenology, previous knowledge is used intentionally to create new understanding.

Data sources: A literature search of bracketing in phenomenology and qualitative research.

Review methods: This is a methodology paper examining the researchers' impact in creating data in creating data in qualitative research.

Discussion: Self-knowledge, sensitivity and reflexivity of the researcher enable bracketing.

Conclusion: Skilled and experienced researchers are needed to use bracketing in unstructured qualitative research interviews.

Implications for research/practice: Bracketing adds scientific rigour and validity to any qualitative study.

Keywords: Bracketing; phenomenology; qualitative interview; reflexivity; researcher’s role; unstructured interview.

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Research: What Companies Don’t Know About How Workers Use AI

• Jeremie Brecheisen

Three Gallup studies shed light on when and why AI is being used at work — and how employees and customers really feel about it.

Leaders who are exploring how AI might fit into their business operations must not only navigate a vast and ever-changing landscape of tools, but they must also facilitate a significant cultural shift within their organizations. But research shows that leaders do not fully understand their employees’ use of, and readiness for, AI. In addition, a significant number of Americans do not trust business’ use of AI. This article offers three recommendations for leaders to find the right balance of control and trust around AI, including measuring how their employees currently use AI, cultivating trust by empowering managers, and adopting a purpose-led AI strategy that is driven by the company’s purpose instead of a rules-heavy strategy that is driven by fear.

If you’re a leader who wants to shift your workforce toward using AI, you need to do more than manage the implementation of new technologies. You need to initiate a profound cultural shift. At the heart of this cultural shift is trust. Whether the use case for AI is brief and experimental or sweeping and significant, a level of trust must exist between leaders and employees for the initiative to have any hope of success.

• Jeremie Brecheisen is a partner and managing director of The Gallup CHRO Roundtable.

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'I conducted global health and policy research in Moshi, Tanzania'

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My favorite class was NS 2600: Introduction to Global Health taught by Professor Jeanne Moseley, where I learned about the impact of social determinants on health, global inequality and health disparities between high-income countries and low-and-middle-income countries. This class inspired me to pursue a global health minor and fueled my passion for eliminating healthcare disparities for marginalized populations and eradicating preventable diseases with cures, treatments and vaccinations. For my Experiential Learning Opportunity (ELO), I had the privilege of conducting global health and policy research during Cornell's Global Health Program for four weeks in Moshi, Tanzania during summer 2022. We collaborated with fourth-year Tanzanian medical students to interview emergency medicine doctors, police, motorcycle drivers and community health workers. We wrote and presented a policy case study that compiled our research, findings and recommended policy solutions on critical gaps in the Tanzanian emergency medical services system; we highlighted issues like the lack of trained first responders, hazardous transportation to the hospital, and limited health insurance coverage that led to poor health outcomes. I was confronted with the ways that structural poverty and infrastructure impacted people’s health outcomes.

What is your main extracurricular activity and why is it important to you? 

As a freshman, I joined the First-Generation Student Union (FGSU), looking for a safe space for students from underrepresented backgrounds like myself. I devoted myself to advocacy and passion for helping fellow students, and I became president of FGSU. We sought to provide social, academic and professional guidance, creating a podcast to share resources and organizing an annual mentorship program that pairs underclassmen with upperclassmen. To provide professional development opportunities, we hosted a professional speaker series with our first-gen alumni network and held a five-part series on networking and consulting. In addition, we collaborated with various groups including the Basic Needs Coalition to provide access to essential needs, Women in Computing at Cornell on intersectional identities in the workplace, school and beyond and FLIP National, a nonprofit organization, to promote equal opportunity for first-generation low-income (FGLI) students in higher education. To unite the community further, we also led social events such as apple and pumpkin picking, crafts, and community dinners. To celebrate the accomplishments of seniors who are the first in their family to graduate college, I also led the planning and execution of the first-generation graduation ceremony. 

