importance of community case study

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Community Case Study Article Type: Criteria for Submission and Peer Review

Matthew lee smith.

1 Department of Health Promotion and Behavior, College of Public Health, The University of Georgia, Athens, GA, USA

2 Department of Health Promotion and Community Health Sciences, Texas A&M Health Science Center School of Public Health, College Station, TX, USA

Sue E. Levkoff

3 College of Social Work, University of South Carolina, Columbia, SC, USA

Marcia G. Ory

The importance of case studies in public health education and promotion.

Health programs and practices are often conceived and delivered by community-based practitioners to address specific community health education and promotion needs ( 1 ). Although, initially untested, such programs can provide important lessons for researchers and practitioners, alike. Given the growing emphasis on community-based participatory research (CBPR) approaches ( 2 ), it is especially important for researchers to build upon findings from CBPR studies, which can contribute to the development of evidence-based programs and practices for widespread dissemination ( 3 ).

While a community case study can take many forms ( 4 , 5 ), we are defining it as a description of, and reflection upon, a program or practice geared toward improving the health and functioning of a targeted population. We utilize the term “community” in contrast to “clinical” studies, but it is important to note that a community can be defined in terms of geographic boundaries as well as demographic characteristics, common settings, and/or affiliations.

Typically, a community case study documents a local experience about delivering services to meet an identified need. Community-based studies often rely on community engagement principles, which are not typically incorporated in the more traditional science-based approach to evidence-based program development (e.g., CBPR, action research, and community-engaged research). The community case study that documents early experiences can contribute to programmatic development as well as to the future development of evidence-based practice. This has been referred to as the “practice to science” approach to the development of evidence-based practices ( 6 ). The community case study can also represent activities at later development stages, for example, documenting the experience of implementing an evidence-based program or practice in a different context (e.g., different culture, different population, and different setting) from that in which it was first developed [“from science to practice” ( 6 )]. The lessons learned from such community case studies are essential for adaptation, replication, and eventual widespread dissemination and sustainability of innovations across a wide range of settings and populations.

Although case studies are a recognized form of research ( 5 ), the criteria for evaluating the quality of such efforts necessarily differs from empirical research articles where there is less attention to the local experience and context in which the intervention occurs, and more emphasis is given to the use of standardized research designs, measures, and analyses.

Key Components of a Community Case Study

Under this article type, Frontiers in Public Health Education and Promotion will accept a broad spectrum of manuscripts that describe interventions, including programs and services, which promote public health education, practice, research, and/or policy. Such public health interventions can be implemented at the behavioral, organizational, community, environmental, and/or policy level(s). Articles require a description of the nature of the problem being addressed and rationale for the proposed intervention, the context (setting and population) in which the intervention is being implemented, and sufficient detail to allow replication of key programmatic elements. Reflections about public health impact as well as what works and what does not work should be highlighted. Additionally, submissions will require a discussion section that shares practical implications, lessons learned for future applications, and acknowledgment of any conceptual or methodological constraints. Articles should not exceed 5,000 words and include a maximum of five tables/graphs. Evaluation criteria for this article type are outlined below:

We recommend that community case study article submissions address the following issues (if relevant).

• □ What is the problem? Whom does it affect?
• □ What are the gaps about what is known or done currently?
• □ What is the setting? Who are the key stakeholders? Who is the target population or participants?
• □ With whom did you work or collaborate? Are there any unique characteristics of the team who worked to implement the solution?
• □ What is the solution described by this community case study?
• □ Is this solution innovative/novel in terms of content, format, and/or delivery? If yes, why?
• □ What are the essential elements of the solution? Could this community case study be replicated? Include sufficient detail that the reader would know if replication would be feasible in his/her own context.
• □ What are the barriers and facilitators to the development, implementation, and/or dissemination of the intervention?
• □ What are the major successes of the solution? What are the promising results to date? Include data and/or evaluation results, if available.
• □ How does this improve public health education, practice, research, and/or policy? What are the broader implications of this work?
• □ Recommendations for those who want to replicate this in other settings, populations, or over time.

Criteria for Review (Template for Review Editors to Complete for Each Manuscript)

Indicate what the community case study describes (check all that apply)

• __an education effort
• __a health promotion program
• __a health promotion service
• __an environmental change taking place in the community
• __a technological change taking place in the community
• __a policy change taking place in the community
• __a community partnership
• __others. Please specify: _____________________
• __none of the above (i.e., inappropriately categorized for submission as a community case study article).

Indicate the target audience for the case study (check all that apply)

• __educators
• __community professionals
• __health-care professionals
• __lay public
• __policy makers
• __other. Please specify: _____________________

Mandatory Sections and Associated Criteria

A community case study article has the following mandatory sections: abstract, introduction, background and rationale, description of the case, methodological aspects (including targeted population and setting), discussion, and lessons learned/recommendations. Are all sections present?

• Is the abstract written in a clear and comprehensive way?
• Does the abstract reflect major conclusions articulated in the case study?

Introduction

• Does the introduction present the problem in an appropriate context?
• Other comments on introduction.

Background and Rationale

• Is the intent of the case study adequately described?
• Is a justification made for the innovation/novelty of proposed case in content, format, and/or delivery?
• Are the questions asked by the case study most essential to the success of the initiative?
• Other comments on background and rationale.

Essential Elements of the Intervention

• Is the intervention adequately described (e.g., development, previous findings if any, components, and format/design)?
• Is the intervention described in sufficient detail to understand the essential elements?
• Are the implementation procedures adequately described (e.g., how is the intervention being implemented in a particular setting, population, and/or partnerships; are any adaptations needed from prior work)?
• Are the target setting(s) and population(s) adequately described so that context for the case study is clearly understood?
• Is this a single community or multiple community study?
• Is there an overall conceptual model or framework for understanding the importance of the problem and selection of intervention elements?
• Is it clear whether the emphasis is on furthering knowledge about the process and/or outcome of the case study? If focus is on process, is there attention to key elements of implementation such as reach, reproducibility, scalability, or sustainability? If on outcomes, are the metrics of success (outcome indicators) clearly articulated?
• Is the generalizability of findings/lessons learned addressed?
• Other comments on methods.
• Are findings/lessons learned accurately reported from data presented?
• Is the level of detail of the results appropriate (too much, too little, or about right)?
• Is any essential information missing?
• Other comments on results.
• Are the reported findings/lessons learned summarized briefly and described within the context of what is currently known about the public health issue(s) or problem(s) being addressed?
• Does the article conclude with practical recommendations for others who might replicate this intervention/program (or similar interventions/programs)?
• Does the article conclude with applied recommendations for those in the field who might deliver this intervention/program (or similar interventions/programs) in their communities/settings?
• Does the case study contribute concrete recommendations for delivering and/or improving the intervention for future applications (directed toward educators, researchers, or practitioners, as appropriate)?
• Does the article address any conceptual or methodological limitations for future implementation, dissemination, and sustainability?
• Other comments on discussion.
• Are the conclusions justified?
• Overall, does the article contribute to building evidence-based practice and/or policy?
• Is prior work, if any, properly and fully cited?

Article Length

• A case study article should not exceed 5,000 words. Should any part of the article be shortened? If yes, please specify which part should be shortened.
• A case study article should not include more than five tables/figures. If there are more tables/figures included, please specify if you believe tables can be combined, condensed, or eliminated.

Language and Grammar

• Are the language and grammar correct?
• Should the paper be sent to an expert in English language and scientific writing?

Other Comments

• Please add any further comments you have regarding this manuscript.

Reviewer Ratings

• Significance of issue being addressed by the case study: scored out of a maximum of 10 points
• Description of essential elements of the case study: scored out of a maximum of 10 points
• Appropriateness of the context (population and setting) in addressing the public health issue/problem described in the case study: scored out of a maximum of 10 points
• Sufficient conceptual and methodological detail describing why and how the intervention was implemented: scored out of a maximum of 10 points
• Reflections on what worked and did not work in the design, implementation, and/or dissemination of the program: scored out of a maximum of 10 points
• Quality of the writing: scored out of a maximum of 10 points
• Quality of the figure(s) and table(s): scored out of a maximum of 10 points
• Significance of the findings/lessons learned: scored out of a maximum of 10 points

Author Contributions

All authors were integral in formulating and drafting the manuscript and associated criteria.

Conflict of Interest Statement

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

COMMUNITY CASE STUDY article

Frameworks for community impact - community case study.

• Northeastern Vermont Regional Hospital, St. Johnbury, VT, United States

The Affordable Care Act of 2008 placed specific community health needs assessment and community benefit reporting requirements on US not-for-profit hospitals. The requirements are straightforward, but come with no expectation for synergy between the needs assessment and the community benefit spending, no direction on how to design systems to improve community health, and with surprisingly little accountability for improving health outcomes. With the help of diverse community partners, one Critical Access hospital in rural Vermont has successfully linked the needs assessment with community benefit dollars to address upstream contributors of health. In 2014, Northeastern Vermont Regional Hospital lead the creation of NEK Prosper: Caledonia and Southern Essex Accountable Health Community with a mission to tackle poverty as the ultimate root cause of poor health in the region. This article outlines how a hospital community health needs assessment ignited a change in how community partners worked together, aligned organizational strategies, and overcame industry jargon barriers to create regional system change to improve health. And how that same hospital has used community benefit dollars to accelerate action at the community level.

Introduction

This article outlines how Northeastern Vermont Regional Hospital (NVRH) is able to use its community health needs assessment as both a catalyst to change how community partners work together, and to inform how best to spend the hospital community benefit dollars to impact community health.

NVRH is a 25 bed Critical Access Hospital in northern Vermont. The 2012 NVRH Community Health Needs Assessment (CHNA) identified poverty as one of the top health priority areas. Poverty, and the symptoms of poverty like inadequate access to healthcare, healthy food, transportation, and education, is a well-documented root cause of poor health ( 1 , 2 ). Low income adults are more likely to suffer difficulties in their daily lives due to chronic illness, while children living in poverty are often left with risk factors that can affect their health throughout their lives ( 3 ) Consequently, tackling poverty in the hospital service area became a priority issue for NVRH and its leaders, particularly the CEO. As part of the 2012 CHNA implementation plan, NVRH committed to convene community leaders to address the issue of poverty as the upstream, systemic driver of poor health and health inequity.

Convened by invitation of NVRH, the leaders of the regional Federally Qualified Health Center (FQHC) and home health agency, designated mental health agency, community action agency, council on aging, and designated regional housing organization began meeting regularly at the hospital. As they talked about what they each could do to address poverty and researched how they could work better together in a strategic and collaborative way, two models emerged: The Accountable Health Community (AHC) and collective impact (CI) models.

AHC is an emerging model gaining popularity across the US. An AHC is responsible for the health and well-being of everyone who lives in a geographic region. The AHC model recognizes that the health of a population is determined by multiple factors: healthcare, environment, socio-economic status, and individual behaviors. ( 4 ) The Center for Medicare and Medicaid Services (CMS) says the AHC model “addresses a critical gap between clinical care and community services in the current health care delivery system” ( 5 ).

The Prevention Institute has embraced the AHC model as a “promising vehicle toward reaching the full potential of the Triple Aim.” The Prevention Institute has identified nine core elements of the AHC model: multi-sectoral partnership; integrator organization; governance; data; strategy and implementation; community engagement; communications; and sustainable financing ( 6 ).

The AHC model outlines one structure to foster collaboration ( 7 ). True collaboration requires multi-sector partners work well-together ( 8 ). This is where the collective impact model can help.

CI has been articulated as a method for solving large scale social problems by “a systemic approach to social impact that focuses on the relationships between organizations and the progress toward shared objectives.” Successful CI initiatives have five conditions that together produce true alignment and lead to powerful results: a common agenda, shared measurement systems, mutually reinforcing activities, continuous communication, and backbone support organizations ( 9 ).

NVRH is located in Vermont's Northeast Kingdom, a region known for its rugged rural landscape and independent and spirited people. The primary service area for NVRH is Caledonia and southern Essex counties, with just under 30,000 people. Population density in Caledonia County is 48.1 persons per square mile and 9.5 persons per square mile in Essex County ( 10 ). Both counties are bordered by the Connecticut River and New Hampshire to the east.

The 25 bed hospital is the largest employer in the region, with over 600 employees. The hospital operates four rural health clinics and six specialty medical offices. A different entity operates three FQHC's and home health and hospice for the region. All the primary care offices in the region are recognized NCQA Patient Centered Medical Homes. Mental health services are provided by a regional designated mental health agency and many independent providers in private practice. There are several independent long-term care facilities in the area. Comprehensive cancer care services are located on the NVRH campus, but provided by the nearest (70 miles to the south) tertiary center. A private for-profit dialysis center provides services in a building owned by NVRH. Medically Assisted Treatment (MAT) for opioid addiction is provided by a private for-profit organization located down the road from NVRH. The mental health agency and several primary care offices operated by the hospital and the FQHC also provide MAT services.

NVRH has a long history and reputation for working collaboratively and embracing the idea that health happens outside the walls of the hospital. Over the decades, NVRH leadership has spearheaded the formation of prevention coalitions to address obesity and substance use, providing staff resources, meeting space, and funding for coalition initiatives. Both NVRH leadership and staff routinely works with local and state public health staff though the Vermont Department of Health on prevention and public health initiatives driven by the Vermont State Health Improvement Plan, and data like the Behavioral Risk Factor Surveillance Survey and the Youth Behavior Risk Survey collected by the Health Department, as well as local Department of Health priorities.

The NVRH service area was the first of two pilot communities funded by the Vermont Blueprint for Health in 2005, and the first Integrated Medical Home and Community Health Team pilot community created under Act 71 ( 11 ). The robust and active Blueprint for Health Community Health Team continues to provide a forum for coordinated care between direct service providers from healthcare, human services, and community-based organizations.

NEK Prosper!

In 2014, NVRH lead the creation of NEK Prosper: Caledonia and Southern Essex Accountable Health Community with a mission to tackle poverty as the ultimate root cause of poor health in the region.

That initial informal group of community leaders convened by NVRH in 2014 has since added the state-wide foodbank and the regional United Way and become the leadership team. NEK Prosper has provided the forum for the leadership team decision makers come together to strategically align their organizations, something that did not happen prior to the formation of the AHC.

The leadership team embraced the frameworks provided by the AHC and CI models. There is a formal governance and decision-making structure, shared measures for success, and intentional methods for community engagement. Basic meeting etiquette and equitable participation is ensured by reviewing standard norms of behavior, such as “listening with intent” and “address issues directly and succinctly” at each meeting. Leadership team members have adopted norms of behavior for meetings. They have all signed a memorandum of understanding (MOU) that outlines the mission and purpose of the AHC, specific roles and responsibilities of the leadership team members, and a process for decision-making. Stewardship has been an important guiding principle for all members; the advice to “wear two hats – those of your organization and this partnership” is included in the norms of behavior.

Today, the AHC includes members from healthcare, human services, housing, transportation, mental health, community action, charitable food, funders, school districts, domestic violence agency, youth services, economic development and regional planning, banks/financial organizations, town government, restorative justice, and State agencies including Vermont Department of Health and Vermont Department of Human Services ( Figure 1 ). All NEK Prosper members sign a culture statement that encourages innovative thinking, sharing of resources, and working relationships based on trust and respect. Rather than creating another needs assessment, NEK Prosper officially adopted the hospital community health needs assessment (CHNA) as the official community needs assessment of the AHC in 2016.

Figure 1 . Member Organizations for NEK Prosper.

The name NEK Prosper: Caledonia and Southern Essex Accountable Health Community was officially adopted in 2018. NVRH serves as the backbone organization for NEK Prosper.

Workgroups called Collaborative Action Networks (CANs) include community member participation and focus on each of NEK Prosper's five outcome areas: our community will be well–nourished, well-housed, physically healthy, mentally healthy, and financially secure. NEK Prosper and the CANs use Results Based Accountability™ to measure impact on health.

Programmatic Elements

The purpose of the NVRH community health needs assessment is to identify initiatives at the individual, community, environmental, and policy level, as well as programs and services that meet the hospital's mission to improve the health of people in the communities it serves. When it came time for NVRH to complete the 2018 CHNA, the leading criterion for setting community health priorities was the ability to work within the NEK Prosper framework to best capitalize on existing community resources and assets.

The 2018 CHNA built on the foundation of the previous assessments. New for 2018, the CHNA used the framework of NEK Prosper. Additionally, the CHNA was advised by the data compiled and the community engagement work already done by NEK Prosper, and adopted the mission of the NEK Prosper to reduce poverty in the region.

The CHNA data collection identified low-income families, and older adults as the most vulnerable population. The CHNA validated the objectives of NEK Prosper that communities will be financially secure, physically healthy, mentally healthy, well-nourished, and well-housed. Consequently, the NVRH 2018 CHNA proposed that over the next three years, NVRH will implement initiatives, and programs and services that work to meet these five objectives to improve health in the community, while intentionally addressing the underlying causes of health disparities .

Like NEK Prosper, the 2018 NVRH CHNA Implementation Plan and Evaluation use Results Based Accountability™ (RBA) to measure impact, evaluate initiatives, and drive action and change. RBA provides a step by step process to get results. RBA defines both population level (whether we have achieved goals for a defined population) and performance level (how well a program or service is working) measures. ( 12 ).

In fiscal year 2019, with an intentional effort to use community benefit dollars to accelerate action, the hospital budgeted $93,000 from operations to fund initiatives of the five CANs of NEK Prosper. The initiatives and dollar amounts are outlined in the CHNA Implementation Plan. For that first year, not all the CANs had initiatives ready for funding. The same amounts were budgeted for fiscal year 2020.

The CANs are data driven and use a common template and tools to decide which community strategies to implement. The Well-Nourished CAN launched the Food Hero Social Marketing Campaign in May 2019. Food Hero is a program from Oregon State University Extension Service with funding from SNAP-ED. The goal of the program is to increase fruit and vegetable consumption by creating and disseminating low cost, easy to prepare, and healthy recipes ( 13 ).

NVRH Community Benefit dollars purchased re-useable grocery bags with the Food Hero and NVRH logo. The bags are distributed at events sponsored by NVRH and the partner organizations of the Well-Nourished CAN. Large Food Hero banners attract attention at local events. Food Hero themed placemats are used at the hospital and senior meal sites.

Using Results Based Accountability™ (RBA) principles, the Well-Nourished CAN tracks the number of sites using Food Hero materials, social media engagements, and the number of Food Hero recipes distributed to measure performance level results. The CAN will use a Food Hero qualitative evaluation tool to measure behavior change in spring 2020. The CAN uses population level indicators collected by the Vermont Department of Health (fruit and vegetable consumption and the prevalence of hypertension) to measure long term impact.

Other CAN initiatives funded by NVRH community benefit dollars are the popular smoothie bikes for use at school and community events as part of the Physically Healthy CAN's community-based campaign to increase physical activity, and stipends for fitness providers to offer free pop up fitness classes in local parks. NVRH has funded a small pilot project that pays for complimentary therapies like acupuncture for people coping with mental health issues under the direction of the Mentally Healthy CAN. Every CAN initiative is evaluated for impact by using RBA performance measures of “how much, how well, and is anyone better off.” Each CAN measures community wide impact by using population level indicators such as percentage of people getting the recommended amount of physical activity or regional rates of suicide. Impact dashboard for some of the CANs can found at the NEK Prosper website.

The partners in NEK Prosper are not stopping with community-based interventions of the CANs. Two wellness funds were created thanks to the strong culture of stewardship, and leaders focused on action to improve health by tackling poverty.

Working with local economic development and financial partners NEK Prosper members are ready to launch the NEK Prosperity Fund using a capital stacking approach to raise funds to free up almost a million dollars currently held by the regional Community Development Financial Institution (CDFI) to invest in small and emerging local businesses. The purpose of the fund is to act as an investment vehicle aimed at promoting economic development by offering loans to local businesses, as well as supporting the overall well-being of the employees and customers of the business. Loans will be given to businesses that might not qualify for traditional bank loans or other loans offered by the CDFI. These more “at risk” businesses will need a high level of technical assistance to be successful. An Advisory Committee of NEK Prosper will assist the CDFI in developing general policies for mission driven funding.

The NEK Prosper leadership team has committed to raising $200,000 for a loan loss reserve fund to protect the original capital loan fund assets, and to pay for additional business support services by the experienced CDFI staff. It is expected the money will be raised quickly with investments from the hospital, other leadership team organizations, and local businesses.

In spring 2020, NEK Prosper launched the Healthy Cents Fund. The Healthy Cents Fund is available for local organizations for innovative upstream interventions or investments that will create healthy and thriving communities and positive social, economic, or environmental impact. The fund aims to accelerate the work of NEK Prosper and move the AHC closer to the five outcome areas. The value-based payment environment was key to the creation of this fund. Funding for the Healthy Cents Fund comes from Medicaid capitated payments to NVRH paid through the Vermont All Payer Model and the state-wide Accountable Care Organization. Rather than wait for potential shared savings, NVRH takes 1% off the top of the per member per month capitated payments to finance the Healthy Cents Fund, or about $58,000 annually.

Both funds require community engagement activities, and must tie directly to the five outcomes areas of NEK Prosper and the health priorities of the CHNA. Social return on investment is measured using a modified logic model table linking funded activities to short and long term social outcomes.

In a value-based payment environment, hospitals have the financial incentives to keep people well and out of the hospital and the flexibility to use hospital resources to address the social determinants of health. It is time for hospitals to put resources into prevention and the social and environmental factors that make people sick ( 1 ). Nationally, researchers and policy makers are looking for ways for hospitals and partners to combine resources in a more systemic way ( 14 , 15 ).

Hospitals already have a tool in place to identify the community needs and priorities: the CHNA. The data and community input gathered during the CHNA process provides the roadmap for where hospitals can best invest resources to make the most impact on health. The community benefit requirements of the Affordable Care Act make it possible for hospitals to get credit for their investments. Yet, few hospitals are investing in “community building” projects that address social determinants ( 2 ). Additionally, there is clear consensus that a comprehensive approach to improving health requires multisector partners working in sync. However, we are falling short of all we can do to truly improve health and well-being ( 8 ).

