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Case Study – Methods, Examples and Guide

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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.

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Muhammad Hassan

Researcher, Academic Writer, Web developer

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• What Is a Case Study? | Definition, Examples & Methods

What Is a Case Study? | Definition, Examples & Methods

Published on May 8, 2019 by Shona McCombes . Revised on November 20, 2023.

A case study is a detailed study of a specific subject, such as a person, group, place, event, organization, or phenomenon. Case studies are commonly used in social, educational, clinical, and business research.

A case study research design usually involves qualitative methods , but quantitative methods are sometimes also used. Case studies are good for describing , comparing, evaluating and understanding different aspects of a research problem .

Table of contents

When to do a case study, step 1: select a case, step 2: build a theoretical framework, step 3: collect your data, step 4: describe and analyze the case, other interesting articles.

A case study is an appropriate research design when you want to gain concrete, contextual, in-depth knowledge about a specific real-world subject. It allows you to explore the key characteristics, meanings, and implications of the case.

Case studies are often a good choice in a thesis or dissertation . They keep your project focused and manageable when you don’t have the time or resources to do large-scale research.

You might use just one complex case study where you explore a single subject in depth, or conduct multiple case studies to compare and illuminate different aspects of your research problem.

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Once you have developed your problem statement and research questions , you should be ready to choose the specific case that you want to focus on. A good case study should have the potential to:

• Provide new or unexpected insights into the subject
• Challenge or complicate existing assumptions and theories
• Propose practical courses of action to resolve a problem
• Open up new directions for future research

TipIf your research is more practical in nature and aims to simultaneously investigate an issue as you solve it, consider conducting action research instead.

Unlike quantitative or experimental research , a strong case study does not require a random or representative sample. In fact, case studies often deliberately focus on unusual, neglected, or outlying cases which may shed new light on the research problem.

Example of an outlying case studyIn the 1960s the town of Roseto, Pennsylvania was discovered to have extremely low rates of heart disease compared to the US average. It became an important case study for understanding previously neglected causes of heart disease.

However, you can also choose a more common or representative case to exemplify a particular category, experience or phenomenon.

Example of a representative case studyIn the 1920s, two sociologists used Muncie, Indiana as a case study of a typical American city that supposedly exemplified the changing culture of the US at the time.

While case studies focus more on concrete details than general theories, they should usually have some connection with theory in the field. This way the case study is not just an isolated description, but is integrated into existing knowledge about the topic. It might aim to:

• Exemplify a theory by showing how it explains the case under investigation
• Expand on a theory by uncovering new concepts and ideas that need to be incorporated
• Challenge a theory by exploring an outlier case that doesn’t fit with established assumptions

To ensure that your analysis of the case has a solid academic grounding, you should conduct a literature review of sources related to the topic and develop a theoretical framework . This means identifying key concepts and theories to guide your analysis and interpretation.

There are many different research methods you can use to collect data on your subject. Case studies tend to focus on qualitative data using methods such as interviews , observations , and analysis of primary and secondary sources (e.g., newspaper articles, photographs, official records). Sometimes a case study will also collect quantitative data.

Example of a mixed methods case studyFor a case study of a wind farm development in a rural area, you could collect quantitative data on employment rates and business revenue, collect qualitative data on local people’s perceptions and experiences, and analyze local and national media coverage of the development.

The aim is to gain as thorough an understanding as possible of the case and its context.

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In writing up the case study, you need to bring together all the relevant aspects to give as complete a picture as possible of the subject.

How you report your findings depends on the type of research you are doing. Some case studies are structured like a standard scientific paper or thesis , with separate sections or chapters for the methods , results and discussion .

Others are written in a more narrative style, aiming to explore the case from various angles and analyze its meanings and implications (for example, by using textual analysis or discourse analysis ).

In all cases, though, make sure to give contextual details about the case, connect it back to the literature and theory, and discuss how it fits into wider patterns or debates.

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

• Normal distribution
• Degrees of freedom
• Null hypothesis
• Discourse analysis
• Control groups
• Mixed methods research
• Non-probability sampling
• Quantitative research
• Ecological validity

Research bias

• Rosenthal effect
• Implicit bias
• Cognitive bias
• Selection bias
• Negativity bias
• Status quo bias

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A Better Way to Teach History

One professor is borrowing a method from Harvard Business School to engage students and inspire better decision-making skills.

In a spacious classroom in Aldrich Hall on the Harvard Business School campus, 100 students are passionately discussing a case called “Battle Over a Bank.” But these aren’t MBA students deliberating over how much the government should regulate the financial sector. This group of mostly undergraduates, guided by the award-winning Harvard Business School professor David Moss, is diving into the fierce 1791 debate over whether the Constitution could be interpreted to allow the fledgling U.S. government the power to form a bank at all.

This class, “History of American Democracy,” is no pedestrian historical survey course. It uses the case method—the business school’s signature teaching technique—to immerse undergraduates (as well as a limited number of HBS students) in critical episodes in the development of American democracy.