Also, during the rise of anti-Asian hate and violence during the COVID-19 pandemic and the Atlanta spa shootings, I noticed a gap in Cornell’s Asian American organizations, which focused more on social and cultural aspects of our identity, and a significant need for a safe space to discuss complex and meaningful sociopolitical topics relevant to the APIDA community. In my junior fall, I reestablished Asian Pacific Americans for Action (APAA), a club that seeks to politically empower and advocate for the needs of APIDA students and further Asian/American activism on campus. I am extremely proud of our growth as a club, which has since organized two fundraisers and built coalitions with other groups of color and social justice groups to build solidarity and community. We have educated students with teach-ins on the history of Asian American activism, labor, colonization, imperialism, civic engagement, political participation and affirmative action. In March 2024, I also organized a group of 15 Cornell students to attend the annual East Coast Asian American Student Union Conference at Yale University, participating in workshops and engaging with students from 50+ other universities. For our efforts, we received the “Outstanding Contribution to the APIDA Community” award two years in a row at the APIDA Gala from the Asian & Asian American Center.

What have you accomplished as a Cornell student that you are most proud of?

As a first-generation and low-income student, study abroad has been an extremely formative, eye-opening and integral part of my Cornell experience. I had the privilege of participating in the Global Health Summer program in Moshi, Tanzania, the Danish Institute for Study Abroad (DIS) program in Copenhagen, Denmark for a semester, and the Heat Waves and Global Health spring break program in London, United Kingdom. In Copenhagen, DIS’s unique classes and approach to experiential and hands-on learning allowed me to partake in weekly field studies, learn how to do surgical knots and different types of sutures, how to identify organs and basic pathology on CT scans and ultrasounds, talk to healthcare practitioners about their specialties and learn about different healthcare systems. I joined the students of color affinity group and student media team as a photographer. I loved being able to capture personal memories with my friends and host family. I lived in a homestay in a suburban area, which allowed me to fully immerse myself into Danish society. One of my fondest memories was when my host family organized a traditional Danish birthday for me. My host mom and sister baked traditional Danish layer cake and birthday buns and decorated the house with Danish flags. I invited my friends over for a hyggeligt time. I also went to Legoland and the Hans Christian Andersen museum with my host family! 

In London, I learned about how climate change, particularly heat waves, has greatly affected people of color in working class neighborhoods. We also learned about how race has shaped environmental injustice, access to green spaces, social housing, and urban living. 

In Moshi, I challenged myself to navigate through unfamiliar culture norms and hyper-vigilance as an Asian woman. I reflected on my worldview and preconceived notions of Tanzania. I’m proud to say that I was the best Swahili speaker in my cohort and I loved interacting with locals, especially bargaining! My experiences have profoundly broadened my worldview and instilled a critical approach to global health. Seeking to understand how others experience their lives facilitated a deep understanding of cultural differences, allowing me to connect with individuals of entirely different backgrounds with empathy, compassion and an open-minded attitude. These experiences strengthened my cross-cultural, interpersonal and communication skills. The most meaningful part was building relationships and learning about each other’s cultures. I recognized that our similarities unite us much more than our differences set us apart.

Who or what influenced your Cornell education the most?     

The College of Arts and Sciences gave me the freedom of exploring my educational interests and I enjoyed its interdisciplinary approach to learning. I also took three semesters of Mandarin Chinese, which developed my native fluency. The biology and society, Asian American studies, anthropology and global health departments and faculty have greatly informed my scholarship, thinking and personal development. They helped me become more well-read, gain a better understanding of my identity and comprehend where I stand in the world. In addition, ethnic studies classes helped me understand intersectional identities and the larger structural forces that shaped my and others’ experiences in America.

Where do you dream to be in 10 years?

In 10 years, I dream that I have successfully become a physician, after residency and fellowship and continued with my journey of advocacy and learning. I hope to join Doctors without Borders and provide free services to underserved communities. I can also see myself engaged in public and global health, perhaps through research and perhaps with the Centers for Disease Control and Prevention.

Every year, our faculty nominate graduating Arts & Sciences students to be featured as part of our Extraordinary Journeys series.  Read more about the Class of 202 4.

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USC OORI Awards 10 Zumberge Preliminary Studies Research Awards

The University of Southern California (USC) Office of Research and Innovation (OORI) has announced 10 new awardees named under the Zumberge Preliminary Studies Research Award .