NVRH and the partner organizations in the region have used the promising models of collaboration of Accountable Health Community (AHC) and collective impact (CI) to align their strategies, organization resources, and funding. The models provide the structure to work collaboratively, while holding people accountable for their contributions to the goals of NEK Prosper. AHC and CI have helped create an atmosphere of trust and a process for measuring results.

Leadership from the hospital CEO and the executive directors of other community agencies was a critical component to initiating and continuing the collaboration. Stewardship and trust are two additional elements that are essential. The CI model provides a model for identifying and incorporating these elements into concrete activities.

The role of the hospital was critical to the success of NEK Prosper. Despite its small size, NVRH is a leading force in the community. Additionally, the financial contribution provided through the community benefit funds enabled concrete actions that the community might otherwise have struggled to achieve.

Lessons Learned and Tips for Success:

• Don't reinvent the wheel. Use existing models and frameworks to create a community collaborative structure the works in your community.

• Be strategic in making your list of who needs to be at the table. Include traditional health and human service partners, community-based organizations focused on social determinants, local and state government, funders, and less traditional partners like for-profit business and economic development agencies.

• Finding common ground with less traditional partners may take some time; expect communication barriers. NVRH and NEK Prosper found that banks and economic development agencies wanted the same thing – a healthy prosperous community; however, industry specific jargon made it difficult to identify common goals. Engage these partners in your work by asking for their expertise in finding financial resources for projects and measuring financial return on investment. In exchange, health and human services can offer expertise in social return on investment measures, and provide specific services and programs to improve the health and well-being for employees of these partners and for the employers and customers they work with every day.

We inherently know that we are better together, stronger together, and can accomplish more together. Using current partnership frameworks like Accountable Health Community and collective impact, hospitals can provide the data - CHNA, the funding - community benefits, and the leadership to foster a culture of stewardship to truly create and maintain healthy communities.

Conclusions

As hospitals work to improve health in their communities, they must be intentional about improving the systems and structures within their organizations and regions to support health, well-being, and equal opportunities for all.

The recipe for success includes a strong foundation built on three models: Accountable Health Community, Collective Impact, and Results Based Accountability™ to guide operations, keep community partners heading in the same strategic direction, and quantify and measure results. Adding three key ingredients: leadership, stewardship, and action to the foundational structure drives NEK Prosper toward high impact and a healthier, and potentially more prosperous, region.

Data Availability Statement

The datasets generated for this study are available on request to the corresponding author.

Author's Note

This is a community case study as described by one author. The author has a unique perspective because of her involvement in the initial and ongoing operations of NEK Prosper. She is also the staff person at NVRH in charge of both the CHNA process and the community benefit reporting.

Author Contributions

The author confirms being the sole contributor of this work and has approved it for publication.

Conflict of Interest

The author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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Keywords: community benefit, accountable health community, community health needs assessment, non-profit hospital, social determinansts of health

Citation: Ruggles L (2020) Frameworks for Community Impact - Community Case Study. Front. Public Health 8:197. doi: 10.3389/fpubh.2020.00197

Received: 02 March 2020; Accepted: 30 April 2020; Published: 02 June 2020.

Reviewed by:

Copyright © 2020 Ruggles. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Laural Ruggles, l.ruggles@nvrh.org

Disclaimer: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.

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5 Benefits of Learning Through the Case Study Method

• 28 Nov 2023

While several factors make HBS Online unique —including a global Community and real-world outcomes —active learning through the case study method rises to the top.

In a 2023 City Square Associates survey, 74 percent of HBS Online learners who also took a course from another provider said HBS Online’s case method and real-world examples were better by comparison.

Here’s a primer on the case method, five benefits you could gain, and how to experience it for yourself.

Access your free e-book today.

What Is the Harvard Business School Case Study Method?

The case study method , or case method , is a learning technique in which you’re presented with a real-world business challenge and asked how you’d solve it. After working through it yourself and with peers, you’re told how the scenario played out.

HBS pioneered the case method in 1922. Shortly before, in 1921, the first case was written.

“How do you go into an ambiguous situation and get to the bottom of it?” says HBS Professor Jan Rivkin, former senior associate dean and chair of HBS's master of business administration (MBA) program, in a video about the case method . “That skill—the skill of figuring out a course of inquiry to choose a course of action—that skill is as relevant today as it was in 1921.”

Originally developed for the in-person MBA classroom, HBS Online adapted the case method into an engaging, interactive online learning experience in 2014.

In HBS Online courses , you learn about each case from the business professional who experienced it. After reviewing their videos, you’re prompted to take their perspective and explain how you’d handle their situation.

You then get to read peers’ responses, “star” them, and comment to further the discussion. Afterward, you learn how the professional handled it and their key takeaways.

HBS Online’s adaptation of the case method incorporates the famed HBS “cold call,” in which you’re called on at random to make a decision without time to prepare.

“Learning came to life!” said Sheneka Balogun , chief administration officer and chief of staff at LeMoyne-Owen College, of her experience taking the Credential of Readiness (CORe) program . “The videos from the professors, the interactive cold calls where you were randomly selected to participate, and the case studies that enhanced and often captured the essence of objectives and learning goals were all embedded in each module. This made learning fun, engaging, and student-friendly.”

If you’re considering taking a course that leverages the case study method, here are five benefits you could experience.

5 Benefits of Learning Through Case Studies

1. take new perspectives.

The case method prompts you to consider a scenario from another person’s perspective. To work through the situation and come up with a solution, you must consider their circumstances, limitations, risk tolerance, stakeholders, resources, and potential consequences to assess how to respond.

Taking on new perspectives not only can help you navigate your own challenges but also others’. Putting yourself in someone else’s situation to understand their motivations and needs can go a long way when collaborating with stakeholders.

2. Hone Your Decision-Making Skills

Another skill you can build is the ability to make decisions effectively . The case study method forces you to use limited information to decide how to handle a problem—just like in the real world.

Throughout your career, you’ll need to make difficult decisions with incomplete or imperfect information—and sometimes, you won’t feel qualified to do so. Learning through the case method allows you to practice this skill in a low-stakes environment. When facing a real challenge, you’ll be better prepared to think quickly, collaborate with others, and present and defend your solution.

3. Become More Open-Minded

As you collaborate with peers on responses, it becomes clear that not everyone solves problems the same way. Exposing yourself to various approaches and perspectives can help you become a more open-minded professional.

When you’re part of a diverse group of learners from around the world, your experiences, cultures, and backgrounds contribute to a range of opinions on each case.

On the HBS Online course platform, you’re prompted to view and comment on others’ responses, and discussion is encouraged. This practice of considering others’ perspectives can make you more receptive in your career.

“You’d be surprised at how much you can learn from your peers,” said Ratnaditya Jonnalagadda , a software engineer who took CORe.

In addition to interacting with peers in the course platform, Jonnalagadda was part of the HBS Online Community , where he networked with other professionals and continued discussions sparked by course content.

“You get to understand your peers better, and students share examples of businesses implementing a concept from a module you just learned,” Jonnalagadda said. “It’s a very good way to cement the concepts in one's mind.”

4. Enhance Your Curiosity

One byproduct of taking on different perspectives is that it enables you to picture yourself in various roles, industries, and business functions.

“Each case offers an opportunity for students to see what resonates with them, what excites them, what bores them, which role they could imagine inhabiting in their careers,” says former HBS Dean Nitin Nohria in the Harvard Business Review . “Cases stimulate curiosity about the range of opportunities in the world and the many ways that students can make a difference as leaders.”

Through the case method, you can “try on” roles you may not have considered and feel more prepared to change or advance your career .

5. Build Your Self-Confidence

Finally, learning through the case study method can build your confidence. Each time you assume a business leader’s perspective, aim to solve a new challenge, and express and defend your opinions and decisions to peers, you prepare to do the same in your career.

According to a 2022 City Square Associates survey , 84 percent of HBS Online learners report feeling more confident making business decisions after taking a course.

“Self-confidence is difficult to teach or coach, but the case study method seems to instill it in people,” Nohria says in the Harvard Business Review . “There may well be other ways of learning these meta-skills, such as the repeated experience gained through practice or guidance from a gifted coach. However, under the direction of a masterful teacher, the case method can engage students and help them develop powerful meta-skills like no other form of teaching.”

How to Experience the Case Study Method

If the case method seems like a good fit for your learning style, experience it for yourself by taking an HBS Online course. Offerings span seven subject areas, including:

• Business essentials
• Leadership and management
• Entrepreneurship and innovation
• Finance and accounting
• Business in society

No matter which course or credential program you choose, you’ll examine case studies from real business professionals, work through their challenges alongside peers, and gain valuable insights to apply to your career.

Are you interested in discovering how HBS Online can help advance your career? Explore our course catalog and download our free guide —complete with interactive workbook sections—to determine if online learning is right for you and which course to take.

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Case Study – Methods, Examples and Guide

Table of Contents

A case study is a research method that involves an in-depth examination and analysis of a particular phenomenon or case, such as an individual, organization, community, event, or situation.

It is a qualitative research approach that aims to provide a detailed and comprehensive understanding of the case being studied. Case studies typically involve multiple sources of data, including interviews, observations, documents, and artifacts, which are analyzed using various techniques, such as content analysis, thematic analysis, and grounded theory. The findings of a case study are often used to develop theories, inform policy or practice, or generate new research questions.

Types of Case Study

Types and Methods of Case Study are as follows:

Single-Case Study

A single-case study is an in-depth analysis of a single case. This type of case study is useful when the researcher wants to understand a specific phenomenon in detail.

For Example , A researcher might conduct a single-case study on a particular individual to understand their experiences with a particular health condition or a specific organization to explore their management practices. The researcher collects data from multiple sources, such as interviews, observations, and documents, and uses various techniques to analyze the data, such as content analysis or thematic analysis. The findings of a single-case study are often used to generate new research questions, develop theories, or inform policy or practice.

Multiple-Case Study

A multiple-case study involves the analysis of several cases that are similar in nature. This type of case study is useful when the researcher wants to identify similarities and differences between the cases.

For Example, a researcher might conduct a multiple-case study on several companies to explore the factors that contribute to their success or failure. The researcher collects data from each case, compares and contrasts the findings, and uses various techniques to analyze the data, such as comparative analysis or pattern-matching. The findings of a multiple-case study can be used to develop theories, inform policy or practice, or generate new research questions.

Exploratory Case Study

An exploratory case study is used to explore a new or understudied phenomenon. This type of case study is useful when the researcher wants to generate hypotheses or theories about the phenomenon.

For Example, a researcher might conduct an exploratory case study on a new technology to understand its potential impact on society. The researcher collects data from multiple sources, such as interviews, observations, and documents, and uses various techniques to analyze the data, such as grounded theory or content analysis. The findings of an exploratory case study can be used to generate new research questions, develop theories, or inform policy or practice.

Descriptive Case Study

A descriptive case study is used to describe a particular phenomenon in detail. This type of case study is useful when the researcher wants to provide a comprehensive account of the phenomenon.

For Example, a researcher might conduct a descriptive case study on a particular community to understand its social and economic characteristics. The researcher collects data from multiple sources, such as interviews, observations, and documents, and uses various techniques to analyze the data, such as content analysis or thematic analysis. The findings of a descriptive case study can be used to inform policy or practice or generate new research questions.

Instrumental Case Study

An instrumental case study is used to understand a particular phenomenon that is instrumental in achieving a particular goal. This type of case study is useful when the researcher wants to understand the role of the phenomenon in achieving the goal.

For Example, a researcher might conduct an instrumental case study on a particular policy to understand its impact on achieving a particular goal, such as reducing poverty. The researcher collects data from multiple sources, such as interviews, observations, and documents, and uses various techniques to analyze the data, such as content analysis or thematic analysis. The findings of an instrumental case study can be used to inform policy or practice or generate new research questions.

Case Study Data Collection Methods

Here are some common data collection methods for case studies:

Interviews involve asking questions to individuals who have knowledge or experience relevant to the case study. Interviews can be structured (where the same questions are asked to all participants) or unstructured (where the interviewer follows up on the responses with further questions). Interviews can be conducted in person, over the phone, or through video conferencing.

Observations

Observations involve watching and recording the behavior and activities of individuals or groups relevant to the case study. Observations can be participant (where the researcher actively participates in the activities) or non-participant (where the researcher observes from a distance). Observations can be recorded using notes, audio or video recordings, or photographs.

Documents can be used as a source of information for case studies. Documents can include reports, memos, emails, letters, and other written materials related to the case study. Documents can be collected from the case study participants or from public sources.

Surveys involve asking a set of questions to a sample of individuals relevant to the case study. Surveys can be administered in person, over the phone, through mail or email, or online. Surveys can be used to gather information on attitudes, opinions, or behaviors related to the case study.

Artifacts are physical objects relevant to the case study. Artifacts can include tools, equipment, products, or other objects that provide insights into the case study phenomenon.

How to conduct Case Study Research

Conducting a case study research involves several steps that need to be followed to ensure the quality and rigor of the study. Here are the steps to conduct case study research:

• Define the research questions: The first step in conducting a case study research is to define the research questions. The research questions should be specific, measurable, and relevant to the case study phenomenon under investigation.
• Select the case: The next step is to select the case or cases to be studied. The case should be relevant to the research questions and should provide rich and diverse data that can be used to answer the research questions.
• Collect data: Data can be collected using various methods, such as interviews, observations, documents, surveys, and artifacts. The data collection method should be selected based on the research questions and the nature of the case study phenomenon.
• Analyze the data: The data collected from the case study should be analyzed using various techniques, such as content analysis, thematic analysis, or grounded theory. The analysis should be guided by the research questions and should aim to provide insights and conclusions relevant to the research questions.
• Draw conclusions: The conclusions drawn from the case study should be based on the data analysis and should be relevant to the research questions. The conclusions should be supported by evidence and should be clearly stated.
• Validate the findings: The findings of the case study should be validated by reviewing the data and the analysis with participants or other experts in the field. This helps to ensure the validity and reliability of the findings.
• Write the report: The final step is to write the report of the case study research. The report should provide a clear description of the case study phenomenon, the research questions, the data collection methods, the data analysis, the findings, and the conclusions. The report should be written in a clear and concise manner and should follow the guidelines for academic writing.

Examples of Case Study

Here are some examples of case study research:

• The Hawthorne Studies : Conducted between 1924 and 1932, the Hawthorne Studies were a series of case studies conducted by Elton Mayo and his colleagues to examine the impact of work environment on employee productivity. The studies were conducted at the Hawthorne Works plant of the Western Electric Company in Chicago and included interviews, observations, and experiments.
• The Stanford Prison Experiment: Conducted in 1971, the Stanford Prison Experiment was a case study conducted by Philip Zimbardo to examine the psychological effects of power and authority. The study involved simulating a prison environment and assigning participants to the role of guards or prisoners. The study was controversial due to the ethical issues it raised.
• The Challenger Disaster: The Challenger Disaster was a case study conducted to examine the causes of the Space Shuttle Challenger explosion in 1986. The study included interviews, observations, and analysis of data to identify the technical, organizational, and cultural factors that contributed to the disaster.
• The Enron Scandal: The Enron Scandal was a case study conducted to examine the causes of the Enron Corporation’s bankruptcy in 2001. The study included interviews, analysis of financial data, and review of documents to identify the accounting practices, corporate culture, and ethical issues that led to the company’s downfall.
• The Fukushima Nuclear Disaster : The Fukushima Nuclear Disaster was a case study conducted to examine the causes of the nuclear accident that occurred at the Fukushima Daiichi Nuclear Power Plant in Japan in 2011. The study included interviews, analysis of data, and review of documents to identify the technical, organizational, and cultural factors that contributed to the disaster.

Application of Case Study

Case studies have a wide range of applications across various fields and industries. Here are some examples:

Business and Management

Case studies are widely used in business and management to examine real-life situations and develop problem-solving skills. Case studies can help students and professionals to develop a deep understanding of business concepts, theories, and best practices.

Case studies are used in healthcare to examine patient care, treatment options, and outcomes. Case studies can help healthcare professionals to develop critical thinking skills, diagnose complex medical conditions, and develop effective treatment plans.

Case studies are used in education to examine teaching and learning practices. Case studies can help educators to develop effective teaching strategies, evaluate student progress, and identify areas for improvement.

Social Sciences

Case studies are widely used in social sciences to examine human behavior, social phenomena, and cultural practices. Case studies can help researchers to develop theories, test hypotheses, and gain insights into complex social issues.

Law and Ethics

Case studies are used in law and ethics to examine legal and ethical dilemmas. Case studies can help lawyers, policymakers, and ethical professionals to develop critical thinking skills, analyze complex cases, and make informed decisions.

Purpose of Case Study

The purpose of a case study is to provide a detailed analysis of a specific phenomenon, issue, or problem in its real-life context. A case study is a qualitative research method that involves the in-depth exploration and analysis of a particular case, which can be an individual, group, organization, event, or community.

The primary purpose of a case study is to generate a comprehensive and nuanced understanding of the case, including its history, context, and dynamics. Case studies can help researchers to identify and examine the underlying factors, processes, and mechanisms that contribute to the case and its outcomes. This can help to develop a more accurate and detailed understanding of the case, which can inform future research, practice, or policy.

Case studies can also serve other purposes, including:

• Illustrating a theory or concept: Case studies can be used to illustrate and explain theoretical concepts and frameworks, providing concrete examples of how they can be applied in real-life situations.
• Developing hypotheses: Case studies can help to generate hypotheses about the causal relationships between different factors and outcomes, which can be tested through further research.
• Providing insight into complex issues: Case studies can provide insights into complex and multifaceted issues, which may be difficult to understand through other research methods.
• Informing practice or policy: Case studies can be used to inform practice or policy by identifying best practices, lessons learned, or areas for improvement.

Advantages of Case Study Research

There are several advantages of case study research, including:

• In-depth exploration: Case study research allows for a detailed exploration and analysis of a specific phenomenon, issue, or problem in its real-life context. This can provide a comprehensive understanding of the case and its dynamics, which may not be possible through other research methods.
• Rich data: Case study research can generate rich and detailed data, including qualitative data such as interviews, observations, and documents. This can provide a nuanced understanding of the case and its complexity.
• Holistic perspective: Case study research allows for a holistic perspective of the case, taking into account the various factors, processes, and mechanisms that contribute to the case and its outcomes. This can help to develop a more accurate and comprehensive understanding of the case.
• Theory development: Case study research can help to develop and refine theories and concepts by providing empirical evidence and concrete examples of how they can be applied in real-life situations.
• Practical application: Case study research can inform practice or policy by identifying best practices, lessons learned, or areas for improvement.
• Contextualization: Case study research takes into account the specific context in which the case is situated, which can help to understand how the case is influenced by the social, cultural, and historical factors of its environment.

Limitations of Case Study Research

There are several limitations of case study research, including:

• Limited generalizability : Case studies are typically focused on a single case or a small number of cases, which limits the generalizability of the findings. The unique characteristics of the case may not be applicable to other contexts or populations, which may limit the external validity of the research.
• Biased sampling: Case studies may rely on purposive or convenience sampling, which can introduce bias into the sample selection process. This may limit the representativeness of the sample and the generalizability of the findings.
• Subjectivity: Case studies rely on the interpretation of the researcher, which can introduce subjectivity into the analysis. The researcher’s own biases, assumptions, and perspectives may influence the findings, which may limit the objectivity of the research.
• Limited control: Case studies are typically conducted in naturalistic settings, which limits the control that the researcher has over the environment and the variables being studied. This may limit the ability to establish causal relationships between variables.
• Time-consuming: Case studies can be time-consuming to conduct, as they typically involve a detailed exploration and analysis of a specific case. This may limit the feasibility of conducting multiple case studies or conducting case studies in a timely manner.
• Resource-intensive: Case studies may require significant resources, including time, funding, and expertise. This may limit the ability of researchers to conduct case studies in resource-constrained settings.

About the author

Muhammad Hassan

Researcher, Academic Writer, Web developer

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The Case for Strong Family and Community Engagement in Schools

• Posted March 21, 2023
• By Elizabeth M. Ross
• Families and Community
• K-12 School Leadership

About 50 years of research has revealed the striking benefits of schools actively partnering with families to improve their children’s learning. For some educators though, it was not until COVID-19 blew the doors off their schools and the walls off their classrooms that the penny dropped, as Sonja Santelises, CEO the Baltimore public schools and Harvard Graduate School of Education alum, described in Education Week that first bleak winter of the pandemic.

“During the pandemic, educators realized that families knew a lot more about teaching and learning than they had given them credit for,” especially when it came to understanding the needs of their own children, explained Karen Mapp , a senior lecturer at HGSE. She recently shared some of Santelises’ insights and many of her own during a virtual event about effective family and community engagement, hosted by the Harvard Graduate School of Education’s EdRedesign Lab . “Now, a lot of educators want to know more about how to engage families because of the lessons that they learned during COVID,” Mapp added.

Mapp, a renowned family engagement specialist who said she has encountered a fair share of resistance to her ideas over the years, makes a strong case for them in the new book Everyone Wins! The Evidence for Family-School Partnerships & Implications for Practice . She and co-authors Anne Henderson, Stephany Cuevas, Martha Franco, and Suzanna Ewert dive into the latest research and drill down on the same question that senior citizen Clara Peller asked in the infamous 1984 Wendy’s commercial, as Mapp recalled with a chuckle, “Where’s the beef?” In other words, for any remaining skeptics, who benefits from effective family-school-community partnerships and what is the return on their investment?

As the title of Mapp’s book suggests, the answer is everyone:

• Students who enjoy higher grades, better engagement and attendance at school, greater self-esteem, and higher rates of graduation and college/ post-secondary enrollment.
• Educators who have increased job satisfaction, greater success in motivating and engaging with students from different backgrounds, more support from families, and an improved mindset about students and families.
• Families that enjoy stronger relationships with their children, better rapport with educators, and that can navigate their school systems, advocate for their children, and feel less isolated.
• Schools because of improved staff morale and school climate, greater retention of teachers, and more support from the broader community.
• School districts and communities , which become better places to live and raise children in, have students with fewer suspensions and high-risk behaviors, greater participation in afterschool programs, and expanded family and youth involvement in decision-making.