The field of history is often dismissed as dull, but educators like Moss are experimenting with innovative teaching strategies to teach history in a way that is effective, exciting, and productive. There’s “Reading like a Historian,” based at Stanford and aimed at the K-12 level, which explicitly hones the ability to take primary sources and interpret, construct meaning, recognize competing narratives, and contextualize as a historian would. “Reacting to the Past,” started at Barnard College by Mark Carnes, is a student-centered college curriculum consisting entirely of role-playing games. “Facing History and Ourselves,” which grew out of a course focused on the Holocaust, uses a multi-pronged approach to get young people in grades six through 12 thinking about the ramifications of genocide and mass violence as a way of reflecting on moral choices they themselves face in their own lives.

History education generates heated controversy among educators and policymakers. There is a long history of tension over which historical facts children should be learning in school and when, whether a particular set of proposed standards is too patriotic, too multicultural, or whitewashes uncomfortable truths. Controversies over the content and nature of what children are learning often fall along political lines: The Michigan State Board of Education recently delayed voting on its new social-studies standards because of a controversy over whether liberal bias was behind proposals to include civil rights in the curriculum before high school, while in Texas, critics repeatedly accuse textbook authors of reflecting conservative political views in their coverage of topics such as religion or slavery.

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Perhaps the most major current-day divide falls along the lines of content versus skills: Should history classes be about acquiring facts and information, or should they emphasize historical thinking abilities and processes? And if the latter, which skills and how might they best be taught? While a positivist view of history—the 19th-century notion that history was akin to a science, and that the accumulation of historical facts would eventually lead to an objective understanding of events—fell out of favor long ago, this idea seems to remain the operative assumption behind traditional history curricula that emphasize content, chronology, and comprehensiveness.

According to Bob Bain, a professor of history and education at the University of Michigan and faculty lead on the Big History Project , the debate over factual content versus skills—one that has actually waxed and waned ever since history emerged as a field of study a century and a half ago—pertains to a false dichotomy. “You can’t do historical thinking without facts, and you can’t acquire stuff without some sort of historical thinking,” he points out. A good history teacher can teach both effectively, agrees Elaine Carey, a history professor at St. John’s University and the former vice president of the teaching division of the American Historical Association. She emphasizes that teachers can teach “skills through content,” and that you “can’t understand historical continuity if you don’t have historical knowledge.”

The case method goes beyond historical skills and factual content; it aims to hone decision-making skills. Each case is a concentrated story about a specific episode in history. Students are asked what they would have decided had they been, say, an advocate arguing for compulsory public education in 1851, or Theodore Roosevelt deciding whether to intervene in a dispute between labor and industry in 1901. It’s not until after they have fully discussed the case that the historical outcome is revealed to them. (Class participation, even though it is mandatory, is enthusiastic: “We can have 40 hands in the air at any given moment,” Moss tells me.)

Few students think about history that way, according to Moss. Instead, they’re often taught that “what happened is what happened.” Unlike with many history courses, where students look back at historical events students in Moss’s course “play history forward. If you were in that place as that voter, that labor leader, or that congressperson, what decision would you have made?”

One of the reasons American children often appear to struggle in history, Bain says, is because their knowledge is primarily assessed through multiple-choice tests. Multiple-choice assessment, by nature, often privileges factual content over historical thinking. “If you’re testing historical content out of context, that might explain why they don’t do so well,” Bain says. He advocates embracing the use of narrative—even if that narrative is flawed or one-sided. “The grand narrative is pejorative to many in the historical profession—people say that it tries to inculcate a particular viewpoint in kids. But having a big picture or story is cognitively critical to historical knowledge.”

Similarly, history textbooks appear omniscient and objective, and tend to gloss over competing narratives. But educators say that understanding whose narrative is being told helps students to engage with it; even if it is wrong or they disagree with it, the narrative provides context and a more effective way to learn and remember. “The argument I make all the time is, it’s like if I were to ask someone to assemble a 1,000-piece jigsaw puzzle without the box-top picture of it. You could of course eventually put it together but the effort to match shapes and colors on each piece would be monumental, and you’d likely give up quite quickly. Such is what happens to many kids in school.”

It’s difficult to track down research corroborating the academic benefits of the case method, but anecdotal evidence speaks to its power. Moss tells me he has observed the results of story-based teaching in his classroom. “People remember cases incredibly well—and often at a level of detail that’s almost shocking. Stories stick in the mind, and when you learn history with a focus on particular stories it’s much easier to remember the pieces around them.”

David Kaufman, a student who took the course last year, says that discussing history through a series of cases allowed the students to “focus a lot more on the process than on, say, the actual legislative result, which I think was much richer.” It is well known that stories aid learning because of how memory is structured. The cognitive psychologist Jerome Bruner wrote of two modes of knowing: paradigmatic and narrative; with the latter, attention and emotion influence the strength of a memory. Stories activate emotion, which helps students stay engaged and remember. They also feed the human need to fit things into a coherent structure in order to make meaning of them.