Coordinated by OORI sub-unit Research Initiatives and Infrastructure (RII), the Zumberge Preliminary Studies Research Award provides researchers with funds to plan and conduct circumscribed research projects that will generate preliminary data to enhance the competitiveness of their future proposals submitted to external sponsors. The Zumberge Preliminary Studies Research Award consists of three subprograms: (1) Large Program Award; (2) STEM Program Award; and (3) Diversity, Equity, and Inclusion (DEI) in Research Award. The 2024 cycle of applications saw numerous submissions coming from schools across the university, with awardees representing USC entities including Rossier School of Education, School of Pharmacy, USC Libraries, Viterbi School of Engineering, and Dornsife College of Letters, Arts, and Sciences. OORI and RII have continuously worked to build-out and expand the support available through the internal funding programs and are thrilled to see the increase in widespread interest and participation of faculty across USC’s schools and departments in the internal programs.

“We have witnessed immense growth of interest in our internal funding programs, with increased applications overall, and involvement from schools and entities across the entire university,” said Dr. Steven Moldin, Associate Vice President of Research Strategy and Innovation, “we want to continue on this path, providing the support and resources that our faculty need to be successful in their external funding applications, and look forward to continuing to build-out our internal funding program offerings.”

The 2024 Zumberge Preliminary Studies Research Award recipients are as follows:

• Proposal Title: How do Mixed-Income Neighborhood Initiatives Reduce Educational Inequality for Low-Income Black Youth?
• Proposal Title: Structure-based investigation of neurotransmitters as modifiers of tau aggregation
• Proposal Title: Before the Bulldozers: Bunker Hill in the New Deal Era
• Proposal Title: Correlated Electron-Phonon Coupling from First-Principles GW Perturbation Theory
• Proposal Title: Development of Bright and Stable Diamond Quantum Emitters for Quantum Sensing Applications
• Proposal Title: Developing reliable and scalable methods for deep immune phenotyping in public transcriptomics databases across diverse populations
• Proposal Title: Skin-line wearable sensor development for diagnostic ECG and MRI at 0.55 T
• Proposal Title: Foundation Models for Materials Physics to Accelerate the Development of Solid-State Batteries
• Proposal Title: APOC2-CD36 deregulation presents a metabolic vulnerability in Acute Myeloid Leukemia
• Proposal Title: Understanding Attitudes towards Homelessness through an Expert-Guided AI Social Engine

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As the FDA evaluates ecstasy treatment for PTSD, questions mount about the evidence

Research on MDMA has shown it can be effective for PTSD, but approval of the treatment isn't yet guaranteed. The Washington Post via Getty Images hide caption

Research on MDMA has shown it can be effective for PTSD, but approval of the treatment isn't yet guaranteed.

In a matter of months, the Food and Drug Administration is expected to decide whether the drug commonly known as ecstasy can be used as a treatment for post-traumatic stress disorder.

An approval by the agency would represent an enormous milestone for the movement to bring psychedelics into the mainstream of mental health care. An FDA rejection of MDMA, the abbreviation of the drug's chemical name, would deal a major setback to the effort.

Clinical trials have inspired optimism in the drug for its potential to help the millions of Americans who experience PTSD. Accounts from some of those who've participated in the trials describe the treatment as transformational.

But new and troubling questions about this research are now threatening to upset the final stretch in the drug's path to market.

The allegations surfaced in a draft report released in March by the Institute for Clinical and Economic Review , a nonprofit that evaluates clinical trials and drug prices, which found "substantial concerns about the validity of the results" of the MDMA clinical trials.

The ICER report was followed in April by a citizen petition to the FDA. In that document, a group of concerned people allege possible misconduct and ethical violations that could compromise the MDMA research. The petition asked the agency to hold a public meeting to address the concerns.

If true, the claims could jeopardize the drug's chances of receiving FDA approval, a decision that is expected to come by early August .

"There's the possibility that the data might not be representative of what's actually happened in clinical trials," says Neşe Devenot , one of the authors of the citizen petition and a senior lecturer in the writing program at Johns Hopkins University who is involved in psychedelic research. "I don't think this has been publicly reckoned with."

That may soon happen. The FDA announced Thursday that it plans to hold a public advisory committee meeting on MDMA-assisted therapy on June 4.

At the heart of the controversy are the organizations that have pioneered research into MDMA: the Multidisciplinary Association for Psychedelic Studies , and the public benefit corporation incubated by MAPS, which was recently rebranded as Lykos Therapeutics .