"This is love-work, [you must] love fully the families and the children and communities you serve."

Mapp, a former deputy superintendent for family and community engagement in the Boston Public Schools, shared the following strategies for putting effective partnership into practice:

•    Successful family engagement requires resources, infrastructure, and leadership.

Parent and community ties need to be an essential ingredient, not an add-on. “It’s real when I see it on your budget sheets,” Mapp explained in the webinar. Collaborate with your community to tap into outside resources as well.

•    Educators need to be intentional about building relationships based on mutual respect and trust.

Schools have not valued all families, especially those in historically underserved communities that have experienced “generational disrespect.” Listen to all parents and offer opportunities to them for leadership. Efforts should focus on students’ learning and development. Effective family engagement is never weaponized.

•    Educators must be trained and supported to work with families from all backgrounds.

“A lot of unlearning has to happen around family and community engagement,” according to Mapp who said some educators have adopted “bad and ineffective strategies” shaped by systemic racism. Context matters and engagement initiatives need to be designed to work at the local level. Home visits may not be appropriate in some communities, for example.

•    Begin reaching out to families when children are young.

Help families navigate the school system from the beginning and continue to engage with them up to college and career. Don’t forget middle and high school parents who need help supporting their students as well, albeit in different ways than younger children.

•    Communicate clearly and consistently.

Messages need to be accessible to everyone, including families who speak different languages.

•    Don’t forget equity.

Educators should be sensitive about the realities of busy family life, including parents’ work demands and childcare concerns. Immigrant families can also face unique challenges.

•    Show some love.

Student-centered schools focus on what is best for the children and the community, not just the educators. “This is love-work,” explained Mapp. You must “love fully the families and the children and communities you serve.”

Additional resources:

• The Dual Capacity-Building Framework for Family-School Partnerships
• A Family Engagement Framework for All, Usable Knowledge
• Supporting Success Through Authentic and Effective Family and Community Engagement, EdRedesign Lab
• Making Schools a Welcoming Place for Immigrant Students, Usable Knowledge

Usable Knowledge

Connecting education research to practice — with timely insights for educators, families, and communities

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Pivoting to Meet the Moment: A Case Study of Community Organizing Amid the COVID-19 Pandemic

In 2019, Community Catalyst launched a project in partnership with three advocacy organizations aimed at organizing their local communities, primarily communities of color, to influence health systems to be more responsive to community needs.

With support from Community Catalyst, they sought to: identify a community-driven policy agenda; work with local health care institutions to strengthen community engagement; and advance public policies that support community engagement in health care.

The COVID-19 pandemic impacted both the relationships each organization had with health systems and the way they could organize their communities.

Additionally, the movement in support of Black lives opened new opportunities for more explicit conversations about racial justice and health equity. Each organization adapted its work to address the emerging crises in their communities, and Community Catalyst supported partners’ strategies to be both flexible and resilient in responding to community needs.

While the specific details and milestones of each project changed, each partner successfully forged deep relationships with community members, other community-based organizations, and health systems.

This case study highlights community resilience and illustrates the importance of adapting projects — including project funding — to enable organizations to respond to community priorities, especially among indigenous, immigrant, AAPI, Latinx, low-income and justice-involved communities.

Get Involved

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What the Case Study Method Really Teaches

• Nitin Nohria

Seven meta-skills that stick even if the cases fade from memory.

It’s been 100 years since Harvard Business School began using the case study method. Beyond teaching specific subject matter, the case study method excels in instilling meta-skills in students. This article explains the importance of seven such skills: preparation, discernment, bias recognition, judgement, collaboration, curiosity, and self-confidence.

During my decade as dean of Harvard Business School, I spent hundreds of hours talking with our alumni. To enliven these conversations, I relied on a favorite question: “What was the most important thing you learned from your time in our MBA program?”

• Nitin Nohria is the George F. Baker Jr. and Distinguished Service University Professor. He served as the 10th dean of Harvard Business School, from 2010 to 2020.

Partner Center

Website maintenance is planned from 8:00 a.m. CDT Saturday, July 6 through 5:00 p.m. CDT Sunday, July 7. Temporary disruptions may occur during this time.

This supplement is sponsored by the American Academy of Family Physicians. The project has been made possible with funding from Bristol Myers Squibb.

BRIAN FORREST, MD, CASEY WILLIAMS, MD, MARSHA BROUSSARD, DrPH, MPH, TIFFANY HILL, MD, WHITNEY KIRKMAN, PBT-ASCP, MA, AND RAJANI BHARATI, PhD, MPH

Fam Pract Manag. 2023;30(2):29-34

Cardiovascular disease (CVD) is the leading cause of mortality and morbidity in the United States. 1 Approximately one in five deaths is due to CVD, and the United States spends around $229 billion each year on CVD-related care and productivity losses. 2 Though the mortality rate due to CVD is decreasing, racial disparities in outcomes have persisted, mainly driven by the complex interplay of social determinants of health (SDoH) and structural racism. 3 , 4

Beginning in March 2021, the American Academy of Family Physicians (AAFP) implemented a two-year project to address cardiovascular disparities in African American communities, with a focus on atrial fibrillation (AFib). The project utilized a clinic-community partnership model within which family physicians and their health care teams explored the needs of their communities and leveraged the resulting information to foster innovative ideas and work with community partners to reduce cardiovascular disparities.

Three family medicine practices participated in the project:

Access Healthcare, a direct primary care (DPC) clinic in Apex, North Carolina

DePaul Community Health Centers (DCHC), a federally qualified health center (FQHC) network in New Orleans, Louisiana

Trenton Medical Center dba Palms Medical Group, an FQHC in Trenton, Florida

A physician expert and the Prevention Institute trained the participating family physicians and their care teams on topics such as AFib detection and management; disparities in cardiovascular care and outcomes; SDoH and health equity; and community engagement. Applying insights from this training, each practice used patient surveys and in-depth interviews to assess their community's needs. They also conducted environmental scans to identify existing community resources (e.g., community needs assessment reports, community health improvement plans) and possible public health partners. An action planning workshop was held in collaboration with the University of Kansas to help practices develop interventions based on their assessment findings. The practices subsequently implemented these interventions. The AAFP assisted with the institutional review board (IRB) application, design of data collection instruments, and data analysis.

The project was completed in February 2023. While the full impact of this project has not yet been evaluated, the following case studies describe each participating practice's experiences and what they learned on their unique journey from needs assessment to interventions.

CASE STUDY 1:

Access healthcare, brian forrest, md, and whitney kirkman, pbt-ascp, ma.

Access Healthcare is a DPC safety-net practice, and 40% of our patients are uninsured. Between April and May of 2022, we surveyed 58 patients and conducted in-depth interviews with three patients. It was challenging to get people to complete a patient survey and even more challenging to engage them in lengthy interviews, but it was heartening to get positive feedback about our practice. Through the assessment, we learned that our patients' biggest concern about getting cardiovascular care was out-of-pocket costs for labs, visits, and medication. During interviews, our patients also described the bias they experienced in other health care settings. Learning about ways that discrimination, bias, and lack of food and transportation resources impacted patients' access to care changed our perspective.

We also conducted interviews with local community leaders from the African Methodist Episcopal (AME) Church, the North Carolina Medical Society, and an Alliance for Health Equity Grant organization, as well as with insurance company executives and hospital system CEOs. These interviews focused on finding out how we could more effectively improve health equity and decrease disparities. Fixing a problem starts with innovation, so the ideas generated for this project were aimed at improving in three focus areas.

Improve the structural determinants of health, such as inequities in power or status: For this focus area, we reimagined and redirected health care media content, such as Access Health Radio, a live AM/FM radio show and podcast focused on cardiovascular topics. To improve health literacy through education, we made this programming available through more accessible platforms. We also convened community-driven educational sessions to increase health literacy and awareness of CVD. For example, we partnered with AME Church leaders to broadcast live question-and-answer sessions on CVD that were available to the public across our state. Additionally, we identified and addressed patients' barriers to accessing transportation, food, and exercise resources by creating a set of standardized screening questions for use during check-in at our practice.

Advocate for policies across all settings that advance greater health equity: These policies were aimed at increasing awareness and education regarding SDoH and inequities in our community, as well as addressing these issues. We worked with policymakers at the North Carolina Leadership Forum to identify solutions to alleviate inequities, with a focus on food deserts, transportation problems, barriers to access to expanded Medicaid and insurance options, and caps on Supplemental Nutrition Assistance Program (SNAP) benefits for healthy food options. We also advocated for resources to support community-driven transportation solutions, such as free public transportation or rideshare vouchers.

Target service disparities and inequities in health care access and quality: We started by routinely assessing the affordability of medications and follow-up care and intervening when necessary, and we applied Plan-Do-Study-Act (PDSA) quality improvement cycles to see what impact we were having. One of our ideas was partnering with a national mail-order pharmacy to create a program that offers a $30 monthly cap on all generic medication shipped at no cost to our patients. This program is now available nationwide for practices that want to participate. We also created a $35 subscription plan in the DPC model 5 , 6 for patients with AFib and CVD. All coagulation testing and visits and consultations with an in-house clinical practicing pharmacist (PharmD) were made available at no additional charge for medical optimization. We also advocated for lower costs and improved access and quality for all patients, and we continue to look for ways to accomplish these goals.

Through this project, we learned the importance of meeting people where they are rather than where we expect them to be. We also learned that the process of working with community leaders and bridging ideological gaps was more productive than we expected. New legislation, policies, and grant programs are likely to improve CVD disparities. We are now developing a systematic program to assess discrimination bias in health care facilities and reduce it through peer-to-peer coaching and PDSA initiatives that are being funded jointly by Bristol Myers Squibb and Pfizer. We hope to create a self-sustaining nonprofit to offer these assessments and interventions to practices willing to embrace the challenge.

CASE STUDY 2:

Depaul community health centers, casey williams, md, and marsha broussard, drph, mph.

DePaul Community Health Centers is an FQHC network with ten locations in the New Orleans metropolitan area that serve ten distinct communities. With an enrollment of over 50,000 patients, DCHC provides a comprehensive range of services for all ages, including prevention and primary health care, prenatal and pediatric care, dental and optometry care, and mental and behavioral health care. We also administer the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) for families with food insecurity. DCHC serves some of the city's most vulnerable patients, including a majority African American population that experiences disparities in CVD treatment and outcomes. With its focus on reducing AFib health disparities, this project gave DCHC the opportunity to obtain feedback from our affected population and work with colleagues across the country to explore innovations in primary prevention.

Our project began with a community needs assessment that was conducted at one of the DCHC locations and included three components:

A survey of patients experiencing cardiovascular health issues: The primary objective of the survey was to obtain feedback from our cardiovascular patients regarding the quality of care at DCHC, barriers to accessing care, and concerns regarding their medications. The survey also collected demographic information (e.g., income, education, employment) to inform our analysis.

Interviews of patients with cardiovascular health issues: A DCHC physician conducted these interviews with his patients to delve deeper into cultural and environmental factors that influence patients' health conditions.

Interviews of community organizations with a mission to address the need for healthy food and promote physical activity: Two of the project coordinators conducted interviews with seven community agencies to create understanding, promote alignment, and identify local resources available to help DCHC patients improve their cardiovascular health.

The survey showed that our patients' primary concerns in getting cardiovascular care were appointment scheduling issues and out-of-pocket costs for labs/visits, medication, and transportation. The interview findings were very interesting because patients in different age groups had varied perspectives. For instance, patients in their 40s were concerned with the interventions necessary to improve health and prolong longevity. They wanted improvements in neighborhood walkability and access to local parks for exercise. Patients in their 60s had concerns related to navigating the health care system. In particular, they noted that insurance determines what options are available for medical devices (e.g., hearing aids), and there can be drastic differences in the quality of these options. Patients in this age group were also concerned about how the expansion of medical facilities would affect the character of their neighborhood. They wondered how these facilities would benefit the area's long-term residents before and after establishing their presence and whether interventions would be implemented equitably. Patients in their 80s expressed concern about their neighborhood's changing demographics and the impacts of gentrification. Specifically, they mentioned that the types of vendors and options available locally had changed over time, as well as citing increased food prices and a lack of places to park.

Based on our assessments of needs and feasibility, we offered a series of three educational sessions to provide information on the prevention of AFib, which has some modifiable risk factors. We offered information on AFib risk factors, epidemiology, symptoms, and prevention. To support lifestyle interventions, we engaged with several community organizations: the American Heart Association for educational resources; New Orleans Recreation Development Commission for access to exercise facilities; and Sankofa Community Development Corporation for healthy food options, such as fresh produce. Based on the individual patient's determination of their concerns and needs, we provided contact information so they could pursue the opportunities these community resources offered to optimize heart health. We faced some timing and location challenges when executing our educational events. In consideration of accessibility and patients' schedules, we offered the sessions at the end of the day at our clinic facility. However, the topics and concerns covered could have been more conveniently addressed via a virtual health meeting. In the future, we may implement this change in how we deliver and design our outreach programs for CVD prevention.

We plan to provide more information about the medication assistance we offer and to do more outreach with our health coach program and chronic care management (CCM) team. Steps we have taken to identify patients who may benefit from our health coaches and CCM program include identifying SDoH and overutilization of emergency department services. To sustain our model for the practice, we plan to have sessions that recur monthly/quarterly to reinforce and remind our population about the importance of AFib prevention and the availability of existing community resources.

CASE STUDY 3:

Trenton medical center dba palms medical group, tiffany hill, md.

Palms Medical Group is an FQHC with 12 locations throughout northeast Florida, including Trenton Medical Center, which is located on the outskirts of Jacksonville, Florida. The center provides a full range of medical services to patients with commercial and public insurance and to patients who are uninsured. When this project began, the medical group had a partnership with Orange Park Family Medicine Residency Program, and I had dual responsibility as both a clinician at Trenton Medical Center and faculty for the residency program. My interest in participating in this project stemmed from my desire for both academic development and attainment of a more tangible approach to addressing the community's medical needs.

Assessment of our African American patients' perception of health care was obtained via qualitative measures (i.e., in-depth interviews) and quantitative measures (i.e., survey accessed via QR code) during April and May of 2022. Although the patient survey had a low response rate, we obtained comprehensive perspective through our in-depth patient interviews. As an FQHC, we can provide affordable medications to our uninsured patients through the 340B Drug Pricing Program. But despite measures in place to help them overcome financial obstacles, an overwhelming number of surveyed patients reported that out-of-pocket cost of medication was one of their primary concerns about getting cardiovascular-related care. Additionally, almost 40% of the surveyed patients stated that concern about adverse effects was a barrier to taking medications. The qualitative data revealed that our African American patients want to focus on mitigating CVD through a healthy diet and physical activity and showed how structural determinants (e.g., community context, living or working conditions) affect their ability to adopt a healthy lifestyle.

In-person interviews offered a useful perspective on the large impact relationships can have on health care. Patients were more inclined to participate and engage with physicians they trusted. Numerous patients repeated the themes of community and education. Motivated by altruism, they wanted to empower other African American individuals. Specifically, they expressed the importance of instilling awareness of early CVD detection and preventive care. For example, one patient with a history of CVD explained their impetus for participating in the interview by saying, “I want to help someone know what to look for before something like that happens, so they don't have to go through what I have.” Additionally, the interviewees emphasized the significance of family history, advocacy, and accountability.

Unfortunately, our momentum came to a halt when the relationship between Orange Park Family Medicine Residency Program and Palms Medical Group dissolved, but the project was transitioned to the residency program. To expand our outreach to the African American community, we have partnered with a new free clinic that provides sexually transmitted infection (STI) testing in the inner city of Jacksonville. We will provide screenings for risk factors of CVD, hypertension, diabetes, and hyperlipidemia. Patients will be connected with an insurance broker to help them obtain affordable insurance.

Partnering with local food banks and urban farms will help us facilitate lifestyle changes that can reduce cardiovascular risk. Additionally, we will identify patients whose passion for health and community engagement aligns with ours, and they will serve as liaisons by providing outreach via community events and social media. We hope this will improve trust and intracommunity education. Further education on CVD will occur through small groups conducted by family medicine residents. The residency program has implemented a lifestyle medicine residency curriculum that gives residents the necessary tools for educating and guiding patients.

We did encounter some challenges in strategizing and finding ways to create more community engagement. Development of partnerships and solutions that would create a sustainable construct to address the community's needs did not align with my clinic's goals. Despite my personal passion for this project's focus, organizational buyin was lacking. However, the formation of a new partnership allowed me to achieve project aims.

KEY TAKEAWAYS

Make an impact on improving health equity by reducing barriers created by SDoH.

Identify your community's needs and explore community resources in your area. Counties often already have community needs assessment reports and community health improvement plans.

Connect with patients and listen to their input. It can be an enlightening experience.

Form community partnerships or engage in existing community coalitions to link your patients with resources.

Meet members of your community where they are. It is not productive to provide information and patient education via formats or platforms that your patients do not use or see.

Offer information in a variety of ways (e.g., audiovisual content, paper packets, internet links, text messages) to improve access and maintain awareness.

Be mindful of patient concerns about access and expense. Modify management based on need, if necessary.

Establish organizational goals that align with a commitment to building sustainable relationships within the community.

Be innovative and customize solutions that meet the needs of your community and practice. You can improve the care you provide and your patients' outcomes by improving health literacy, increasing access to affordable care and medications, and advocating locally for policy solutions to help ameliorate the impacts of SDoH. Keep in mind that the same solutions may not work in all locations.

CDC – Office of Minority Health & Health Equity (OMHHE)

This project has been made possible with funding from Bristol Myers Squibb. | © 2023 American Academy of Family Physicians. All rights reserved.

HOP22121387

Virani SS, Alonso A, Aparicio HJ, et al. Heart disease and stroke statistics—2021 update: a report from the American Heart Association. Circulation . 2021;143(8):e254-e743.

Center for Disease Control and Prevention. Heart disease facts. October 14, 2022. Accessed November 18, 2022. https://www.cdc.gov/heartdisease/facts.htm

Mazimba S, Peterson PN. JAHA spotlight on racial and ethnic disparities in cardiovascular disease. J Am Heart Assoc . 2021;10(17):e023650.

Singh GK, Siahpush M, Azuine RE, et al. Widening socioeconomic and racial disparities in cardiovascular disease mortality in the United States, 1969–2013. Int J MCH AIDS . 2015;3(2):106-118.

Sprey E. New practice models are gaining acceptance in primary care. Physicians Practice. August 20, 2014. Accessed December 13, 2022. https://www.physicianspractice.com/view/new-practice-models-are-gaining-acceptance-primary-care

Forrest B. New primary-care models can change the way you practice medicine. Physicians Practice. December 7, 2011. Accessed December 13, 2022. https://www.physicianspractice.com/view/new-primary-care-models-can-change-way-you-practice-medicine

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Revitalized Public Spaces: Fostering Human Connections in Cities

• Written by Paula Pintos
• Published on August 18, 2020

Public space has always been a top priority in every city’s urban planning agenda and given today’s world context, these urban spaces have emerged as fundamental elements of cities and neighborhoods. Plazas, squares, and parks, undeniable necessities in the urban fabric, have become, today, more vital than ever.

Not only do these spaces have a positive impact on health, but they generate recreational space to exercise, play, meet, and socialize with others. In addition, quality public and open spaces are key in generating human connections within cities’ neighborhoods. Having an open space to enjoy, certainly prompts a sense of community and belonging to one’s own proximate environment, whilst creating positive psychological effects by establishing relationships between members of the community. 

To provide people with accessible, human-centered, quality spaces, cities have sought help from architects. In fact, the high demand for these types of places required excellent design and architectural value. Below is a selection of projects that have successfully regenerated existing urban spaces and transformed them into active and vibrant squares, plazas, and riverfronts.

Israels Plads Square / Cobe + Sweco Architects

The plaza also works as a transition between two worlds, the city, and the neighboring park. The landscape character of the park continues into the plaza in the form of the organic pattern of trees. Towards east and west, the plaza is raised up and folded to provide niches. In addition, it has a sculptural expression that refers to its historical past as part of the fortifications. The surface functions as a large urban playground and a space for activity. The idea with the new Israels Plads is to celebrate the significance and the history of the site and revitalize it, turning it into a vibrant, diverse plaza for all kinds of people - for leisure, culture, activity and public events.

Superblock of Sant Antoni / Leku Studio

A people-centred planning that offers the opportunity to gain new public spaces by creating proximity squares in the chamfer corners and green-healthy streets where previously there were cars. Where previously there was an urban highway, now there is a healthy street full of life and green, where there was a traffic intersection now there is a liveable plaza. Car noise has been replaced by children playing, cheerful conversations between neighbours or elderly people chess games ... The transformation continues together with this flexible landscape capable of integrating new changes derived from urban testing and social innovation.

V-Plaza Urban Development / 3deluxe architecture

What was previously a largely unused space adjoined by historical buildings is now becoming a new, inviting public amenity where you can casually enjoy a coffee in your lunch break or get some work done outdoors while children play in the water, young people skate and students relax in the sun… The real challenge was to preserve cultural heritage while creating space for social transformation. And the solution was innovative architecture that caters to the needs of today’s society: bright, friendly, open, and connecting.

Memory of the Land / NODE Architecture & Urbanism

Based on thorough field investigation, the following strategies were proposed: 1. Separate pedestrians from vehicular traffic to give way to slow-traffic circulation and ensure safe daily trips of residents; 2. Highlight the functional characteristics of each public space and simplify/enhance the existing site as needed; 3. Enhance the slow-traffic loop and public experience, and link up the industrial exhibition area, river landscape, community park, market, theater, and buildings of different historical periods to offer diverse daily experience.

Azatlyk, Central Square of Naberezhnye Chelny / DROM

We transformed the square into a captivating, dynamic public space with multi-character environments and qualities that are inclusive of different groups of people. In place of the former central axis, we created a “city carpet” that functions as three squares, each with its own unique character: The Event Square is a paved urban space that is also used for weekly outdoor markets. The “Green Square” is for relaxing on the lawn and enjoying the seasonal landscaping by the city’s planting department. The Cultural Square has a renovated fountain and a new shallow pool for playing in water on hot days. This square is connected to the municipality and a movie theater that is located inside.  

Skanderbeg Square / 51N4E

The project’s landscaping was studied anew, and turned into a local ecosystem anticipating the creation of a new urban ecology for the city. Local species were chosen to increase the system’s natural resistance by reacting to ongoing climate change. Trees, shrubs and perennials were combined to foster urban biodiversity and control the city center’s microclimate. Albania’s nature’s richness in diverse species and varieties is thus valorized, allowing public space to assume bot recreational and educative functions.

Tainan Spring / MVRDV

The mall’s underground parking level has been transformed into a sunken public plaza dominated by an urban pool and verdant local plants and surrounded by a shadowed arcade. The pool has been carefully planned to be a perfect gathering spot for all seasons: the water level will rise and fall in response to the rainy and dry seasons, and in hot weather mist sprayers will reduce the local temperature to provide welcome relief to visitors, reducing the use of air conditioning in the summer months. This space hosts playgrounds, gathering spaces, and a stage for performances, while the artful deconstruction of the building’s concrete frame has left a number of follies that can in due course be converted to shops, kiosks, and other amenities.

Victoria on the River / Edwards White Architects

 At a macro level, the design seeks to establish a park that serves two functions. Firstly, as a destination where people can pause, interact, and enjoy river views. Secondly as a device that links the disparate levels of the lower river path, upper promenade, and main street. For some, it’s a space to play, for some a place to contemplate, a place to find solitude or a place to be in community. For others, it’s a means of access or a place to exercise. A new market, concerts, yoga classes, boot camps, skateboarders, meeting friends to eat together, all occupy this space. Sitting down in the park and overhearing both young and old as they discover it for the first time is a real joy.

Niederhafen River Promenade / Zaha Hadid Architects

With construction of all phases now complete, the redevelopment of Hamburg ’s Niederhafen flood protection barrier re-connects its river promenade with the surrounding urban fabric of the city; serving as a popular riverside walkway while also creating links with adjacent neighbourhoods. A minimum width of ten metres ensures this popular riverside promenade offers generous public spaces for pedestrians, joggers, street performers, food stalls and cafes. Shops and public utilities are also accommodated within the structure at street level facing the city. Wide staircases resembling small amphitheatres are carved within the flood protection barrier at points where streets from the adjacent neighbourhoods meet the structure; giving passers-by at street level views of the people strolling along the promenade at the top of the barrier as well as views of the masts and superstructures of ships in the Elbe.

Note: The quoted texts are excerpts from the archived descriptions of each project, previously sent by the architects. Find more reference projects in this My ArchDaily folder created by the author.

This article is part of the ArchDaily Topic: How Will We Live Together . Every month we explore a topic in-depth through articles, interviews, news, and projects. Learn more about our monthly topics here . As always, at ArchDaily we welcome the contributions of our readers; if you want to submit an article or project, contact us .

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• Volume 21, Issue 1
• What is a case study?
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• Roberta Heale 1 ,
• Alison Twycross 2
• 1 School of Nursing , Laurentian University , Sudbury , Ontario , Canada
• 2 School of Health and Social Care , London South Bank University , London , UK
• Correspondence to Dr Roberta Heale, School of Nursing, Laurentian University, Sudbury, ON P3E2C6, Canada; rheale{at}laurentian.ca

https://doi.org/10.1136/eb-2017-102845

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What is it?

Case study is a research methodology, typically seen in social and life sciences. There is no one definition of case study research. 1 However, very simply… ‘a case study can be defined as an intensive study about a person, a group of people or a unit, which is aimed to generalize over several units’. 1 A case study has also been described as an intensive, systematic investigation of a single individual, group, community or some other unit in which the researcher examines in-depth data relating to several variables. 2

Often there are several similar cases to consider such as educational or social service programmes that are delivered from a number of locations. Although similar, they are complex and have unique features. In these circumstances, the evaluation of several, similar cases will provide a better answer to a research question than if only one case is examined, hence the multiple-case study. Stake asserts that the cases are grouped and viewed as one entity, called the quintain . 6  ‘We study what is similar and different about the cases to understand the quintain better’. 6

The steps when using case study methodology are the same as for other types of research. 6 The first step is defining the single case or identifying a group of similar cases that can then be incorporated into a multiple-case study. A search to determine what is known about the case(s) is typically conducted. This may include a review of the literature, grey literature, media, reports and more, which serves to establish a basic understanding of the cases and informs the development of research questions. Data in case studies are often, but not exclusively, qualitative in nature. In multiple-case studies, analysis within cases and across cases is conducted. Themes arise from the analyses and assertions about the cases as a whole, or the quintain, emerge. 6

Benefits and limitations of case studies

If a researcher wants to study a specific phenomenon arising from a particular entity, then a single-case study is warranted and will allow for a in-depth understanding of the single phenomenon and, as discussed above, would involve collecting several different types of data. This is illustrated in example 1 below.

Using a multiple-case research study allows for a more in-depth understanding of the cases as a unit, through comparison of similarities and differences of the individual cases embedded within the quintain. Evidence arising from multiple-case studies is often stronger and more reliable than from single-case research. Multiple-case studies allow for more comprehensive exploration of research questions and theory development. 6

Despite the advantages of case studies, there are limitations. The sheer volume of data is difficult to organise and data analysis and integration strategies need to be carefully thought through. There is also sometimes a temptation to veer away from the research focus. 2 Reporting of findings from multiple-case research studies is also challenging at times, 1 particularly in relation to the word limits for some journal papers.

Examples of case studies

Example 1: nurses’ paediatric pain management practices.

One of the authors of this paper (AT) has used a case study approach to explore nurses’ paediatric pain management practices. This involved collecting several datasets:

Observational data to gain a picture about actual pain management practices.

Questionnaire data about nurses’ knowledge about paediatric pain management practices and how well they felt they managed pain in children.

Questionnaire data about how critical nurses perceived pain management tasks to be.

These datasets were analysed separately and then compared 7–9 and demonstrated that nurses’ level of theoretical did not impact on the quality of their pain management practices. 7 Nor did individual nurse’s perceptions of how critical a task was effect the likelihood of them carrying out this task in practice. 8 There was also a difference in self-reported and observed practices 9 ; actual (observed) practices did not confirm to best practice guidelines, whereas self-reported practices tended to.

Example 2: quality of care for complex patients at Nurse Practitioner-Led Clinics (NPLCs)

The other author of this paper (RH) has conducted a multiple-case study to determine the quality of care for patients with complex clinical presentations in NPLCs in Ontario, Canada. 10 Five NPLCs served as individual cases that, together, represented the quatrain. Three types of data were collected including:

Review of documentation related to the NPLC model (media, annual reports, research articles, grey literature and regulatory legislation).

Interviews with nurse practitioners (NPs) practising at the five NPLCs to determine their perceptions of the impact of the NPLC model on the quality of care provided to patients with multimorbidity.

Chart audits conducted at the five NPLCs to determine the extent to which evidence-based guidelines were followed for patients with diabetes and at least one other chronic condition.

The three sources of data collected from the five NPLCs were analysed and themes arose related to the quality of care for complex patients at NPLCs. The multiple-case study confirmed that nurse practitioners are the primary care providers at the NPLCs, and this positively impacts the quality of care for patients with multimorbidity. Healthcare policy, such as lack of an increase in salary for NPs for 10 years, has resulted in issues in recruitment and retention of NPs at NPLCs. This, along with insufficient resources in the communities where NPLCs are located and high patient vulnerability at NPLCs, have a negative impact on the quality of care. 10

These examples illustrate how collecting data about a single case or multiple cases helps us to better understand the phenomenon in question. Case study methodology serves to provide a framework for evaluation and analysis of complex issues. It shines a light on the holistic nature of nursing practice and offers a perspective that informs improved patient care.

• Gustafsson J
• Calanzaro M
• Sandelowski M

Competing interests None declared.

Provenance and peer review Commissioned; internally peer reviewed.

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Empirical Research

The importance of community in fostering change: a qualitative case study of the rigorous research in engineering education (rree) program.

• Cheryl Allendoerfer
• Ruth Streveler
• Juan Ortega-Alvarez
• Cheryl Allendoerfer , Shoreline Community College, United States
• Ruth Streveler , Purdue University, United States
• Juan Ortega-Alvarez , Universidad EAFIT, Colombia
• Karl Smith , Purdue University, United States
• Page/Article: 20–37
• DOI: 10.21061/see.7
• Accepted on 2 Jul 2020
• Published on 9 Oct 2020
• Peer Reviewed

National League of Cities’ Case Study on Community Violence Intervention in Chicago

This case study from the National League of Cities (NLC) highlights the Rapid Employment and Development Initiative (READI Chicago) and cites the Crime Lab’s analysis showing a 79 percent reduction in READI participants’ shooting or homicide arrests.

This case study is part of the Reimagining Public Safety Impact Updates Resource , which highlights successful programs in cities, towns and villages across the country. View the NLC’s Reimagining Public Safety Initiative page to learn more about their work in creating safe, equitable communities for all.

See All Resources

Predicting and Preventing Gun Violence: An Experimental Evaluation of READI Chicago – Final Paper

Learn more about the technical details of the READI study.

READI Policy Brief

Read more about our preliminary findings.

Community Violence Intervention (CVI) Leadership Academy Spotlight

Watch violence prevention experts speak to the significance of our CVI Leadership Academy in this short video.

2024 Video: Community Violence Intervention Leadership Academy (CVILA) Inaugural Cohort

Watch our latest video about the inaugural cohort of the CVILA.

Latest Updates

See All Updates

A New Way To Address Gun Violence You’ve Never Heard Of

Former Chief of the Los Angeles Police Department Charlie Beck, Crime Lab Faculty Director Jens Ludwig, and CVILA Executive Director Dr. Chico Tillmon penned this Newsweek op-ed on the importance of raising awareness about community violence interventions and how they can be used to continue the gun violence reduction trends we saw in 2023.

Vice President Kamala Harris Recognizes the CVILA at White House Ceremony

On February 9, 2024 Vice President Kamala Harris recognized the work of the University of Chicago Crime Lab’s Community Violence Intervention Leadership Academy (CVILA) at an event that will acknowledged the accomplishments of its inaugural cohort at the White House.

UChicago Launches Initiative to Help Combat Gun Violence Across America

In this piece, Tacuma Roeback, Managing Editor of the Chicago Defender writes about the launch of the Community Violence Intervention Leadership Academy with remarks by Illinois Attorney General Kwame Raoul, former acting Superintendent of the Chicago Police Department Charlie Beck, and CVILA Director Chico Tillmon.

Community-Based Water Management Initiatives: Case Studies And Success Stories

I am pleased to present an article that explores the topic of “Community-Based Water Management Initiatives: Case Studies And Success Stories.” In this article, we will examine a series of case studies highlighting various community-based water management initiatives. By delving into these real-world examples of successful initiatives, we aim to shed light on the importance of community involvement in water management practices. Through this comprehensive overview, we hope to inspire and educate readers about the potential for collaborative efforts to address water challenges in a sustainable and effective manner.

Table of Contents

Overview of Community-Based Water Management

Community-based water management refers to the active involvement and participation of local communities in the planning, decision-making, and implementation of water resource management initiatives within their respective regions. It is a decentralized approach that recognizes the importance of local knowledge, engagement, and ownership in achieving sustainable water management.

Community-based water management plays a crucial role in addressing the challenges of water scarcity, pollution, and inequitable water access. By involving local communities, it ensures that decisions are made considering the specific needs, priorities, and capacities of the people who depend on water resources. This approach promotes inclusivity, enhances social and environmental sustainability, and fosters resilience in the face of changing climate conditions.

While community-based water management has numerous benefits, it also presents challenges that need to be addressed effectively. Limited financial resources, lack of technical expertise, and inadequate institutional support can hinder the successful implementation of community-led initiatives. Additionally, conflicting interests, power dynamics, and unequal access to resources within communities can pose obstacles to achieving collective action for sustainable water management. To overcome these challenges, it is essential to promote capacity building, foster collaboration, and enact supportive policies that empower local communities.

Case Study 1: Farmer-Led Water Conservation

Project description.

In a rural farming community, a farmer-led water conservation project was initiated to address water scarcity and support sustainable agriculture. The project aimed to improve water-use efficiency, reduce wastage, and enhance water availability for irrigation purposes. It involved the installation of modern irrigation systems, the adoption of efficient agricultural practices, and the promotion of water harvesting techniques.

Community Involvement

The success of this project was largely attributed to extensive community involvement. Farmers actively participated in the planning and implementation stages, attending workshops, and receiving training on water-efficient practices. They also established farmer-led water user associations, which facilitated collective decision-making and equitable water allocation.

Results and Impact

The farmer-led water conservation project yielded significant results. Water-use efficiency improved by 30%, leading to higher crop yields and reduced water consumption. The project also brought about a positive change in farmers’ attitudes towards sustainable water management. This initiative not only enhanced agricultural productivity but also contributed to the resilience of the farming community, ensuring their long-term water security.

Case Study 2: Women-Led Water Management

In a predominantly rural community, a women-led water management project aimed to empower women by providing them with access to safe and reliable water sources. Recognizing the critical role women play in water collection and management, this initiative aimed to address gender inequalities, improve women’s living conditions, and promote their active participation in decision-making processes.

Empowering Women

The project empowered women by training them in water management techniques, providing them with tools and resources, and facilitating their participation in water-related decision-making forums. Women were given leadership roles within water user associations, enabling them to influence water management policies and practices.

Sustainable Water Use

Through this project, women actively contributed to sustainable water use practices in their community. They implemented techniques like rainwater harvesting, non-conventional water sources utilization, and water conservation measures. This resulted in improved access to water, reduced water-borne diseases, and enhanced livelihood opportunities for women and their families.

Case Study 3: Indigenous Community Water Rights

In an indigenous community, a water rights project aimed to protect and restore the water-related rights of the community members. Indigenous peoples have historically faced water-related injustices, including the loss of access to traditional water sources. This project sought to address these issues by advocating for policy changes and securing legal recognition of indigenous water rights.

Cultural Perspectives

The project took into consideration the cultural perspectives and traditional knowledge of indigenous communities. It recognized the community’s spiritual and cultural connection to water and aimed to safeguard their rights. Through community consultations and engagement, the project ensured that the voices and concerns of indigenous peoples were heard and incorporated into water management decision-making.

Advocacy and Policy Impact

The water rights project successfully advocated for the recognition of indigenous water rights, leading to the formulation and implementation of policies that protect these rights. This not only restored access to traditional water sources but also affirmed the cultural identity and self-determination of the indigenous community. The project’s success inspired similar initiatives in other indigenous communities, promoting a broader movement for indigenous water rights worldwide.

Case Study 4: Urban Community Rainwater Harvesting

In an urban community facing water scarcity, a rainwater harvesting project was established to address water stress, reduce dependence on external water sources, and enhance urban resilience. The project involved the installation of rainwater collection systems in households, schools, and public buildings, as well as the promotion of water conservation awareness among community members.

Infrastructure and Technology

The project focused on deploying appropriate rainwater harvesting infrastructure and technologies, including rooftop rainwater catchment systems, storage tanks, and filtration systems. The community was engaged through workshops, training sessions, and awareness campaigns to ensure the effective use and maintenance of these systems.

Urban Resilience

Rainwater harvesting not only provided a reliable source of water for the community but also contributed to urban resilience. By reducing reliance on centralized water supply systems, the community became less vulnerable to water shortages during times of drought or other disruptions. The project’s success inspired other urban communities to adopt similar rainwater harvesting practices, promoting sustainable water management at a broader scale.

Success Story 1: Community-Based Water Governance

Collaborative decision-making.

In a region facing water scarcity, a community-based water governance initiative empowered local communities to make collective decisions regarding water allocation and management. This initiative promoted inclusive decision-making through the establishment of water user associations and participatory platforms where community members, experts, and stakeholders could discuss and prioritize water-related issues.

Effective Water Allocation

Through collaborative decision-making, the community successfully allocated water resources in a manner that addressed the needs and preferences of diverse stakeholders. The initiative facilitated equitable distribution, ensuring that water was allocated fairly among different user groups, such as households, agriculture, and industries.

Positive Environmental Outcomes

Community-based water governance led to positive environmental outcomes. By involving local communities in decision-making, the initiative promoted responsible water management practices, including efforts to reduce pollution, protect natural ecosystems, and restore water bodies. The success of this approach demonstrated the potential of community-led initiatives in achieving both social and environmental sustainability.

Success Story 2: Bottom-Up Approach to Water Management

Community empowerment.

A bottom-up approach to water management in a rural community empowered local residents to take ownership of water resource management. By providing training, resources, and technical support, the project empowered community members to become active participants in decision-making processes and take responsibility for the sustainable management of water resources.

Local Knowledge and Innovation

Acknowledging the invaluable knowledge and innovation held by local communities, the initiative encouraged the integration of traditional practices and indigenous knowledge into water management plans. By combining scientific expertise with traditional wisdom, the project fostered innovative solutions that reflected local realities and contributed to the sustainability of water resources.

Sustainable Resource Use

The bottom-up approach resulted in sustainable resource use practices. Community members implemented water-saving techniques, such as drip irrigation and efficient irrigation scheduling, which reduced water waste and increased agricultural productivity. The project’s success highlighted the importance of harnessing local knowledge and empowering communities in achieving sustainable water resource management.

Success Story 3: Building Resilient Communities

Climate change adaptation.

In a coastal community vulnerable to climate change impacts, a community-based water management initiative focused on building resilience to climate-related hazards, such as sea-level rise and increased storm surges. The project involved mapping areas at risk, identifying adaptation measures, and engaging community members in resilience-building activities.

Disaster Preparedness

The initiative prioritized disaster preparedness by implementing early warning systems, conducting evacuation drills, and establishing community response mechanisms. By involving the community in disaster risk reduction and response planning, the project enhanced the community’s capacity to cope with and recover from water-related disasters.

Community Cohesion

Through resilience-building activities, the initiative fostered community cohesion and social capital. Community members worked together to protect their shared resources, ensuring the availability of water for all during times of crisis. This sense of unity and collective action promoted the overall well-being and resilience of the community.

Success Story 4: Water Management for Economic Development

Entrepreneurship and job creation.

A community-based water management project in a rural area focused on utilizing water resources to drive economic development. By providing training and support in water-related entrepreneurship, the project enabled community members to establish businesses that utilized water sustainably, such as small-scale irrigation enterprises, fish farming, and water purification systems.

Improved Livelihoods

The water management project improved the livelihoods of community members by creating employment opportunities and generating income. Small-scale entrepreneurs contributed to local economic growth, while job opportunities in water-related sectors provided an alternative source of income for community members.

Economic Resilience

By diversifying the local economy and reducing dependence on single sectors, the project enhanced the economic resilience of the community. Water management for economic development ensured a more sustainable and stable economic foundation, contributing to the overall well-being and long-term prosperity of the community.

Community-based water management initiatives have demonstrated their effectiveness in addressing water-related challenges, fostering resilience, and promoting sustainable development. From farmer-led water conservation projects to urban rainwater harvesting initiatives, these case studies and success stories highlight the importance of involving local communities in water resource management processes. The key lessons learned include the significance of community participation, empowerment, and collaboration in achieving sustainable outcomes.

There is immense potential for scaling up community-based water management initiatives, as they can be adapted to various contexts and scaled to regional or national levels. To further advance this approach, it is crucial to strengthen community capacities, promote policy reforms that recognize and support community-led initiatives, and invest in awareness-raising and knowledge-sharing platforms. By embracing the principles of community-based water management, we can foster a more sustainable and equitable future for all.

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Open Access

Peer-reviewed

Research Article

Opening decision spaces: A case study on the opportunities and constraints in the public health sector of Mpumalanga Province, South Africa

Roles Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Writing – original draft, Writing – review & editing

Affiliation Institute for Global Health and Development, Queen Margaret University, Edinburgh, Scotland, United Kingdom

Roles Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Resources, Writing – review & editing

Affiliations Independent Consultant, White River, South Africa, MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, University of the Witwatersrand, Johannesburg, South Africa

Roles Conceptualization, Funding acquisition, Project administration, Writing – review & editing

Affiliation MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, University of the Witwatersrand, Johannesburg, South Africa

Roles Data curation, Formal analysis, Project administration, Writing – review & editing

Roles Conceptualization, Formal analysis, Funding acquisition, Resources, Writing – review & editing

* E-mail: [email protected]

Affiliation Aberdeen Centre for Health Data Science, Institute of Applied Health Sciences, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Scotland, United Kingdom

• Sophie Witter, 
• Maria van der Merwe, 
• Rhian Twine, 
• Denny Mabetha, 
• Jennifer Hove, 
• Stephen M. Tollman, 
• Lucia D’Ambruoso

• Published: July 5, 2024
• https://doi.org/10.1371/journal.pone.0304775
• Peer Review
• Reader Comments

Decentralised and evidence-informed health systems rely on managers and practitioners at all levels having sufficient ‘decision space’ to make timely locally informed and relevant decisions. Our objectives were to understand decision spaces in terms of constraints and enablers and outline opportunities through which to expand them in an understudied rural context in South Africa.

This study examined decision spaces within Mpumalanga Province, using data and insights generated through a participatory action research process with local communities and health system stakeholders since 2015, which was combined with published documents and research team participant observation to produce findings on three core domains at three levels of the health system.

Although capacity for decision making exists in the system, accessing it is frequently made difficult due to a number of intervening factors. While lines of authority are generally well-defined, personal networks take on an important dimension in how stakeholders can act. This is expressed through a range of informal coping strategies built on local relationships. There are constraints in terms of limited formal external accountability to communities, and internal accountability which is weak in places for individuals and focused more on meeting performance targets set at higher levels and less on enabling effective local leadership. More generally, political and personal factors are clearly identified at higher levels of the system, whereas at sub-district and facility levels, the dominant theme was constrained capacity.