Lykos sponsored the clinical trials of MDMA. The results are included in the company's application to the FDA seeking approval to market the drug for therapy-assisted PTSD treatment.

Researchers and clinicians involved in the trials have pushed back strongly against the accusations that their clinical data isn't sound.

Jennifer Mitchell , lead author of the published papers from the Phase 3 trials, says she stands behind their findings.

"I didn't feel any pressure from the sponsor to come up with anything different than what the data was providing," says Mitchell, a professor of neurology and psychiatry at the University of California, San Francisco and associate chief of staff for research at the San Francisco VA Medical Center. "I wouldn't have continued to work with them if I had felt that."

Promising MDMA research for PTSD

The Phase 3 trials evaluated MDMA-assisted therapy, a protocol in which the drug is given under the supervision of two therapists.

In the second stage of the trials , 94 people with moderate and severe PTSD received either the drug or a placebo during three sessions, each spaced a month apart. There were also follow up "integration" sessions to help people process their experiences while on MDMA.

By the end of the trial, about 71% of participants in the MDMA arm no longer met the diagnostic criteria for PTSD, compared to about 48% who underwent the same therapy but took a placebo instead. Those findings built on promising results from earlier studies .

The study documented various adverse events in both groups — ranging from nausea and anxiety to heart palpitations — but none of them qualified as serious. The treatment was "generally well tolerated."

"Consistent with PTSD, suicidal ideation was observed in both groups," the authors reported in the journal Nature Medicine , "MDMA did not appear to increase this risk, and no suicidal behavior was observed."

Casey Tylek, a participant in the Phase 3 trials, says he had no experience with the drug prior to the study.

Tylek was in the placebo group, but was later given the opportunity to undergo the therapy with MDMA.

"It was incredibly powerful," says Tylek, a veteran who lives in Massachusetts, "I truly don't know if I would be alive today if I hadn't gone through that trial."

ICER report raises concerns

In its report , ICER acknowledges that the MDMA data suggest it would be an "important addition to treatment options for PTSD," but it questions whether the published findings tell the full story.

Among the concerns, the ICER report details a well-known challenge in psychedelic research around how to make sure study participants don't know if they got the experimental treatment or a placebo. Most of those in the MDMA group were able to identify they had received the drug. It also suggests the method used to assess PTSD — considered the gold-standard — showed improvements in symptoms after the treatment, even though some people were worse overall.

Beyond that, however, the report brings up the possibility that "very strong prior beliefs" among therapists, investigators and patients influenced the results.

"Concerns have been raised by some that therapists encouraged favorable reports by patients and discouraged negative reports by patients including discouraging reports of substantial harms, potentially biasing the recording of benefits and harms," the report states.

ICER does not identify the sources who were interviewed, although it did include two trial participants, a "trial therapist" and those who worked on a podcast called Cover Story , says Dr. David Rind , the chief medical officer for ICER.

"This was a very unusual review," says Rind.

The podcast, produced by New York Magazine and the nonprofit media organization Psymposia , brought to light claims by a participant named Meaghan Buisson, who appeared in a video of two therapists , a married couple, engaged in what Buisson described as inappropriate physical contact while she was under the influence of MDMA at a Phase 2 trial site in Canada.

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MAPS determined the therapists "substantially deviated" from the treatment manual. The organization also barred the two therapists from becoming providers of MDMA-assisted therapy in affiliation with MAPS, and health authorities were notified in Canada and the U.S.

The podcast also interviewed two people (their full names were not revealed) who said they received MDMA in the large-scale, or Phase 3, trials and experienced feelings of suicidality and other distress after the studies.

The ICER report is yet to be finalized, but Rind says their analysis showed "there's still a lot of uncertainty" about the treatment.

"You have a group of people who are very upset about how these trials went," he says. "We couldn't tell, even though we talked with people where this happened, whether that represents a tiny fraction of bad events or a number of bad events large enough to have rendered the trial just not believable."

Pushback against the allegations

According to Rind, MAPS and Lykos had "very little" engagement with ICER on the draft report.

But since then, a group of more than 70 clinicians, investigators and others involved in the Phase 3 MDMA trials have published a detailed response , saying that certain aspects of the trials were "misrepresented" and that a number of assertions amount to "hearsay."