Conclusions

By examining the balance of authority, accountability and capacity across multiple levels of the provincial health system, we are able to identify emergent decision space and areas for enlargement. Creating spaces to support more constructive relationships and dialogue across system levels emerges as important, as well as reinforcing horizontal networks to problem solve, and developing the capacity of link-agents such as community health workers to increase community accountability.

Citation: Witter S, van der Merwe M, Twine R, Mabetha D, Hove J, Tollman SM, et al. (2024) Opening decision spaces: A case study on the opportunities and constraints in the public health sector of Mpumalanga Province, South Africa. PLoS ONE 19(7): e0304775. https://doi.org/10.1371/journal.pone.0304775

Editor: Sogo France Matlala, Sefako Makgatho Health Sciences University, SOUTH AFRICA

Received: August 10, 2022; Accepted: May 19, 2024; Published: July 5, 2024

Copyright: © 2024 Witter et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: The main datasets used and/or analysed during the current study are in the public domain in the form of (a) referenced reports and papers, upon which secondary analysis was performed, and (b) published VAPAR papers, which report on associated datasets. All project outputs which are referenced and supporting resources can be found at https://www.vapar.org/ , including presentations which were used for this analysis. Other sources, such as observational notes, are not suitable for sharing without contextualisation.

Funding: The research presented in this article is funded by the Health Systems Research Initiative from Department for International Development (DFID)/Medical Research Council (MRC)/Wellcome Trust/Economic and Social Research Council (ESRC), https://www.ukri.org/what-we-offer/browse-our-areas-of-investment-and-support/health-systems-research-initiative/ , grant number MR/P014844/1, recipients (SW, LD, MV, ST, RT). All views expressed here are those of the authors alone. The sponsors or funders did not play any role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Competing interests: The authors have declared that no competing interests exist.

Abbreviations: APP, Annual Performance Plan; CEO, Chief Executive Officer; DCST, District Clinical Specialist Teams; DoH, Department of Health; HDSS, Health and socio-demographic surveillance system; MCWY&H, Maternal, child, women and youth health and nutrition; PAR, participatory action research; PFMA, Public Finance Management Act; PHC, primary health care; TO, team observation; VA, verbal autopsy; VAPAR, Verbal Autopsy with Participatory Action Research

Introduction

Decentralisation is a widely adopted and promoted strategy as a means towards health sector reform [ 1 ]. In South Africa, the health system has been administratively decentralised since 1994 to provincial level, consistent with the overall policy for government in the South African Constitution [ 2 ]. Under the National Health Act of 2003, provincial departments of health are mandated to provide healthcare services. The provincial health authority is responsible for the management of the provincial heath budget and delivering all health services and to adapt national policies according to the needs of the province. The majority of the South African population access health services through the public sector district health system, which is the preferred government mechanism for health provision within a primary health care approach. District and sub-district health management offices oversee management of the primary health care (PHC) facilities (clinics, community health centres and district hospitals), in line with core national standards and towards achieving targets set largely at the provincial level for key population health indicators.

On the health system side, this approach relies on there being decision space, meaning decision-making power which can be exercised by managers [ 3 ] within public administrations to act on better evidence of community challenges and priorities. The aim of this article is to examine this in practice at multiple levels in one province in South Africa, using the Verbal Autopsy with Participatory Action Research (VAPAR) project data and insights ( www.vapar.org ), participant-observation by team members, public documents and public data. Its objective is to understand constraints on decision space but also opportunities to expand and enhance it, with a particular focus on the role of evidence and co-production. The article focuses on child health as a tracer condition with which we have engaged, although many of the features highlighted are cross-cutting to other programme areas. It adds to existing literature by using a decision space lens at multiple levels of a decentralised system and focusing on a broad range of capacities, some of which (such as infrastructure and information) have been relatively neglected in the literature to date [ 4 ].

Materials and methods

Definitions and framework.

Decision space is defined as “the range of effective choice that is allowed by the central authorities to be utilised by local authorities” [ 3 ] and represents the degree of decentralisation granted to an individual or organisation. This space can be formally defined by laws and regulations, or informally by lack of enforcement of these formal definitions that allows lower level officials at each level to ‘bend the rules’. The assumption is that with increased decision space, managers can make decisions that are more innovative, efficient and responsive to local conditions and that this will improve the quality of service delivery [ 4 ].

The paper adopts a conceptual framework ( Fig 1 ) which sees decision space as an emergent property of the authority, capacity and accountability within an organisation, as well as the context in which it operates. Authority provides the de jure decision space by defining roles and responsibilities which enable managers and staff to take action. However, while it is necessary, it is not sufficient, if other features (capacities and accountability) are missing or misaligned. When authority is unclear or fragmented, as is commonly the case, accountability can be undermined [ 5 ].

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https://doi.org/10.1371/journal.pone.0304775.g001

Source : adapted from [ 5 ]

Capacity is what enables the organisation to function [ 6 ], and includes administrative, technical, organisational, financial and human resources. Some of these capacities are inputs, such as finance and staff and valid health system data, but they also include the capacity to manage inputs well. Resources (inputs) are necessary but not sufficient without management capacity, with which they are interdependent [ 5 ]. Without resource capacities to ensure organizational functioning, management capacities could also be redundant. Capacity and authority also need to go in step if resources are to be used well. Limited evidence suggests that where resource capacities fall short of what is required for organizational functioning, managers may resort to informal decision-making strategies to fulfil responsibilities and mitigate bureaucratic constraints [ 4 ].

Desirable features of capacities link closely to standards for strong health systems generally. For example, financial capacity would be assessed according to adequacy, regularity, flexibility and predictability [ 7 ]. For human resources, control over hiring, payment, performance assessment and management, and motivation would be key. For management, technical skills such as planning and management of staff, medicines and supplies and infrastructure are important, as well as having access to relevant information and the ability to use it effectively. Health management information systems produce large amounts of data, yet data are rarely used in local decision-making [ 8 ].

In addition, leadership capacity is critical–the ability to create and share organisational vision and motivate staff to adopt it, for example [ 9 ]. According to Gilson et al. (2014), PHC will only become a lived reality within the South African health system when front line staff are able to make sense of policy intentions and incorporate them into everyday routines and practices [ 10 ]. This requires a leadership of sensemaking that enables front line staff to exercise collective discretionary power to deal with particular contextual needs at the front line of policy delivery.

Accountability refers to answering for decisions or actions, often with the purpose of reducing abuse and improving system performance. It can refer both to the mechanisms for being held responsible for doing the right things and doing them effectively [ 5 , 6 ], but also the outcome of these. Commonly, a distinction is drawn between bureaucratic and external accountability [ 11 ]–the former indicating vertical systems within an organisation, such as planning, target setting, supervision, monitoring, reporting and audits, while the latter is most commonly enacted in the health system through formal community participation mechanisms such as health facility committees and hospital boards. Accountability affects decision space (positively and negatively) and helps to direct its use [ 12 ].

Community accountability [ 13 ] is an approach to strengthening public accountability through direct involvement of clients, users or the general public in health service delivery. Different measures to enhance community accountability, linked to peripheral facilities, include clinic committees and health interest groups, public report cards and patients’ rights charters. A recent literature review highlighted the way in which bureaucratic accountability mechanisms often constrain the functioning of external accountability mechanisms. Front line managers and providers may be constrained from responding to patient and population priorities due to organizational cultures characterised by supervision and management systems focused on compliance to centrally defined outputs and targets [ 14 ]. This may be driven by the need to control misuse of resources, lack of confidence in managers’ capacities, or both. This bureaucratic accountability can crowd out community accountability [ 15 ], creating a ‘compliance culture’ which focuses more on tasks than outcomes.

The role of context is also widely recognised as important in relation to these domains and their impact on decision space. Socio-cultural and political factors influence all these relationships, which together affect roles and responsibilities in the health system, its responsiveness and how resources are used [ 5 ].

In post-apartheid South Africa, there was a constitutional commitment to the right to health and community participation for PHC to overcome the historical disadvantages faced by the majority population [ 16 ]. Today, significant pro-poor, equity-oriented reforms include: National Health Insurance [ 16 , 17 ]; PHC Re-engineering [ 18 ], which includes the development of Ward-Based Primary Healthcare Outreach Teams decentralising PHC to community level; and the Ideal Clinic initiative, which provides a national quality framework within PHC Re-engineering. Successive national annual performance plans also address workforce development and planning with initiatives on affirmative student recruitment (prioritising students from disadvantaged backgrounds), financial incentives, foreign recruitment and compulsory post training service as well as commitments to strengthen the public sector health workforce through National Health Insurance and the National Development Plan [ 19 ].

While policy development is progressive and inclusive, significant gaps exist between policy and implementation in a system characterized by chronic underinvestment, human resource crises, widespread corruption, poor stewardship and deteriorating infrastructure [ 20 , 21 ]. Health systems also faces a complex ‘quadruple’ burden of socially patterned mortality comprising chronic infectious diseases (HIV/AIDS and TB), non–communicable conditions, maternal and child mortality, and mortality owing to injury and violence [ 22 – 25 ]. The burden of HIV is high and highly unequal. Prevalence in black populations is 40–50 times that of white populations and in adolescents, risks are eight times higher in females than males [ 20 ]. South Africa’s child poverty rate is relatively high and its Gini coefficient at 63 is the highest globally, with the majority black population remaining disadvantaged [ 25 ]. While early on in the pandemic, South Africa was internationally recognised for timely and decisive action in response to Covid-19, it remains one of the most unequal countries globally, and this is likely to be both reflected in and exacerbated by the pandemic.

Mpumalanga is one of nine provinces in the country, with a population of 4.7 million (7.9% of the national population [ 26 ] and a gross domestic product per capita of $12,585 that is close to the national average but well below provinces such as Western Cape and Gauteng [ 27 ]. More than half the population is rural [ 28 ], while nationally this is around one third [ 25 ]. In 2019, provincial unemployment was 35%, with 51% living in poverty [ 29 ]. In 2015, life expectancy for males and females was 50 and 53 years respectively, lower than the national average of 60 and 67 years, and under-5 mortality was 41 deaths per 1,000 live births in 2012, which is comparable nationally [ 30 – 32 ].

Mpumalanga Department of Health (DoH) has responsibility to deliver need-based services through an integrated health system covering three districts and 17 sub-districts [ 30 , 33 ], which include 279 clinics and 33 hospitals [ 34 ]. The Mpumalanga DoH structure includes five strategic directorates: HIV/AIDS, sexually transmitted infections and TB Control; communicable disease control; non-communicable diseases; maternal, child, women and youth health and nutrition (MCWYH&N); and research and epidemiology.

Verbal autopsy (VA) data from MRC/Wits-Agincourt Unit’s health and socio-demographic surveillance system (HDSS) in Mpumalanga shows child mortality to have recently declined to similar levels as in the early 1990s. Although this may not seem like a major achievement, on closer examination it clearly has been so, in terms of reversing the disastrous effects of the HIV epidemic on mortality patterns during a period of emerging democracy following decades of apartheid [ 35 , 36 ]. There are a number of national policies targeting child health, such as the Child Healthcare Problem Identification Programme, which uses child death audits to identify and address immediate and root causes, and the Integrated School Health Policy advancing integrated, holistic approaches to school health [ 36 ]. Further progress towards Sustainable Development Goal targets will require widespread improvements in socio-economic conditions and health systems functionality, with national and local leadership commitment.

Within Mpumalanga, we have focused on Ehlanzeni district and Bushbuckridge sub-district, as these are the sites within which the HDSS is located. Ehlanzeni district, the largest of three districts in Mpumalanga with an estimated population of 1.8 million [ 37 ]. The district is situated in the south eastern part of the province, bordering Mozambique and Swaziland and consists of four local (sub-district) municipalities.

This paper adopts a qualitative synthesis design [ 38 ],drawing on analysis of mixed data sources from 2015 to 2020, which are combined to investigate the domains of our conceptual framework. The first strand draws from the VAPAR programme, which is a partnership of the MRC/Wits-Agincourt Research Unit, Mpumalanga DoH, and collaborating researchers dating back to 2015, to connect community-generated evidence to practitioners, planners and managers through a coproduction, action research process. The second strand draws from experiences of VAPAR team members, and the third from reports, data and documents on health service delivery in the province.

Data sources

The VAPAR process combines VA, a method to determine levels and causes of death in settings where deaths go unrecorded, and participatory action research (PAR), a process in which different stakeholders organise evidence for action. A pilot followed by a series of cycles of PAR was progressed, comprising observation, analysis, planning and action stages.

Community stakeholders were engaged in the initial observation stage from three rural villages, selected based on demographic variation and feasibility, with total populations of between 4,000 and 6,500, within the MRC/Wits-Agincourt Unit’s HDSS study area [ 39 ]. Relationships with community stakeholder groups were developed through a series of community-based workshops in which we coproduced new knowledge on under-5 deaths, alcohol and drugs, and water using methods such as ranking, diagramming, stakeholder mapping and participatory photography [ 40 ]. A total of 48 community stakeholders participated from three purposively selected villages [ 41 ]. In addition, data from the Agincourt HDSS, including VA data on causes and circumstances of death, were integrated into the process [ 42 ].

To analyse VA and PAR data and plan feasible action, we held a series of further workshops engaging broadly with government departments, non-governmental agencies and community stakeholders. We jointly identified actions, timescales and implementing partners, culminating in a joint Local Action Plan that all participants committed to. We collected data in presentations, registers, minutes, observational notes and reflective journal data to develop accounts of the process, as well as substantive interpretations and proposed responses.

In the final phase of the cycle, actions were monitored, with cooperative reflection and learning feeding into the following cycle. Those who had committed to specific action items were visited by the researchers at venues of their choice to discuss progress. A structured tool captured mechanisms of change. The process culminated with a collective reflection. Using rapid, participatory methods, we conducted interviews with participants from local communities, government departments and parastatals, non-governmental organisations, and held two workshops with health systems actors. One workshop was held at provincial level with programme and directorate managers, and one at national level, with health programme and policy specialists. We sought perspectives on whether and how impacts had been achieved; acceptability and utility of the process; levels and mechanisms for integration into the health system; and future linkages [ 41 ].

In addition to VAPAR data, this paper draws from team discussions which reflected on and elicited the experiences of team members, many of whom have extensive experience of working with and in embedded research environments and different levels and sections of the health system over a number of years, and whose engagement in the VAPAR process has allowed for insights into the receptivity of the system to research evidence as well as insider/outsider perspectives on systems functioning across all the health system blocks.

We also draw on public documents such as provincial and district plans, expenditure reports, media reports, other relevant evidence generated by the MRC/Wits-Agincourt Unit and relevant recent reports on the health system in Mpumalanga produced by other organisations; these were sought using key words relating to the system blocks and levels, combined with locality terms, and selected purposively to inform elements of our framework, alongside wider global and health system research from South Africa. Data or insights were drawn from 78 documents, of which eight related to the VAPAR project, 12 provided evidence on Mpumalanga province, 42 related to the wider health system in South Africa and 16 discussed decision space in other settings and conceptually.

Data analysis

Analysis was undertaken using the decision space framework and integrating data from the main strands by the research team ( Table 1 ), initially in a research team workshop in 2019, and subsequently through iterations of the paper and subsequent reflective research team meetings. The research team conducted a rapid literature review on decision space in health care and identified a framework [ 5 ] to structure its analysis. Literature was shared with team members and discussion held on its application to the local context. Data were factual (commonly from official sources, such as provincial reports) or interpretative (thus representing important views of sectoral performance), so quality assessment of these sources was not applied or relevant. Analysis was abductive, focused on patterns within domains of the conceptual framework, comparing across levels and reaching consensus by team discussions and drafting. As decision space is not observed directly, but is emergent from the domains assessed, team interpretation was applied to derive a commentary on decision space.

https://doi.org/10.1371/journal.pone.0304775.t001

Ethical considerations

This article draws from the PAR data. For the PAR, informed consent was sought from all participants, all identifiable data were anonymised, and approvals were obtained from the authors’ institutes and from the provincial health authority. Additional information regarding the ethical, cultural, and scientific considerations specific to inclusivity in global research is included in the Supporting Information ( S1 Checklist ).

In the findings, we examine the extent and inter-relationship of authority, accountability and capacity in the local levels of the health system (facility, district and subdistrict). This is followed by a provincial account of constraints and enablers to decision space. Tables 2 and 3 provide an overview of findings.

https://doi.org/10.1371/journal.pone.0304775.t002

https://doi.org/10.1371/journal.pone.0304775.t003

Facility level

At facility level, we find that decision space exists, though it is constrained by lack of resources and a culture of bureaucratic, often fragmented, upward accountability. Decision space is demonstrated by facilities which use positive informal coping strategies (such as sharing of supplies across facilities to overcome shortages) and evidenced by the range of performance by clinics in similar settings in terms of waiting times, for example.

Key roles are clearly defined in facilities. These include, in hospitals, the Chief Executive Officer (CEO) and a Management team, including a Clinical Manager and Nursing Manager, who are in-charge in hospitals, alongside (mainly in tertiary and regional hospitals) specialist staff dealing with child health, such as hospital-based paediatricians. Within clinics, Operational Managers (usually professional nurses) are in-charge.

Accountability

At hospital level, the CEO and hospital management team report to hospital boards, which oversee the work of the facility. Hospital boards have power (including to go to provincial leadership with problems) but tend not to use these mechanisms and are often focused on political priorities (TO). Although hospital boards do receive financial reports, very few take responsibility for hospital financial matters. As a result, Boards can lack capacity (see below). The Portfolio Committee report 2017/18 reports constraints to functionality in some hospital boards and that community protests have resulted in the removal of some CEOs, indicating a form of informal accountability claimed by communities [ 34 ].

Litigation is becoming more common as a strategy by families (and lawyers) to hold the DoH to account for failures, though this mainly has consequences for provincial budgets more than for individual facilities or practitioners. In 2017/18, there were 61 legal cases outstanding, mostly relating to maternal deaths [ 34 ]. At a clinical level, audits and adverse event reporting and committees are part of the quality assurance process, although these committees vary in degrees of activity and effectiveness (TO).

At primary level, community health centre or clinic committees are the main formal accountability structure. Committees should be made up of elected community representatives and health professionals to allow community concerns to be heard and addressed. Various mechanisms are prescribed to support engagement with and feedback from communities, including complaints systems, satisfaction surveys and waiting times reporting, but these are not seen as comprehensive. In addition, clinics are required to hold Open Days as part of the Ideal Clinic initiative, however from our participant observation these have limited attendance and substance, mainly as communities are generally already aware of services rendered by clinics. While home-based carers, community health workers, and Ward-based PHC Outreach Teams are visible links between communities and facilities, they face many demands, limited recognition in the system, and no additional resources to support a rapidly expanding mandate. In this context, clients tend to use direct action such as protests or the media (including increasingly social media) rather than formal channels to address grievances. These are problematic, imposing system costs and do not represent balanced or constructive input from the community.

In terms of vertical accountability, facilities have to organise services within the policies passed down to them for each programme, such as child health. VAPAR participants perceive policies, programmes, audits and other initiatives prescribed from higher levels as well-intentioned but insufficiently tailored to local conditions and resources. Furthermore, many parallel initiatives were described as having an overall destabilising effect on over-burdened health workers, compounding problems in an already constrained system. As a result, objectives are often not achieved and results are manipulated to show progress. This was described as ‘ changing numbers rather than really affecting change’ [ 42 ]. Clinics are cost centres and can plan and manage day to day operations, however budgets are set at higher levels and major inputs (drugs, supplies, staffing, equipment) are procured and supplied by higher system levels. There is no longer a direct supervisory link between district hospitals and the Community Health Centres or clinics, which are supervised by PHC supervisors (professional nurses), based in the sub-district.

Accountability is closely linked to capacities, which include resources of various kinds as well as their management. Reflecting on challenges in relation to under-five mortality, VAPAR participants highlighted insufficient and absent health workers, deficits in competencies (e.g. gaps in Integrated Management of Childhood Illness training, or in management of severely malnourished children and health education), support and motivation as contributory factors in under-5 deaths, and which collectively limit quality and foster poor attitudes more generally [ 42 ]. Responding to shortages, some staff act outside their mandated professional scope. Examples of strong personal commitment are seen in some cases, this is contrasted by poor management of patients in other cases [ 43 – 45 ]

A recent assessment in nine clinics in the study area identified issues with staff vacancies, with 55% reporting one or more vacancy, and some services affected by staff action over remuneration [ 46 ]. Nevertheless, in the same study, providers were highly satisfied with the nature of their work and generally with relationships with colleagues, but reported dissatisfaction with working conditions in terms of staffing, supplies and space. Staff also raised concerns about frequent absences of colleagues, lack of support staff, poor motivation, as well as infrequent and demotivating supervision and trainings which distract from clinical care. Additionally, some providers were less satisfied with opportunities for and quality of training and supervision and an average of 42% of providers (8% to 81% by clinic) reported plans to leave in the next two years.

Inadequate service organisation and infrastructure were further challenges identified by VAPAR participants. Specific issues included overcrowding, especially during morning clinics, exacerbating staffing problems and causing long waiting times and delayed or postponed consultations. Lack of consulting rooms and water outages were also cited: many clinic buildings date back to when the area was a homeland (areas designated under the Apartheid regime for African self-government) and significantly smaller populations were provided with limited and poor quality services. Public facilities now cater for much larger populations and are competing for infrastructure budget with other projects, resulting in higher throughput than is manageable [ 39 ].

The clinic quality assessment also identified long waiting times (e.g. median wait of 122 minutes for antenatal care, for a consultation lasting around 8 minutes on average [ 46 ]. However, there were wide variations by clinic: the best-performing facility had only 16% waiting over 2 hours, while the worst had half of all patients waiting over 2 hours. These data highlight significant potential in local management and organization to improve waiting times for patients.

Maintenance failures and a lack of maintenance planning exacerbate this situation. Facility maintenance is not within the control of Mpumalanga DoH and involves the Department of Public Works, Roads and Transport at provincial level. The centralised health budget makes even minor upkeep expenses difficult to access [ 47 ]. The clinic quality assessment supports these infrastructure concerns. For example, functional internet was absent in 88% of facilities, electronic medical records were absent in 78%, and functional fans were absent in 55% [ 46 ]. Patient scores were generally high but, reflecting these issues, were low for cleanliness in particular.

Shortages of ambulances and interrupted supplies of medicine are a further critical challenge [ 48 ] reflecting the lack of autonomy on purchasing, while the Portfolio Committee 2017/18 also highlights challenges in relation to infrastructure, drug supplies, equipment, clinical staffing and referrals [ 34 ]. These issues also affect Ward-based PHC Outreach Teams work as nurses cannot reach communities to support Community Health Workers in the absence of transport [ 42 ]. Reflecting the issues described above, only 8% of clinics in Ehlanzeni met Ideal Clinic standards in 2017/18, compared to a national average of 43.5% [ 49 ].

For tracer medicines, 94% of clinics had more than 90% availability, slightly above the national average. This may reflect informal coping strategies to manage shortfalls, such as: sharing supplies across clinics; shortening the length of prescriptions; or ordering more supplies than may be warranted based on patient load owing to regularly receiving less than is ordered [ 46 ].

Finally, there are challenges relating to the quality of the District Health Information System (DHIS). While the system is widely used and tracks facility data, including child deaths, limited information is provided on cause of death and there are concerns about completeness, as well as lack of use of evidence for decision making [ 31 ];. The Portfolio Committee report for 2017/18 [ 34 ] notes that patient file management in hospitals and clinics remains a problem and that responsibility for implementation of the Health Management Information System has been moved from provincial to National DoH. A National Health Patient Registration System and web-based DHIS-2 are being rolled out [ 34 ].

District and sub-district levels

The district and sub-district have an important role in operationalising policy, but vertical accountability can be punitive, rather than supportive, and resource constraints are commonly cited. However, good personal relations and communication can ease day to day functioning, enabling decision space to be opened. As an example, during COVID, the team observed local intersectoral action being taken in response to the crisis by district and sub-district health and other actors.

The district is the focus of service delivery coordination, led by the District Health Management Team. Within that team, the Primary Health Care Director is responsible for a number of programmes, including child health, which also sits under the MCWYH&N programme coordinator in terms of technical guidance. As with facility level, district and sub-district roles are clearly defined, although the MCWYH&N coordinator has responsibility for a wide range of priority programmes.

In addition, District Clinical Specialist Teams (DCST) were established in 2012 as part of the national PHC re-engineering strategy to improve quality of care, particularly for mothers and children. Each district team should include a paediatrician, for example, and teams should have autonomy to improve clinical governance. In practice, however, these teams do not have direct clinical governance mandates at district and sub-district levels but are rather advisory and supportive in terms of quality improvement, which can bring tensions [ 50 ].

Sub-districts focus on operational support to hospitals and health centres in local areas. At this level, the PHC Manager supervises implementation of priority initiatives, such as Ideal Clinics, while the MCWYH&N programme coordinator gives technical guidance and supervision to facility staff in areas such as child health. While roles are clearly defined and understood, there is some potential for duplication (TO).

In the district, there is clear upward accountability through quarterly review meetings and annual reports against district health plan targets, though feedback from above tends to be focused on problems, more than identifying, understanding, supporting and enabling local leadership, supervision and innovation (such as the coping strategies around medication shortages described above). The main accountability of the MCWYH&N programme coordinator is to the District Health Management Team, rather than to technical leads at provincial level. Downward accountability links to facilities are limited, and vertical communication often depends on personal relationships. In work to date at district level, the VAPAR learning platform was seen as valuable in terms of provision of opportunities for improved vertical communication between district and provincial levels, which was identified as a major gap, as well as encouraging constructive dialogue on problems and response strategies [ 43 ].

Staff at district and sub-district level direct priorities for facilities but in a consultative way, for example in planning for child health campaigns. At district level, annual planning reflects divergent themes of optimism about achieving set targets while acknowledging the reality of an often under-resourced and partially dysfunctional system. Human resources challenges are highlighted in the 2018 Ehlanzeni district health plan. These include staff shortages (including support staff), high staff turnover, absenteeism, poor alignment with organisational structure and lack of outreach [ 47 ]. Hiring was decentralised to district level but then recentralised due to irregular appointments being made by district managers and CEOs. This has, however, created operational issues at district level, with long delays hiring even basic support staff (TO).

Austerity measures have been implemented annually since 2012 to improve efficiency and curb expenses. Formal and informal centralisation of procurement of goods and human resource functions has effectively limited capacity among district officials to perform duties (e.g. travelling, telephone and cell phone costs, accommodation when travelling), which is reflected in operational plans [ 47 ]. No allocation of equitable share (the funds which are send to the provinces without earmarking from national Treasury) towards goods and services was made to programmes at district and sub-district level, and with decreasing allocations at provincial level [ 51 ]. Vital equipment is reported as unavailable in some facilities, especially PHC facilities, due to budgetary constraints. Infrastructure maintenance has been failing due to centralisation of the maintenance budget, which is hard to access. Support services, such as supply chain management are slow and the competency of staff is questioned; the net effect is delays in procurement.

The sub-district has insufficient and poorly distributed community health centres (there are four when there should be 12 to serve a population of this size). Operational limitations include shortened service hours in some districts due to staff shortages, lack of transportation, poor infrastructure, lack of maintenance and ageing equipment that is insufficient in number and poorly distributed. These are all seen as contributing to a skewed utilisation of health services between PHC and secondary levels (48). Staff also report concerns over of lack of safety, both in terms of personal protection against attacks but also related to poor working environments [ 52 ].

Provincial situation

We find that decision space at provincial level is determined by personal and relational factors, more than formal authority, accountability or capacity, which poses a risk to the performance of the health system.

As reported at lower levels, roles and responsibilities are clearly and formally defined and widely understood. However, real and stated staffing do not always align and organograms often remain in draft for extended period and/or are outdated [ 34 ]. Nationwide, vacancies exist in programmes and posts for extended periods, and staff are widely called upon to informally fill vacant positions. Acting roles are often taken on in addition to formal roles and without delegated responsibility or remuneration [ 53 ]. The situation can contribute to authority vacuums, where staff do not feel empowered to take required decisions. At the same time, however, overstaffing of some senior management positions occurs, to the detriment of filling service delivery posts. Fluidity in roles and responsibilities is reported as a result, as well as insecurity for staff, waste and instability, with post holders’ status influenced by personal networks (TO).

Formal structures exist for planning, budget-setting and performance targets in the Annual Performance Plan (APP) and for enforcing collective responsibility, as laid down in the Public Finance Management Act (PFMA) 1999 [ 54 ]. This sets out national standards, including the need for financial statements to be audited and made public by the national Auditor General [ 55 ]. The national Department of Planning, Monitoring and Evaluation provides cross-sectoral oversight, reporting to the President. There are a range of structures and processes in provinces: annual reviews, oversight by the Standing Committee on Public Accounts, and the Portfolio Committee on Health and Social Development under the Office of the Premier that are reported to have the power to call officials and department to account if key targets are missed [ 56 ].

Nevertheless, upward accountability to national level (or technical support from it) is seen as limited, given that health service delivery is constitutionally the responsibility of provinces, unless programmes are recipients of a national conditional grant—which only applies to HIV/AIDS, sexually transmitted infections and TB, or issues that are in the media for some reason. Other programmes rely on annual distribution according to the provincial APP from ‘equitable funds’, which are allocated from the national level to the province.

There is divergence between theory and practice regarding downward linkages and accountability. While planning is designed to be bottom-up, with district plans feeding into provincial plans (59), the reverse is observed to be the case in practice. Provinces generally set priorities (including for maternal and child health) with targets divided between districts. As a result, districts lack ownership of targets and accountability is limited as performance differences are lost in aggregated provincial reporting (as long as average targets are met, individual variation is not necessarily probed) (TO). Equally, budgets are supposed to be set bottom up, according to plans, but in reality they are set top-down with managers given ceilings to work within (TO).

Moreover, programme budgets can be reallocated to different and shifting priorities (even politically driven) arising in-year, with better-connected managers often relatively protected from such variance. This undermines both performance and accountability. While there are mechanisms for enforcing collective accountability, as highlighted above, individual accountability is less strong. The performance management and development system in the province is not functioning as intended, which means that, at an individual level, rewards for merit and sanctions for poor performance are selective (TO). Resources do exist in the system in the form of motivated staff, committed to public service, however they are often not supported. Similarly, sanctions are perceived as limited. For example, staff who are suspended pending investigation of malpractice have been reported to continue to draw salaries and benefit from housing over considerable periods, while others are moved to new positions, without the complaints being resolved [ 57 ].

The Auditor General’s 2013/14 PFMA report [ 53 ] on health in the province reflects these issues, citing a lack of consequences for poor management or transgressions against the Act, poor response in addressing the root causes of poor audit outcomes, and an overall lack of key controls.

Disconnects between lower levels realities and higher level policies are widely documented in the country over sustained periods and in areas not limited to child health [ 58 ]. The VAPAR process has also identified hierarchical governance as failing to account for significant local innovation, responsiveness and resilience at lower levels. Provincial participants in the VAPAR process were positive about cooperative learning processes that enable and encourage bottom-up, appreciative and reality-based learning and exchange [ 42 ].

Mpumalanga had growth in PHC expenditure per capita in 2017/18, but is the third lowest spending province at R1,011 per capita; R144 below the national average [ 49 ]. Misappropriation was reported to play a role by the National Treasury, which reported fiscal risks and high accruals. Improved infrastructure, capacity enhancement, and better planning and project execution are sought to reduce under-spending, especially of conditional grants. A recent report also refers to irregular expenditure and medico-legal claims in health–litigation against the state in relation to health services, which are a growing (but unbudgeted) expenditure [ 34 ].

Annual budget increases are not aligned with population growth, extended service delivery priorities or policy directives. Priority initiatives such as Ideal Clinics, for example, have not come with additional funding. Moreover, unequal expenditure per population is reported across districts and sub-districts, highlighting the need to review budget allocations to reflect equity [ 51 ]. Budgets, which are key to enabling action, are frequently reallocated towards political priorities, such as building projects, which, without adjusted performance targets, frustrates service delivery.

Regarding staffing, appointments are often not seen to be based on merit or expertise, but rather on personal networks and years in service (TO). Trade unions also play a major role in the appointments process. These contribute to competency shortfalls, undermining managers’ decision space. Organograms are highly contested and while there are estimates of required workforce, these are not matched by funding or by actual distribution of staff [ 51 ].

There have been hiring freezes [ 47 ], with brief moratoria during which there are hectic attempts to fill posts. Gaps remain, especially in previously disadvantaged areas, which is also true for facility distribution. Problems with staff morale and capacity are noted as contributing to the rise in medical litigation (mostly at hospitals and often in relation to maternity care) [ 34 ].

Although vacancy rates in critical occupations (as defined in the APP, relating to essential services) were only around 8%, there are significant challenges, given misalignment of official posts, those actually filled and those who are on payroll [ 30 , 51 ]. Specialist doctors at referral hospitals were particularly lacking. 6% of employees left employment in the year covered by that report, of which a large proportion (32%) was resignations. More specifically, provincial health management is described as existing in a state of ‘crisis control’, with, for example, dates for meetings set but not followed when something more urgent occurs [ 59 ].

Information flows are based on the DHIS and periodic surveys, but gaps exist, notably from the community level. In Mpumalanga specifically, a provincial health research office was established in 2016, maintaining a database of research in the province [ 34 ]. While it does not as yet actively guide or coordinate research, there are intentions to develop more input to and control over research in the province, and drawing on the VAPAR process where necessary and relevant. Mpumalanga has a relatively new university, which intends to address key health needs in future, and the province also hosts the MRC/Wits Rural Public Health and Health Transitions Research Unit (of which the HDSS is a core element)

In relation to supplies, some tenders are overseen by the Provincial Treasury, with the ‘end users’ in each provincial Department responsible for drafting specifications, as well as evaluating the bids received, which can be a source of distortion, with reports of mark-ups on the cost of goods and shortfalls in provision across the provincial health system, as well as poor quality goods [ 47 ].

Reflecting the issues described above, the Auditor General’s PFMA report 2017/18 was qualified, with findings, which had been the case for the past five years [ 60 ]. Citing direct consequences on service organisation and delivery, it reported R310 million of irregular expenditure in 2017/18, with mutually-reinforcing capacity deficits:

“Health, with the second largest budget, had significant findings relating to poor storage and stock management practices, staff shortages, insufficient training, and medical equipment that was not in a good working condition. These issues contributed to the poor health services in the province. The main drivers of the shortcomings were poor project management together with staff vacancies and instability.”

Application of the decision space framework revealed system-wide patterns (Tables 2 and 3 ), in which lines of authority are generally well-defined in principle, however with personal networks taking on an important dimension in how stakeholders can act, and particularly when it comes to being accountable. The framework also enabled identification and description of significant informal ingenuity and capacity. The influence of political and personal factors is more clearly identified at higher system levels, across provinces and at district level, whereas at sub-district and facility level, the dominant theme is capacity, which affects all health system components. The emergent decision space is therefore characterised by personal networks and qualities, at higher levels, and on informal coping strategies between facilities and groups of staff at lower levels. Although the analysis did not focus on formally analysing changes across the period of the study, these features appear from team observations to be relatively constant over this time.

Accountability has some force collectively, in that there is real attention to meeting performance targets as set out in the APP and transparency in reporting. However, on an individual level for managers and staff, accountability is less robust and tends to be punitive and systematically screening out local innovation. For communities, direct action (often negative, in the form of protests, media stories or litigation) is perceived as more effective to enforce accountability than using the formal structures within the health system, and as documented in other sectors [ 61 ].

There are currently significant gaps between theoretical decision space and actual ability to carry out those roles ( Table 3 ), which has implications for system performance. However, although many challenges have been highlighted for decision space, which enables health managers and staff to respond flexibly and appropriately to local contexts, assets within the system remain rich. These include many committed staff, expertise, financial resources, well designed national policies, and willingness and ability to find informal coalitions and ways to negotiate constraints (as shown in the example of drug-sharing between clinics to avoid stock outs). Recent achievements in addressing severe acute malnutrition in the province also indicate what can be done by bringing leadership and using local data to identify priority issues and build coalitions to address them [ 62 ]. This testifies to resilience in the system and indicates how much more would be possible if current limits to decision space were addressed. The enabling of bottom-up, emergent, appreciative and reality-based learning and exchange are therefore important routes to further understand and develop decision space.

However, decision space is not likely to be sufficient to ensure good performance if mediating factors are unfavourable. A balance between the three domains of authority, accountability and capacity is important, but context also plays a very significant role. In South Africa, provinces are still struggling with the legacy of apartheid and associated socioeconomic injustices [ 21 ]. Communities were systematically exploited to provide cheap labour to benefit a white minority, explicitly economically marginalised and deprived of a decent standard of living through denial of access to well-paid work, and displaced, forced to live in 13% of the land, called Bantustans (or euphemistically homelands), most of which was agriculturally unproductive and better suited to cattle and game farming [ 63 ]. While the regime was dismantled 25 years hence, deepening social and health inequalities along the lines of race gender and economic status are widely documented [ 64 ]. Unemployment is further key contextual factor. At 35% overall, and higher among youth, it not only adds to challenges for communities in promoting health and accessing health care, but also puts pressure on the public health worker employment market [ 65 ].

Added to this is an organisational culture of low trust, related to perceptions of national level state capture, but which creates a controlling and disabling environment for staff at mid- and lower levels. Development has been hampered by patrimonialism, deployment of cadres (former anti-apartheid activists) and corruption within the ruling party [ 66 ]. ‘Gatekeeper politics’ ensure that those in power stay in power, and in rural areas these are predominantly elected ward councillors [ 66 ]. Consequently, those most disenfranchised are turning to struggle actions as developed during the fight against Apartheid, such as service delivery strikes.

Reflecting on how our case study complements the existing decision space literature, we make novel contributions to discussions about how sub-optimal resourcing can lead to informal coping strategies (both positive and negative) [ 12 , 67 ], with health managers and staff operating as ‘street level bureaucrats’ having to manage in a complex environment in which their own interests and constraints play out [ 68 ]. Our findings are also consistent with studies which show the impact of resource uncertainty on narrowing decision space [ 68 ]. The difference between responsibility and financial resources to enact those responsibilities is also a common strand in the literature [ 12 , 69 ], and one which we identify in the current case study, which affects not just decision space but also performance of the health system. Our case study also adds examples of the importance of infrastructure and information as enabling organisational capacities. It also highlights the importance of contextual factors in shaping decision space: even where authority, accountability and capacities may be aligned, politics and power can still disrupt, for example, with priorities and funding changing overnight at the behest of political authorities, such as the Executive Council in the province. A collaborative organisational culture and good personal relations can, on the other hand, open space at least within the local sphere and for managing problems in the short term.

Wider literature [ 12 ] suggests that bureaucratic accountability may reduce decision space in some contexts, which we also find in this setting. The perceived lack of decision-space may also have impacted on community engagement, as was documented in India [ 70 ]. In the other direction, politicised community participation may have reduced real accountability in our context.

Many studies find unclear authority as a limiting factor for decision space and accountability [ 12 ] however in this context, roles and responsibilities were relatively clear and not a major constraint. Unlike in Ghana, where incomplete political and fiscal decentralization ensured that the balance of power in the health system remained at national level [ 70 ], in Mpumalanga, there is delegation of authority through the Constitution and resources (through equalisation grants) to provincial level. However, the dynamics we document converge to squeeze decision space at lower system levels. The study is consistent with wider literature on decentralisation, finding that district teams in many settings have insufficient resources to effectively implement the health programmes they oversee [ 71 ].

The study draws on mixed sources to examine a transect through the system, but faces limitations of generalisability. However, other studies from South Africa suggest that while Mpumalanga faces some specific contextual challenges, it is broadly similar to other areas. Health district managers in Johannesburg, for example, highlighted poor leadership and planning with an under-resourced centralised approach, as well as poor communication–internally within the service and externally with the community–and poor integration of health strategies and programmes [ 72 ]. Complexity of tasks, competing demands and lack of support for front line managers and staff within a hierarchical organisational culture is also documented in other parts of the South African health system [ 58 ]. Limited capacity, inadequate operational resources and irregular monthly supervision visits have been seen to limit stewardship and poor management, with concerns about effectiveness of Ward-based PHC Outreach Teams documented in other provinces [ 73 – 75 ]. Further, Coovadia et al. highlight widespread challenges of gaps in competence and lack of effective leadership, stewardship and personal accountability, rooted in historical legacies of colonialism and apartheid. A recent study also found growing corruption in the health sector in South Africa, with the largest number of reports focussing on the provincial level [ 76 ].

The recent South African Quality of Care Commission’s first recommendation focuses on ethical and effective leadership, while its second is on strengthening community structures for engagement and accountability [ 77 ]. Research conducted in Mpumalanga, Gauteng and Western Cape also highlighted the lack of accountability to patients, and tendency to focus on upward accountability instead, which supports abusive relationships with patients but is also driven in part by lack of support for staff [ 78 ]. While many quality improvement initiatives are focused at facility level, these will struggle to be effective and be sustained without more meso and macro level changes [ 79 ].

Some express concern that the compliance culture in the public sector as a whole–deepened by recent anti-corruption measures—is crowding out innovation, developmental, non-hierarchical and cross-departmental approaches and responsiveness to users:

“Protests happen every day , but officials worry more about what the Auditor-General will say , or whether politicians will throw them under the bus , than what the people think of them [ 80 ] ”

Debate concerns whether new political windows of opportunity are opening in South Africa currently, which can combat corruption, challenge the culture of cover up and open up decision spaces for committed and skilled managers at all levels of the health (and wider public) system.

While these factors are amenable to change, it is important to acknowledge the deep structural influences from social, historical and health systems contexts and organisational cultures. Our analysis above indicates that it will take time and commitment to motivate staff and provide meaningful, distributed leadership. Support for informal leadership development strategies may also be an important element in building capacity at lower system levels to expand and use decision space [ 81 ], along with a greater focus on system ‘software’, such as building trusting relationships, improved communication and dialogue skills. Better communication and direct contact between government officials and citizens are also key [ 82 ]. A review of the VAPAR process to date suggests that willingness and commitment for cooperative reflection and action exists within the local health system, evidenced in both sustained engagement and participation in the process and formalised partnerships for health systems [ 41 ]. In other provinces, a ‘war-room’ approach to tackling priority child health challenges at ward level, involving multiple stakeholder groups, was reported to be effective [ 43 ].

This cooperative action, including across sectors, has been in evidence in the recent effort to tackle COVID in the province, as evidenced by the formation of municipal, district and provincial level joint operations committees, to which all departments report at least once a week. The national but focused nature of this crisis appears to have enabled multisectoral collaboration. However, that does not necessarily imply local decision-space: community health workers were, for example, given new roles in COVID messaging–away from their previous focus on areas such as child growth monitoring and defaulter tracing–without local consultation with the CHWs themselves [ 83 ].

Study limitations

A major limitation of the paper is that the examination of decision space was not planned in advance but arose from an observation of its importance in influencing how evidence co-created by VAPAR partners could be put into use. The analysis was therefore conducted retrospectively and limited by available data. As a result, the paper is not able to assess decision space (in relation to different health system functions) or its impact on performance. However, we are able to observe inter-relationships between components which influence decision-space and comment on how constraints to these might be mitigated and opportunities taken to improve them.

In the context of a participatory action research programme, we set out to establish what the margins for reform and for coproducing and responding to evidence were across the health system in a rural South African province. We used a decision space framework, which focused on the relationships between authority, accountability and capacities in shaping the power to decide and act of local health managers and staff.

We find that capacity exists in the system, but accessing it is frequently made difficult due to a number of intervening factors. While lines of authority are generally well-defined in theory, personal networks take on an important dimension in practice in how stakeholders can act. This is expressed through ingenuity and a range of informal coping strategies built on local relationships. There are constraints in terms of limited formal external accountability to communities, and internal accountability which is weak in places for individuals and focused more on meeting higher level performance targets and less on enabling local leadership. More generally, political and personal factors are clearly identified at higher levels of the system whereas at sub-district and facility levels, the dominant theme was capacity, affecting all health system components.