Willa Hall , a clinical psychologist in the Phase 3 trials, says she and her colleagues were shocked by how ICER described their work.

"I didn't recognize the study that they were talking about," Hall told NPR. "I think a lot of us felt quite insulted actually by that characterization. I saw nothing like that. I only saw professionalism ."

In their response, Hall and her colleagues write that "[ICER] does not note the many measures taken to train, support, and evaluate therapists on those trials—measures that met, and in some cases exceeded, the accepted standards in the field of psychotherapy research."

They also take issue with ICER relying on "a small number of undisclosed study participants and unnamed 'experts' rather than validated research outcomes." The critiques that participants knew they received the treatment or that the measure of PTSD symptoms might not capture someone's overall condition would also apply to other clinical trials, unrelated to MDMA, they say.

UCSF's Jennifer Mitchell says the clinical trial was designed to safeguard against bias.

Therapists on site were not collecting key data from participants about their PTSD symptoms following the sessions. Instead, that was being done online by "independent assessors" who didn't know who had received the treatment or a placebo.

Hall says therapists "meticulously" captured any adverse events. "We encouraged our participants to be very honest," she says. "We're all invested in knowing how it works and what are the risks for people."

Still, Mitchell acknowledges she doesn't have full insight into what was going on at each trial site on a given day.

"This is my own frustration," she says. "I can't attest to what was happening at one of the sites in Israel on a day to day basis, or on one of the sites in Canada."

But she contends that ICER tried to conduct an investigation without access to the full data.

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The FDA granted MDMA "breakthrough therapy" status, she says, which means the agency was involved in the study design and "many aspects" of the trial.

"So there's no keeping things from the FDA," Mitchell says.

The ICER report points out that therapists and participants in the study were "pulled heavily from the existing community of those interested and involved in the use of psychedelics for possible psychological benefits."

For her part though, Mitchell says she's not what some would call a "true believer."

"My personal feeling is that psychedelics are complicated compounds and they do not work for everyone," she says.

Petition adds to controversy ahead of the FDA meeting

On the heels of the ICER report, Neşe Devenot and four others, including Meaghan Buisson, submitted the citizen petition to the FDA calling for a public advisory meeting about the Lykos' application for MDMA.

In it, they ask for extended time for stakeholders who are concerned about the "risks and shortcomings" of the research.

"Evidence from multiple sources indicates that the sponsor has engaged in a pattern of systematic and deliberate omission of adverse events from the public record while minimizing documented harms," the petition states.

It continues: "We cannot rule out the possibility that MAPS/Lykos manipulated clinical trial data to hide adverse events from regulatory agencies."

The petition cites media reports and public statements from figures at Lykos and MAPS — and disclosures from a former employee of the MAPS public benefit corporation "who prefers to maintain anonymity at this juncture."

In addition, the petition alleges that clinical trial investigators would phone MAPS in the event of an incident during the trial to see whether that should be reported as an adverse event and that a suicide attempt during a dosing session was discouraged from being reported.

In an email to NPR, a spokesperson for MAPS rejects the claim.

It's not clear if the FDA's decision to hold a meeting was influenced by Devenot's petition, which has over 80 signatures .

Alaina Jaster , who has a doctorate in pharmacology and toxicology, is another author of the petition.

"We need to listen to people [in the trials] who are having these experiences, instead of telling them that they are liars and that they're going to ruin the psychedelic renaissance," says Jaster who hosts a podcast on psychedelics.

"None of us are against this as a useful tool, or none of us are against treating mental health. We don't have any monetary interests in this not going through," she says.

Neşe Devenot and Brian Pace, another author of the petition, are affiliated with Psymposia , the media organization that produced the podcast, but Devenot says they were not involved in the podcast and are unpaid board members.

In response to the petition's call for a public meeting, a spokesperson for Lykos sent NPR a statement in April saying the company supports holding an advisory meeting. "The voice of the PTSD patient is incredibly important," the email reads.

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MAPS "remains fully supportive of comprehensive, high-quality research; careful analysis of safety and efficacy; and stringent regulatory oversight of any psychedelic-assisted therapy research or delivery," according to the statement it also sent to NPR in April. "We stand behind Lykos' execution of the clinical program and support the clinical results."