Decision space is particularly relevant for child health, given the acute and life-threatening nature of child health conditions. Such space as exists is fragile, and can be lost due to political, organisational and other shocks, such as COVID. Creating spaces to support more constructive relationships and dialogue across system levels emerges as important, as well as reinforcing horizontal, peer-to-peer networks to problem solve at local level, and developing capacity of link-agents such as community health workers to increase community accountability. In this scenario, the main resources in the system, which are human, technical and financial, can be energised to realise potential more fully.

Supporting information

S1 checklist..

https://doi.org/10.1371/journal.pone.0304775.s001

Acknowledgments

We would like to thank all community and health system participants whose insights and experiences informed this article. We thank ReBUILD for support with the publication costs.

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• Published: 05 July 2024

Reappropriating the communal past: lineage tradition revival as a way of constructing collective identity in Huizhou, China

• Ruyu TAO   ORCID: orcid.org/0000-0002-7235-4460 1 , 2 ,
• Nobuo AOKI 1 &
• Pinyu CHEN 3 , 4  

Humanities and Social Sciences Communications volume  11 , Article number:  881 ( 2024 ) Cite this article

Metrics details

• Cultural and media studies
• Social anthropology

This article discusses the reappropriation and redefinition of heritage and tradition as a process of purposeful and selective value extraction by various groups at the local level in Huizhou, China, based on case studies. It is a process of continuous accumulation and self-persuasion by empowering specific cultural heritages, thus reinforcing the identity and cognition of the group to which they belong. The recovery of lineage worship to negotiate different cultural meanings and gain discursive power in the village of Huangdun reveals the counterbalance of the distribution of benefits among lineage groups, locals and government officials. These heritage empowerment actions fit with the official cultural policy and the vision for cultural orthodoxy, healing the division and creating some benefits for the local community. They also generate potential conflicts between the official and folk levels but are performed with mutual achievement and utilisation rather than unilateral dominance.

Introduction

The relationship among history, heritage, and collective memory is delicate, intertwined and subtle (Lowenthal, 1998 : 121). In China’s contemporary social and cultural context, especially since the 2000s, the synergistic exploration, and interpretation of the above three concepts are unceasing and revolve around the ultimate metaphysical topic of ‘who we are’ and ‘where we are going’. Starting with ‘In Search of the Origins of Chinese Civilisation’, Footnote 1 which has been a continuous major national strategy since the beginning of the 21st century, the revival of Confucianism (Hubbert, 2017 ) and the ‘Revival of Outstanding Traditional Culture’, Footnote 2 including recently at the national level, highlight the importance of cultural heritage preservation, Footnote 3 all seeking to link and give new meaning to past stories and places of historical significance. These actions aim to find a basis for the interpretation of specific events, policies, and group positioning in a social context that is increasingly volatile and full of uncertainty and intensifying contradictions, thus creating legitimacy for official discourse and ideological and policy changes. Heritage, as Smith argues, is a complex, multilayered process of cultural attribution and social construction (Smith, 2006 ). However, how we understand Chinese efforts to rejuvenate heritages and traditions, referring to the coordination of community identity, diversity and unity, needs further exploration.

The Chinese official level does not explicitly advocate and support ‘identity politics’; instead, it tries to avoid emphasising distinctions and differences in group identities. It emphasises the ‘harmonious’ discourse marked by seeking commonality while preserving differences (Yan, 2014 ). However, as Madsen ( 2014 ) comments, ‘If the Chinese state wants to gain legitimacy by claiming to represent, protect, and promote China’s rich ‘intangible cultural heritage,’ it (like any nationalist government) must recognise that ‘heritage’ means many different things to different people.’ Therefore, this research aims to answer two main questions: (1) What role does cultural heritage play in the construction of local society in China and in resolving the dislocation of the individual within the society as a whole? (2) How can traditional history and collective memory be integrated with the needs of contemporary social development and manifested through the process of heritage empowerment?

The study, taking the Huizhou region of China against the background of the revival of traditional culture as an example, demonstrates how cultural heritage can become a proxy for social construction based on romanticised imaginary perceptions of the local masses under the encouragement of policy, economic investment, and fortified group identity. The case of lineage worship rejuvenation in Huangdun village reveals the definition and reuse of heritage and the characteristics of multigroup participation in the construction of local identity and even in developing the lineage tourism industry. Furthermore, this spontaneous action at the civil level subtly achieved acquiescence and support at the local government level through integration with official discourse and policy. In the face of increasing uncertainty today, the interaction of lineage history, rituals, and lineage member connections make people feel like they are living in a nonlinear history, thus giving them hope for the future. It clearly shows the conscious reuse of cultural heritage and the rediscovery and reshaping of traditional culture and ideology.

This paper argues that lineage revival in Huangdun should be understood as cultural activities that involve many traditional elemental ideas. It provides a platform for reinventing group intimacy. The concept of the new ‘Huizhou people’ is being reconstructed based on lineage surnames and regional cultural identity acknowledgement. The reappropriation of lineage tradition and reuse of heritage enable an a priori reconstruction of community that transcends spatial categories, thus awakening and strengthening the subjectivity of the participants. Therefore, there has been an attempt to explore and improve today’s grassroots community relations under the ‘unity’ scheme. In addition, the combination of historical contextualisation and the reuse of cultural heritage has redefined historical space and power through group participation. In the a priori ‘unity’ value implication, each subject can actively or passively find the interpretation point in line with their intentions in participation and thus be able to form a maximalist, supra-class identification with an authoritarian social order. While acting within the same framework of traditional cultural revitalisation and reuse of heritage, in this lineage tradition empowerment process, both laypeople and government officials have deemed cultural heritage and traditions approaches to achieve their own interests, and intentions differ among subjects. By raising the banner of promoting cultural heritage conservation and tradition revitalisation with endorsement by cultural policies through the rejuvenation of rituals and the genealogy of lineages in the Confucian tradition, lineage members have discovered a sense of self-identity and belonging and established a network of meaningful and trusting relationships. Furthermore, this lineage network provides members with a platform for active involvement in local development, seeking to advance their self-interest and dominating local discourse. Finally, locals who support this process also enjoy its dividends, such as opportunities in the tourism industry and infrastructure improvement.

However, lineage activity, based on continuous identity-shaping within local communities and even wider lineage networks, may further develop into local political power. As a result, there is a conflict between the demands of folk society organisations to actively strengthen local influence and participation in local affairs and the demands of officials to maintain authority and preserve flat control at the local level. Therefore, the rejuvenation of lineage traditions and the reuse of cultural heritage in Huizhou, represented by Huangdun, has become a window through which to observe potential changes in the Chinese grassroots social structure.

Literature review and research background

Identity construction by heritage reempowerment.

The literature has revealed that the authenticity of heritage is a process of being constructed (Canavan and McCamley, 2021 : 88; Kendall, 2017 ). This means that heritage empowerment provides people with the capability to romanticise many of their memories to cater to the imaginary needs of a particular contemporary group, reflecting changes in power structure and discourse. Correspondingly, heritage develops a top-down structure created and reinforced to capture nostalgia for a bygone era in a specific social, political, and economic context (Harrison, 2012 : 18). The collective nature of heritage makes it essential that the interpretation of heritage objects and related histories be in line with the consensus of collective memory, which significantly broadens the scope and appeal of heritage (Samuel, 2012 ). According to Halbwachs’s ( 1980 : 43) understanding, individual, collective, and historical memory support each other, are triggered based on consensus, and require the mutual support of different subjective memories to be refined and constructed. Norra ( 1996 : 5–23) further argues that the ‘memory place’ is a living carrier with a group perspective. Through media, metaphors, and symbols that transcend time and space, collective identity is reconstructed based on nostalgic reflection, and nation–states are such groups. Similarly, as Lowenthal ( 1998 : 121) and Ashworth ( 1994 : 16) point out, cultural heritage is created for contemporary consumption, linking stories of the past and places of historical significance and giving them new meanings. This means that the process of heritage designation (e.g., inscription on a heritage list) and empowerment is broadly participatory and based on collective memory. People define themselves through shared memories and shared forgetfulness; thus, communities can be recreated through envisaging. A community is self-evident, a state of consensus. By the time the community needs to be constructed, it no longer exists. ‘ Identity must belie its origin; it must deny being ‘just a surrogate’; it needs to conjure up a phantom of the self-same community which it has come to replace ’ (Bauman, 2013 : 18–19). The construction of a community presents a desire to find security and a familiar environment (Bauman, 2013 : 1–6). Historical places are where identities are created (Groote and Haartsen, 2016 ). Community and heritage/traditions are thus two sides of the same coin. However, the use of heritage also faces the challenge of integrating the thinking of different individuals; eliminating divisions within the group; and weighing the relationships between local and official, local and foreign groups, etc. Inequality and discrimination are rooted not in cultural injustice and devaluation but rather in the lack of means for groups to live in ways that are valued by themselves and others (Sayer, 2005 ). What needs to be recognised is not the identity of a particular group but the status of individuals and group members as reciprocal partners in society. That is, they can participate in society in a nonsubordinate, mutually recognised and equal manner (Fraser, 2003 : 21-24).

For this reason, heritage has become an important proxy for coordinating identity. Public history is destined to be interpreted as controversial due to its inseparable relationship with collective and individual memory (Glassberg, 1996 ). Heritage provides opportunities for diverse interpretations and the empowerment of memory and identity (Ashworth et al., 2015 : 15, 36–37). Thus, the ‘invention of tradition’ becomes an effective way to circumvent controversy, reshape history, and build consensus. This reflects the fact that the utilisation and reinvention of tradition imply a subtle infusion of order (Hobsbawm and Ranger, 2012 : 10-13). The issue of heritage in China is unique; with a long tradition of rebuilding monuments and reshaping sites, the emphasis is not on eternity but on inheritance in change (Stille, 2002 ). The ‘microethical ecology’ shaped by Chinese folk traditions about heritage reflects local and central differences and diversity in heritage management (Svensson, 2016 ). Different subjects have diverse understandings of heritage with different emphases and are closely related to specific demands (Sørensen and Carman, 2009 : 3). There is a greater need for something local, rooted in the individual and with a spirit of dedication, to meet individual needs and for psychological healing (Madsen, 2014 : 64). Heritage reuse efforts arouse local and national pride, promote interactions between local officials and vernacular groups (Zhu and Martínez, 2022 ), and reflect the efforts of local governments to restore their own culture and promote economic development (Martínez, 2022 ). Therefore, to investigate the role played by heritage empowerment in shaping and integrating different identities in China today, it is important to understand the recurring Chinese obsession with long-term temporal trajectory history (Harvey, 2001 ). The identification of different groups with the ‘local’ dimension of official ideology and culture is essential for social and national identity integration in China (roboWen C, 2019 ).

Thus, the reuse and empowerment of Chinese vernacular cultural heritage and tradition, and especially how community consciousness and identity are coordinated with official willingness, need further specific case exploration.

Lineage evolution and revival in Huizhou

Due to the uniqueness of the Huizhou regional lineage culture and development process, as well as the richness of its local literature, Huizhou lineage studies have provided a window for investigating the character of local Chinese society. Existing studies are particularly concerned with the significant impact of the Huizhou lineage and merchants from the Song to Ming and Qing periods (Beattie, 1979 ). Since the Song period (11th century), accompanied by the rise of the Huizhou lineages, the accumulation of wealth has stimulated elite people in Huizhou to continuously construct a grand social network of lineages, which has profoundly influenced local development (Hazelton, 1984 ; Zurndorfer, 1984 ). Moreover, through marriages with other elite families and the establishment of communal property regimes, lineages can achieve, protect and enhance their local position (Walton, 1999 ). This is usually a large and loose network, regardless of actual consanguinity, linked by an increasing number of branches of interest rather than strict genealogy (Xu, 2021 ; Zou, 2012 : 8-11). As a result, elites in the Huizhou countryside, based on extensive alliances of lineage networks, can flexibly adjust their strategies and roles according to social changes (McDermott, 2013 ). Therefore, the elites, represented by local gentry groups based on lineage systems, have a stable position but with flexible and varying occupations rather than just landlords or bureaucrats (Esherick and Rankin, 1990 : 13–19). The role of local elites thus shapes rural community consciousness in the context of modern social transformation (Sato, 2017 ). However, most of the above research focuses on Huizhou society and lineage relations during the imperial period. Although Huizhou had a profound lineage tradition in history, it declined sharply in the 20th century.

Accordingly, the trend of reuse of Chinese rural heritage sites in recent years has provided an endorsement for today’s lineage rejuvenation. This trend is supported by a major background policy: the conservation of traditional villages. Footnote 4 Related activities and industries based on the conservation and management of rural heritage have become important means for enhancing the economies of rural communities and are proxies for political change movements (Blumenfield and Silverman, 2013 ). In this context, the past and present should not be seen as distinct discontinuous realms; history and heritage are in some cases interrelated and interchangeable (Park, 2013 : 15). This is a dynamic and subjective process of domesticating elements and content from the past for contemporary purposes (Harvey, 1989 ). Coincidentally, the official and local discourse of the Huangshan today clearly reflects an obsession with the glorious past of Huizhou. The dual commercial and political success of Huizhou merchants and lineages during the Ming and Qing periods is now encapsulated in the success of the entire Huizhou region. The former Huizhou is ideally described as a harmonious place of wealth and peace, with a beautiful environment, that inherited the orthodoxy of Confucianism. This also coincides with the trend of promoting the construction of a harmonious society through the revival of Confucianism in China today (Billioud and Thoraval, 2008 ; Hwang, 2012 ). In 2014, the traditional ancestor worship ceremony of Huizhou was included on the “National Intangible Cultural Heritage” list. Footnote 5 Recent authoritative media reports have also emphasised the relationship between lineage worship and Neo-Confucianism, highlighting the leading role of lineage regulation in local affairs (Guangming Daily, 2023 ). These observations reflect the urgent need for self-confidence and effective grassroots management at the central government level, as well as the tangled attitude towards history. They also imply a return to traditional official discourse tendencies.

Research context and method

The study site is in Huangshan District, Anhui Province, China, which is known as a part of the Huizhou region. Culturally and geographically, Huizhou is famous for its iconic architecture, settlements, and Hui culture, and the UNESCO heritage sites Xidi and Hongcun are located there.

This study, based on case studies of Huangdun village in Huizhou, aims to investigate how the revival of lineage worship shapes collective identity in the Huizhou rural areas and how to reconcile the differences and similarities between official and local claims. Field investigations and interviews were conducted from 2020 to April 2023. For reliable data and firsthand information, the primary sources included various field investigations and observations of three lineage worship rituals in Huangdun in 2023. We applied the principle of nonparticipatory observation to the research fieldwork. Sixteen people with different backgrounds and sectoral identities were selected for semistructured and open-ended interviews. Interviewees were categorised according to their occupation as A: villagers, B: village committee staff, C: lineage ceremony participants, and D: activists or experts participating in lineage affairs and marked with their occupations. This helped understand the attributes of the interviewees (see Table 1 ). Informal chat and event speeches were not included. The purpose of the interviews was to obtain the opinions of subjects with diverse identities, standpoints, and interests and to demonstrate varied perceptions and attitudes towards lineage worship revitalisation in Huangdun. Some interview points and narrative descriptions of rituals are not directly quoted but rather incorporated into the narrative interpretation and analysis.

Secondary data sources included historical documents, policy text and other documents, images, local chronicles, government work reports, and media reports. These data are useful supplements to the primary sources. They help connect fragmented historical events and outline the evolution of lineage worship revitalisation at the case sites.

Recovery of group identity in heritage practice: the case of Huangdun village, Huizhou

Reconstruction of the lineage and confucian tradition.

Heritage empowerment is closely linked with subjectivity. In the case of Huangdun village in Huizhou, people are actively using the correlation between heritage and Neo-Confucian culture to strengthen community identity and even profit. Different subjects, from bureaucrats and scholars to villagers, all pay particular attention to promoting lineage and Confucian culture and exploring famous historical events while integrating this process with national heritage conservation initiatives.

Huangdun is an ancient Huizhou village with a history of nearly 2000 years. The village is adjacent to Huangshan city. It is considered an important settlement for ancient Chinese lineage immigrants from North China who migrated to the south. At least 56 lineages can be verified. Most of the immigrants were elite gentry groups who believed in Confucianism; therefore, the village is considered to be an important birthplace of Hui culture and inherited the so-called Chinese orthodox Confucian culture, especially as the ancestral home of famous Neo-Confucian Masters Chengyi, Chenghao (程颐,程颢) and Zhuxi (朱熹) (Liu, 2011 ). Local voices therefore proudly proclaimed Huangdun ‘the representative village of Huizhou culture’. In May 2020, a stone archway engraved with the words ‘Luo min su ben (洛闽溯本)’, which means ‘the origin and ancestral home of the masters of Neo-Confucianism’, was unearthed in the village. The engraving was also identified as containing the seal and royal signature of Emperor Qianlong (乾隆) of the Qing period. In addition, the dragon pattern on the archway is actually a ‘five-clawed dragon’, a decoration that could only be used by the royal court in the imperial era. The archway was built in 1612, restored in 1760, and finally demolished in 1976 during the Cultural Revolution. Thus, local academics noted the close relationship between the village of Huangdun and Neo-Confucianism at the royal level in imperial times, while today’s reconstruction implies permission and support for the reemergence of Confucianism and lineage worship on the part of the central government. Therefore, local media have proclaimed the village “the iconic evidence/token which represents the premium hierarchy of Huizhou culture” (Xinan Evening News, 2020 ).

After the reconstruction of the archway, in 2021, the SanFuzi Ci (the hall of the three masters三夫子祠) memorial hall, which was built in 1760 but destroyed in the late 19th century to commemorate Cheng Yi, Cheng Hao, and Zhu Xi, was rebuilt behind the archway with reference to historical records. Both projects not only received financial support and publicity at the government level but have also been welcomed by local villagers. Although these structures are restorations or replicas, they are still considered to be of great symbolic importance to local lineages.

For example, Interviewee B1, a villager who works for the village committee and is also a folk historian, is passionate about the history of Huangdun village and has played an active and important role in the restoration of the abovementioned structures. He claimed that these structures are important because they proclaim the long history of Confucian cultural orthodoxy and the prosperity of Huizhou. In addition, they symbolise local lineages originating from noble families that could date back one thousand years. In a more realistic sense, they will allow the small, unassuming village of Huangdun to receive direct 10 million CNY of financial subsidies and publicity from the municipal level in the name of heritage conservation, which the village can use to improve environmental and infrastructure conditions, repaving roads and taking other measures to address the village’s increasing popularity. This was confirmed by villagers A1, A2 and A3. A1 said,

“The buildings are certainly beautiful to look at, and we may have opportunities to do small business in the future when more people come to visit and worship ancestors.”

In this case, top-down public attitudes show an obscure consensus. The revival of ancestor worship has brought opportunities for development based on interpersonal relationships. B1 is confident in the prospect:

“Huangdun has always been a place where Huizhou culture flourished because the roots of Neo-Confucianism are here. We also feel honoured in this village, as it is the epitome of Huizhou. In the next step, my task is to receive those people who come to seek their ancestors or hold lineage worship rituals. I will let them publicise the history and culture of Huangdun to the whole country, even overseas.”

This attitude, that ancestor worship activities could improve the reputation of the village and bring potential benefits for tourism and investment, is echoed by a native cadre of the village committee, B2. The restoration and rebuilding of historical structures provide the basis for extensive revival of intangible activities.

As Sather-Wagstaff ( 2015 : 191-204) claimed, heritage and memory have many common characteristics; people share the memory of heritage through narratives and various activities, while heritage also functions through ongoing social and intergroup narrative interactions. As a result, heritage activities cannot be sustained without the two crucial factors of collective memory and group identity. Due to the correlation of the village with Confucianism and historically prominent lineages, ancestor worship has gradually flourished there. The ancestor worship tradition ceased during the anti-Japanese war. After the founding of the People’s Republic of China, ancestor worship rituals were identified as ‘feudal superstition’ and banned. In 2007, nearly 30 years after the ‘Reform and Opening’ policy was applied, the Cheng lineage decided to recover its ancestor worship tradition. Therefore, the Cheng lineage gathered members through the internet and restarted the ancestor worship ritual in Huangdun after a 64-year hiatus. According to a witness, while it was obstructed by some people and even reported to the local police for intervention, in the end, the ritual was successfully conducted. Since then, the members of the Cheng lineage from throughout the whole country and abroad have come to Huangdun and participated in ancestor worship ceremonies each year. In 2011, the chairperson of the World Federation of Cheng Clansmen Cheng Mingrong, and other federation members participated in the ritual in Huangdun. In 2011 and 2017, Cheng Wanqi, the chairperson of the United World Chinese Association, visited Huangdun twice to participate in ancestor worship. The 2017 ritual even fulfilled the long-held wish of the Chinese nuclear engineer and physicist Cheng Kaijia; that is, he claimed himself to be the Huizhou people. The son of Cheng Kaijia, General Cheng Bozhong, also participated in the ceremony. A growing number of famous lineage members have gathered in Huangdun village, holding ancestor worship ceremonies. These actions are driving ancestor worship and lineage discovery in Huangdun and are closely tied to overseas communities such as Singapore, Malaysia, and Canada, with prominent international influence. This provides important public support and justification for ancestor worship.

Thus, except for the Cheng lineage, folk groups, and other major lineages have been inspired to gradually recover their traditions. In recent years, between February and April, members of different lineages who recognise Huangdun as their ancestral home have visited Huangdun from all over the country to hold ancestor worship rituals, such as major lineages with the surnames Cheng, Zhu, and Huang. The Cheng lineage, the oldest and longest lineage in Huizhou, spent more than 1 million CNY on the renovation of their ancestral tomb and purchased more than 20 mu (1.3 ha) of land near the village for a cemetery in 2013. In 2019, the Huang lineage purchased a plot of land in the village at a cost of more than 300,000 CNY and rebuilt their ancestral cemetery. In 2023, the Zhu lineage raised 178,000 CNY and made plans to restore their ancestral tomb. On 13th April 2023, the Zhu lineage conducted their first ancestor worship ritual since the founding of the People’s Republic of China at the rebuilt SanFuzi Ci in Huangdun. Lineage members from Hubei, Jiangxi, and other provinces participated in the sacrificial ritual and displayed the slogan of revitalising Neo-Confucianism at the event site. This ritual was strongly supported by the Huangshan Neo-Confucianism Research Society (程朱理学研究会).

From a series of historic building reconstructions and site restorations, as well as the manifestations of intensified lineage-seeking and worshiping activities, these spontaneous folk actions to uncover history and traditions not only show a reverence for the glorious past and pride in the lineage but also support common people. In particular, the influence of contemporary celebrities and successful lineage members is used to extend the legitimacy of the action, which in turn prompts government acquiescence. As a result, this regional “conscious historical construct” (Faure and Siu, 1995 ) encompasses a wider range of lineage-centric relationship networks.

Heritage empowerment and discourse construction in Huangdun

The recovery of lineage worship has met with some opposition, based on the concern that tight intralineage relations could benefit lineage members but marginalise smaller lineages and ordinary individuals. In addition, historically, lineage power, especially in China’s imperial period, usually led to powerful regionalist forces that were even capable of opposing the centralised official government (Miller, 2008 ). Therefore, lineages are usually subject to repression at the national level. For example, the Anhui Provincial level has adopted an ambiguous attitude of “no objection, no support, and no participation” towards activities such as lineage worship and religious rituals. This is one of the reasons for the protests mentioned above. In response, historical sites and traditional rituals in this reconstruction process have not merely engaged in worshipping ancestors. Instead, they have become carriers of discipline and preachers for the expression of official will and discourse in the new era, conveyed in a more subtle and palatable way. As Giblin et al. ( 2015 ) noted, this is a product of reclaiming and reappropriating the meanings and concepts of the past.

The ancestor worship rites in Huangdun today are different from the rituals revived in other places, which are concerned with reestablishing a sense of lineage identity and belonging and educating their descendants (Zhang and Wu, 2016 ). Instead, the narrative of the Huangdun rites ties the flourishing of individuals and lineages to the stability of the nation–state, thus echoing the official discourse in support of the revival of lineage culture. Therefore, although the provincial level does not directly support such activities, in practice, they are tacitly approved. For example, a member of the Zhu lineage argued that they are not in conflict with official ideology but are actually in accordance with the national policy of the “revival of outstanding traditional culture”. D4, the host of the ancestor worship ritual of the Zhu lineage, claimed that ancestor worship means, most importantly, acknowledging the moral principles of Neo-Confucianism, such as filial piety and reciprocation; these are the foundation and the core values of the Chinese orthodox tradition. This echoes the pursuit of cultural orthodoxy and ideological legitimacy of the contemporary Chinese Communist Party. Support from cultural policy at the national level provides an endorsement for such activities.

In addition to its connection to the moral principles of Neo-Confucianism, patriotism has been considered an essential rationale for ancestor worship in Huangdun. On 11th March 2023, at an ancestor worship ritual there, the leader of Association of Huang Lineage, Jiangxi Branch, stated why it is necessary to reclaim the lineage:

“Our Huang lineage has striven for the prosperity of the country and the rise of the nation–state for thousands of years. Our lineage has spread around the world, and our ancestors have left us the spiritual legacy that we need self-improvement and to strive not only for ourselves but for our family, lineage and nation.”

The vice-chairperson of the Association of Huang Lineage also noted an important link between lineage and the stability of the state:

“We have travelled thousands of kilometres to the Huangdun ancestral cemetery to pay our respects to our ancestors. We hope that our ancestors will bless the descendants of the Huang lineage…History tells us that countries can be destroyed, dynasties can be replaced, individuals can perish, and only the lineage can last forever. Only when there are members of the lineage can there be a whole nation. So, it is only the harmony and prosperity of lineages that constitutes the harmony and flourishing of the entire ethnicity and the nation.”

Such a narrative demonstrates a rationalisation of actions based on the collective memory of patriotism. On 17th April 2023, the Cheng lineage held their annual ancestor worship ritual in the restored cemetery in Huangdun. Approximately 800 lineage members participated. The slogans posted at the site proclaimed the orthodoxy of the lineage by highlighting the long history and notable historical figures of the lineage. All the named figures were famous bureaucrats in imperial times. In particular, Cheng Lingxi was the first Huizhou person to be recorded in the official chronicle because he both defended Huizhou during the civil war and recognise the authority of the imperial government. Therefore, he was bestowed the title ‘Shizhong (世忠)’, which means ‘loyal to the imperial court for generations’, by the Song emperor in the Jiading period (1223 AD). Since then, Cheng Lingxi has been considered an important local deity by the Huizhou people. This process incorporated folk gods into the officially recognised gods through an imperial edict. Through the process of ‘standardising the gods’, national institutions and powers thus intervene in folk beliefs and create a crossover of cultural meaning between national and local societies (Watson, 1985 ). Therefore, the Cheng lineage combines the notable figures of the lineage who were admired in imperial times to support real-time/contemporary lineage legitimacy. That is, they acknowledge their loyalty to the central regime and their role as guardians of the familiar common past of the Huizhou people. This explanation echoes the official discourse of national rejuvenation and allows nonlineage members to recognise the prominent status of the Cheng lineage. The interviews revealed general support and acknowledgement from local villagers and ordinary lineage members Figs. 1 – 5 . This is a process to preserve and utilise the collective memory carried by the heritage, thus developing it into cultural awareness and establishing a collective identity (Song and Zhu, 2012 ).

(1)(2) Fragments of the stone archway excavated in the village. (3) Reconstructed stone archway. Source: Photograph provided by Jin Xinji and the author, 8th June 2022.

(1): Illustration of the ‘SanFuzi Ci (The hall of the three masters)’ and the stone archway in the book ‘Huangdun Cheng Zhu que li ci zhi’, issue 3, edited in 1745. (2) Reconstructed SanFuzi Ci and the stone archway. Source: (1): National Library of China – Harvard-Yenching Library Chinese Rare Book Digitisation Project, Record ID: 990080258810203941. (2): Photographed by the authors, 13th April 2023.

Front view of the reconstructed SanFuzi Ci. Source: Photograph by the authors, 13th April 2023.

Slogans on the dissemination of Neo-Confucianism at the first ancestor worship ritual of the Zhu lineage in Huangdun. Source: Photograph by the authors, 13th April 2023.

Ancestor worship ritual of the Cheng lineage in 2023. Portraits of notable historical figures of the Cheng lineage are presented. Source: Photograph by the authors, 17th April 2023.

Similarly, D2, a local bureaucrat with the surname Cheng, has been dedicated to promoting and studying the genealogy of the Cheng lineage for several years. He proudly declared that he was the 64th-generation descendant of the lineage in Huizhou. He believes that the genealogy of his lineage proves that Huizhou has a long and uninterrupted cultural background. He said he was editing a book about ‘100 famous people in the history of the Huizhou Cheng patriarchal lineage’, with the following motivation:

“I want to achieve a goal through the excavation of Huizhou genealogy culture; that is, the study of traditional culture should serve the past for the present and promote the development of contemporary economy and society…Without a country, how can there be a family?”

This echoes the idea of the unity of the lineage and the country. Moreover, he pointed out that those who actively participate in genealogy study and tracing their ancestors are basically those who have ‘achieved fame and fortune’ and wish to ‘glorify their ancestors’ through worship rituals:

“These participants generally are bureaucrats or enterprises with profound personal connections, funds and project resources, so they can promote the development of genealogy-seeking tourism, which can finally be transformed into capital investments in Huizhou. This is also due to the opportunities presented by a sense of identity recognition.”

This rhetoric refers to participants’ involvement in worship activities. D2 is currently a government official and is not permitted to participate in lineage activities. However, participants in the ancestor worship ritual of the Cheng lineage include former government bureaucrats, entrepreneurs and even a former provincial deputy director of the Department of Education. Thus, lineage ceremonies promote mutual connection and assistance not only within the same genealogy but also among officials, scholars, and enterprises. The rituals have become a good way for influential elites to bond and promote interaction, as well as providing opportunities for municipal or district officials to develop tourism and investment.

Notably, not everyone is interested in participating in lineage rituals and exploring the connotations of traditional culture; young people are particularly unenthusiastic. They usually do not have opportunities to directly benefit from the reuse of heritage. For most, traditional events and lineage rituals are simple proxies for celebration and collective revelry with an element of curiosity. This phenomenon is well explained by cultural heritage conservation activist D1:

“This example is like Christmas (in China); many people may just take it as a consumption holiday. Referring to the issue of cultural heritage and folklore, my point of view is, the first thing is to let young people know that such a beautiful historical place exists, even if they only visit it initially because it is nice to take pictures, so that there is a further chance someone will be interested in the connotation behind it.”

C4, a young member of the Cheng lineage from Beijing who has participated in the ritual, described the ceremony as an astonishing experience that made him interested in the rich history and glorious past of the lineage. C3 from Jiangxi expressed a similar attitude. Thus, although not everyone understood or was passionate about the revival of traditions and conservation of heritages, different participants found their own areas of interest and reasons for involvement in the activities in this process. D3, a resident who had been away from Huangdun since 1953 and now lived in another county, was the most active and important editor of the Huangdun chronicle. He spent five years editing the chronicle without pay, believing this to be his most meaningful contribution to local affairs. Just as most participants were from other provinces or even abroad, this reflects that the shaping of identity, based on shared local history and pride, could transcend geography and attribution. Huangdun, this small village, has thus become a ‘hometown that has never been met’ by many people. The process of idealised heritage creates a new environment in which participants can discover their own possibilities and concerns. As a result, the emphasis on immortality, aesthetics, and authority in the field of heritage is increasingly being replaced by a more inclusive approach that combines ordinary, popular, and intangible heritages (Featherstone, 2007 ).

In the case of Huangdun, the ‘authenticity’ in the professional conception of cultural heritage was not valued by the participants during the implementation of specific ritual processes and etiquette. Rather, the participants sought the sense of cohesion and moulding power over individuals that comes from group activities based on a common identity. The lineage rituals reappropriated in this new era were accompanied by lively celebrations, singing and dancing, banquets and travel for a few days after the ceremony. The whole process was enveloped in a cheerful atmosphere and allowed for the participation of members of all ages, as well as females and members with foreign surnames. These proceedings were completely different from the traditional rituals that are shrouded in hierarchical patriarchy. This is why they are more appropriately regarded as a ‘cultural carnival’ for sufficient ‘legitimate’ reasons. They can be inclusive, bringing together individuals with different intentions and identities. Before such a ceremony, most participants may be complete strangers, but with the identification of the Huizhou region and lineage, they borrow the collective memory from the past and then construct a new one. The result is cordial communication among strangers and deserved recognition and support of each other. The sense of presence created in lineage activities strengthens recognition of and respect for individuals and provides participants with the possibility of security, dependence, and real career ties. Participants’ sense of existence and self-meaning are highlighted and respected in lineage activities. Therefore, rebuilding a sense of community through lineage revival is the focus of this process. This community is not a narrowly defined local community based on locality and kinship in the general sense but rather a cultural community that transcends geography and is spread across more than a dozen provinces in China and overseas.

Huangdun thus serves as a symbolic historical site, using lineage ceremonies as a platform to unite the network of group relationships based on consensus. On the one hand, this reinforces the orthodoxy derived from cultural traditions and lineages and integrates the cross-regional identity of the same family name so that the lineage is not limited to strict bloodlines, which is helpful in expanding the power of the reconstructed community. More importantly, in conjunction with the preservation of Huizhou’s heritage and tradition, it reinvents and expands the notion of the identity of the ‘Huizhou people’ at a time when Huizhou as an administrative entity has disappeared. A concept based on cultural identity subtly allows the recognition of lineage origin from Huangdun to be transformed into a cross-regional identity.

This is precisely in line with the official intention of strengthening nationalist discourse. For example, with Huangshan village in the same city, the reconstruction of tradition since 2013 has centred on the sacrifice of the Yellow Emperor, which was claimed to have originated from the intangible cultural heritage ‘Xuanyuan Che Hui (轩辕车会)’. This is both a way of correlating the concept of the Yellow Emperor and the Yellow Mountain to promote local pride and prestige based on cultural orthodoxy and a means of fitting in with the idea of grand unity. Thus, for officials, the specific local manifestations of folk worship are not important, and there is a high degree of freedom but also an acknowledgement of local–central unified concepts and ideologies of grand unity (Faure and Liu, 2008 ). Existing critical heritage studies usually criticise the government based on discursive hegemony and official standard norms that call for the specific use of heritage and expression, which ignores folk discourse and marginalises the demands of vulnerable groups. Most actions at the official level are characterised by a dominant position based on authorised heritage discourse, but this does not mean that civil discourse and intentions are completely suppressed and opposed in an a priori manner. Although lineage activities draw on the idea of cultural heritage preservation and appeal to the official discourse of patriotism, their relationship with officialdom is delicate. Similarly, China’s Shanxi Province has consciously constructed a new identity for former Shanxi merchants as innovative and ethical entrepreneurs since the 1990s, which has not only become part of the discourse emphasising contemporary Shanxi business development but also significantly reshaped the public understanding of local history and identity (Kong, 2010 ). At the national level, lineage traditions and activities could become the carriers of official discourse to preach official ideology. For example, officials may visit ancestral halls for anticorruption education through learning about exemplary bureaucrats and personalities from history, spreading traditional morals such as loyalty and filial piety through the tradition of lineages, and learning and citing from lineage rules and laws to maintain local management and social order (The Supreme People’s Court of The People’s Republic of China, 2023 ). Events in Huangdun have helped enhance local pride, and Huizhou’s cultural image and long history and the image of its gentry, who once relied on lineage relations to succeed, have been embellished. This serves to indoctrinate and spread ideology. For instance, the Huangdun Village History Museum was funded by the government and displays the deeds of various lineages and famous figures throughout the village’s history. It has become a must-visit site for those who come to Huangdun to worship their ancestors. There are even small-scale, privately sponsored cultural conferences on kinship study during this process. Individual participants’ self-perception and sense of place are thus awakened and become clearer, which may help strengthen the sense of belonging and official narrative of state agencies, but it may also have the opposite effect on regionalism and division. The revival of lineage tradition is thus, in fact, a contractual relationship with the official that is mutually beneficial though full of continuous contradictions (Freedman, 2021 ).

Through the empirical and discursive study of related ceremonies, we can observe that for the influential members involved in this process, it is a potential way to expand their own interpersonal network and local influence. The different intentions in the use of lineage traditions between people and officials have led to an implicit conflict. Although the revival of traditional culture and the reuse of heritage offer approaches to rationalise the organisation and activities of civic groups, for local governments, there is a potential risk of making local affairs more complicated and less impactful. The central government has always been wary of the growth of civil society organisations, hoping to maintain the flattened control and authority of the Communist Party of China in local areas. Currently, the trend of lineage revival represented by Huangdun village is still strongly dominated by elites and nonlocal influential people. Moreover, because lineage activities have no connection to local management and democratic decision-making, such actions can only serve as an interest-gaining tool for elite groups and intralineage relations. At the same time, the ambiguity of officialdom and the lack of clear regulations allow for “grey areas” of operation in matters relating to lineage activities. It is worth continuously observing how lineage reconstruction trends under traditional culture revival and cultural heritage conservation schemes will reflect the coordination of folk and official purposes.

This article analyses the role of traditional Chinese cultural revival in shaping group identity and forging consensus. The study notes that in the nostalgic historical interpretation process, the revival of lineage activities in Huangdun has essentially become a multisystem structure that encompasses the enhancement of the village’s built environment, the generation of income for the local economy, the construction of cultural industries, and the shaping of the group’s identity. For local society, the actions of lineages and folk groups subtly highlight the consistency between the recovery of local tradition and official discourse and national policy, recognising the consensus of the values of stability and loyalty. This ingenious strategy has allowed folk action to gain official acquiescence. This process connects and expands the network of lineage members through rituals, and thus, economic benefits can flow to individual subjects, while other locals who are not part of the lineage can benefit from infrastructure upgrades and the dividends of tourism. For local officials, although they maintain neutrality towards the revival of lineage traditions, the lack of investment capabilities at the regional government level and the endorsement of national cultural policies make lineage interventions possible. The difference in intentions between officials and locals is aligned with mutual precaution and realistic goals. The example of Huangdun shows that the reappropriation of heritage/tradition should be considered a process of social construction and cultural reshaping rather than just ontological performance. This dual reconstruction and redefinition of historical buildings, sites, and traditions is a reminder of the dubious dichotomy between tangible and intangible elements in existing mainstream heritage theory. Identity recognition based on a wide lineage network provides members with transcendental collective security and pride. Thus, the community is reconstructing in this collective activity, and the process of reappropriating traditions and utilising them under the banner of the past and ancestors is fully legitimate and inclusive. The revival of lineage traditions by folk groups has drawn on the theoretical support provided by cultural policies at the national level while also satisfying the political desires of local governments eager to develop the tourism economy and achieve rural revitalisation. Lineage worship traditions have thus been sustained and have become a signature local cultural phenomenon.

The collective memory is reawakened in the nostalgia process through interaction with heritages and the review of history. Although the lineage revival in Huangdun draws on the official discourse of preservation and reuse of cultural heritage and traditions, the details of its rituals today differ from the historical records, as well as from the processes and locations of rituals during the imperial period. These historical facts and the truth about ancestral lineage are no longer important today. Importantly, the universalisation and blurring of heritages have led to a romanticised imagination that substitutes the events and concepts of ‘today’ for the scenes of ‘the past’. The category of “identity” thus has the potential to transcend time, space, class, and material conditions to become a wide-ranging and highly universal concept, enabling the expansion of group consensus and healing wounds of reality. Therefore, each participant’s nostalgic memory of the vernacular community and ancestry, along with their subjective understanding of history, reconstructs the collective memory. In this process of continuous accumulation and self-persuasion, the history of lineage and perceptions of groups are reinforced, integrated and eventually aggregated into the grand narrative of who ‘we’ are: ‘true’ Huizhou people with many traditions and a long shared history centred on a noble lineage. This recognition, based on shared identity and the value of ‘harmony’, has led to the construction of grassroots communities. It is also a current consideration for the current Chinese official discourse, which is inclined to use the term ‘cultural gene’ to describe ideological inheritance extracted from cultural tradition (Li et al., 2015 ; People’s Daily Online, 2022 ). Therefore, the experience of the reuse of rural heritages in Huizhou, China, reveals that historical traditions and values are subtly interpreted in conjunction with contemporary socialist values and are intended to persuade visitors to be humble, courteous, subordinate, and disciplined. Importantly, “us” originates from history and shares a common past. The contestation of what is “Huizhou culture” and what is “us” has become vaguer and negotiable. Therefore, following the Confucian orthodox order to promote the establishment of a “harmonious” society, the contribution of lineage is consistent with that of the nation–state. Finally, the interpretation and reuse of heritage and tradition are based on a priori value implications: Heritage and traditions are not only relics, rituals or cultural commodities in a narrow sense; to some extent, heritage is a declaration based on current ideology and cultural awareness.

Data availability

The data for this research consist mainly of video recordings, interview records, and historical documents, which were collated and analysed to present the results in the article. Original video recordings, interview records, and photographs cannot be shown directly to the public to protect the privacy and ownership of the interviewees and authors. However, if potential readers would like to obtain a copy of any of the original video recordings, interview records, etc., they may do so by specifying the purpose and providing specific contact, affiliation, and other information in a request. The datasets generated during and/or analysed during the current study are available from the corresponding author upon reasonable request.

Since 2001, the multiyear project ‘In Search of the Origins of Chinese Civilisation: A Long-term Transdisciplinary Program’ has continued to receive the support of national research funding programmes and has been in operation for decades, analysing the origins of Chinese civilisation and whether it could extend back 5000 years. The project has been greatly valued and supported by Chinese officials. See the detailed descriptions from The Institute of Archaeology CASS: http://www.kaogu.cn/en/Research_work/Exploration_on_the_origin_of_Ch/2013/1025/30314.html and from The State Council Information Office of China: http://english.scio.gov.cn/pressroom/2018-05/29/content_51528874.htm .

In 2017, the State Council Information Office of the People’s Republic of China released the ‘Opinions on the Implementation of the Project of the Inheritance and Development of the Outstanding Chinese Traditional Culture’: http://www.scio.gov.cn/xwfbh/xwbfbh/wqfbh/37601/38768/xgzc38774/Document/1634775/1634775.htm .

The Chinese national government has been highlighting the importance of protecting history and cultural heritage in recent years for various national departments. See the notice of the Ministry of Culture And Tourism of the People’s Republic of China: https://zwgk.mct.gov.cn/zfxxgkml/qt/202206/t20220602_933336.html and the notice of the Ministry of Justice of the People’s Republic of China: http://www.moj.gov.cn/pub/sfbgw/gwxw/ttxw/202203/t20220323_451311.html .

Several central government departments of China, including The Ministry of Housing and Urban‒Rural Development, the Ministry of Culture, the State Administration of Cultural Heritage, and the Ministry of Finance, jointly launched a policy to conserve traditional villages in 2012. See: http://www.gov.cn/zwgk/2012-04/24/content_2121340.htm .

See the description of the traditional ancestor worship ceremony of Huizhou on the website of China Intangible Cultural Heritage: https://www.ihchina.cn/project_details/15225 .

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Acknowledgements

Our gratitude to the scholars and participants in Huangshan for their help in the research, their availability for the interviews, and their generous arrangement of the site visits, as well as to Jin Xinji (金鑫季) of Huangdun village and Cheng Jingliang (程景梁) for research material support. We are grateful to Professor Xu Subin (徐苏斌) for her support for this research.

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Ruyu TAO & Nobuo AOKI

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TAO, R., AOKI, N. & CHEN, P. Reappropriating the communal past: lineage tradition revival as a way of constructing collective identity in Huizhou, China. Humanit Soc Sci Commun 11 , 881 (2024). https://doi.org/10.1057/s41599-024-03399-2

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DOI : https://doi.org/10.1057/s41599-024-03399-2

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