One of those who signed the petition after seeing it posted online is Dr. Boris Heifets , an anesthesiologist at Stanford University whose lab studies psychedelics, including MDMA.

"I don't know if the allegations are true, it just makes me deeply sad if there was actually malfeasance for such an important trial," says Heifets. "The MDMA Phase 3 trials were very important for mental health, important for a lot of people who may benefit from this therapy."

Learning about MAPS several decades ago was, in part, what inspired Heifets to get involved in this type of research.

He says he donates $100 a year to MAPS and that they have supplied his lab with MDMA. He also consults for one company that's developing a derivative of MDMA.

Heifets says the petition contains some "very strong allegations," particularly the claim that certain adverse events were not disclosed.

"I want to hear MAPS respond," he says. " I would really like to understand the risk profile of this drug before it's approved, not after."

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BBQ Sweet Potato Chickpea Tacos

These BBQ Sweet Potato Chickpea Tacos are your new go-to for a satisfying and healthy meal, ready in just 30 minutes! Packed with plant-based goodness, this recipe features protein-rich chickpeas, nutrient-dense sweet potatoes, flavorful garlic, creamy cashews, and spices that bring it all together. Plus, those tortillas add a dose of resistant starch for a gut-friendly boost!

Ingredients - Sweet Potatoes & Chickpeas

• 1 medium sweet potato, cut into 1/2-inch cubes (1 medium sweet potato is ~400 g or 3/4 lb) 1 (15-oz. / 425 g) can chickpeas, drained and rinsed (or sub ~1 ¾ cups homemade) 2 Tbsp avocado or olive oil 1 Tbsp maple syrup 1 Tbsp smoked paprika 1 ½ tsp garlic powder 1 tsp chili powder blend 1/4 tsp cayenne pepper ( optional ) 1/2 tsp sea salt 1/4 tsp black pepper

Ingredients - Chipotle Crema:

• 3/4 cup raw cashews 1 whole chipotle pepper in adobo sauce (just 1 pepper, not the whole can!) 2/3 cup water (plus more for soaking) 1 ½ tsp maple syrup 1/2 medium clove garlic 1/4 tsp sea salt

Ingredients - For Serving:

• 1 cup thinly sliced green cabbage 8 lime wedges (NOT optional) 8 (~6-inch each) tortillas of choice (we like corn tortillas or Siete almond flour tortillas)

Instructions:

• Preheat your oven to 425 degrees F (218 C) and line a baking sheet with parchment paper. Set aside.
• Add cashews to a heatproof bowl and cover with hot water by at least 1-2 inches. Soak for at least 15 minutes.
• SWEET POTATOES & CHICKPEAS: Meanwhile, add the cubed sweet potatoes and drained and rinsed chickpeas to the parchment-lined baking sheet. Add oil, maple syrup, smoked paprika, garlic powder, chili powder, cayenne pepper (optional), sea salt, and black pepper and toss to coat. Bake for 20 minutes or until the potatoes are tender and the chickpeas are slightly browned. Everything should be slightly caramelized but still soft. You don’t want it to dry out too much.
• CHIPOTLE CREMA: Meanwhile, drain your cashews and place them into a high-speed blender with the rest of the sauce ingredients (chipotle pepper, water, maple syrup, garlic, and salt). Blend on high until smooth and creamy.
• TORTILLAS: To heat your tortillas, place a skillet over medium-high heat. Place a tortilla in the pan and heat on each side for 10-15 seconds until warm, then repeat with the remaining tortillas.
• TACOS: Place ~1/3 cup of the sweet potato chickpea filling into the center of each warmed tortilla, top with a couple tablespoons of shredded cabbage and 1-2 tablespoons of chipotle crema, and serve each taco with a lime wedge. Squeeze the lime over each taco and enjoy!
• If you have any extra crema, you can use it in taco bowls, on salads, or even as a dip for chips! Taco components will stay fresh for up to 3-4 days in the refrigerator when stored separately in airtight containers. Reheat sweet potato chickpea filling in a skillet over medium heat for 3-5 minutes, stirring occasionally, until warmed through. Not freezer friendly.

This recipe is from the Minimalist Baker . 

Stanford Prevention Research Center