All this makes the case method promising for high school, too, and some of Moss’s cases were indeed adopted for use by history teachers at public and private high schools in a pilot program beginning early last year. One of the participants, Eleanor Cannon, a history teacher at St. John’s School in Houston, expressed astonishment at how students who never thought of themselves as history types before grew to love history. “I’ve never had this experience as a teacher before, and it’s explicitly due to the case method—it’s a game changer.” Rather than merely know which decisions historical figures made, her students now understood why. Facts she had taught multiple times, such as that the Constitution was not handed down intact by the founders but emerged from a protracted period of intense tumult, debate, and compromise, made visceral sense now after students read and discussed a case on James Madison and the making of the Constitution. (As one student told Cannon, “I didn’t realize how much they argued!”)

Moss compares immersion in case after case to batting practice that helps train judgment. The idea is to help students develop an instinct for how to respond even to problems—whether they be furor over same sex marriage or a massive financial crisis—that feel unprecedented. Through sheer repetitive exposure to problems and problem-solving, students learn the art of decision-making—and develop better judgment—in “much the same way as you might learn a language. It’s not an algorithm, it’s the development of an instinct—at least in part,” says Moss. They also provide historical perspective when looking at problems today.

Take the current debate over immigration. Although none of Moss’s cases focuses principally on immigration, themes of exclusion/inclusion are woven throughout, potentially reminding readers that unpleasant historical episodes have happened again and again. A group of people will become accepted into the fold, only to see the fire turned on another one; who the “threatening” outgroup is always changing. “You can see it as deeply disturbing,” Moss says, “that there always seemed to be an outgroup that some Americans looked down upon, but you could also see that there is an ongoing process of expanding tolerance, over time. This doesn’t create an excuse for bigotry—absolutely not—but it does give you a little hope that when there is bigotry it’s not necessarily permanent; there is a chance to get past it, group by group, with the result eventually being a broader, more tolerant society.”

One of Moss’s arguments about democracy is that it is far more complex than people tend to realize—that “it is not a machine built to specification.” Instead, democracy can be understood as a living organism that thrives on productive tension, engagement, and change. Without movement, it would die. Moss mentions the de facto national motto first suggested in 1776 by Benjamin Franklin: E Pluribus Unum . “Out of many, one.” Franklin saw difference that achieves common purpose as a core strength of the country. If one were to apply this analogy to history, ongoing debates about how to teach it only enhance the field—as long as educators remain committed to the same shared goal of helping students understand the past in order to face the future. “The best ideas come out of tension, out of disagreeing,” Moss tells his students. “Tension is what ensures the best ideas win out.”

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• Introduction

The case study creation process

Types of case studies, benefits and limitations.

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• Table Of Contents

case study , detailed description and assessment of a specific situation in the real world created for the purpose of deriving generalizations and other insights from it. A case study can be about an individual, a group of people, an organization, or an event, among other subjects.

By focusing on a specific subject in its natural setting, a case study can help improve understanding of the broader features and processes at work. Case studies are a research method used in multiple fields, including business, criminology , education , medicine and other forms of health care, anthropology , political science , psychology , and social work . Data in case studies can be both qualitative and quantitative. Unlike experiments, where researchers control and manipulate situations, case studies are considered to be “naturalistic” because subjects are studied in their natural context . ( See also natural experiment .)

The creation of a case study typically involves the following steps:

• The research question to be studied is defined, informed by existing literature and previous research. Researchers should clearly define the scope of the case, and they should compile a list of evidence to be collected as well as identify the nature of insights that they expect to gain from the case study.
• Once the case is identified, the research team is given access to the individual, organization, or situation being studied. Individuals are informed of risks associated with participation and must provide their consent , which may involve signing confidentiality or anonymity agreements.
• Researchers then collect evidence using multiple methods, which may include qualitative techniques, such as interviews, focus groups , and direct observations, as well as quantitative methods, such as surveys, questionnaires, and data audits. The collection procedures need to be well defined to ensure the relevance and accuracy of the evidence.
• The collected evidence is analyzed to come up with insights. Each data source must be reviewed carefully by itself and in the larger context of the case study so as to ensure continued relevance. At the same time, care must be taken not to force the analysis to fit (potentially preconceived) conclusions. While the eventual case study may serve as the basis for generalizations, these generalizations must be made cautiously to ensure that specific nuances are not lost in the averages.
• Finally, the case study is packaged for larger groups and publication. At this stage some information may be withheld, as in business case studies, to allow readers to draw their own conclusions. In scientific fields, the completed case study needs to be a coherent whole, with all findings and statistical relationships clearly documented.

Case studies have been used as a research method across multiple fields. They are particularly popular in the fields of law, business, and employee training; they typically focus on a problem that an individual or organization is facing. The situation is presented in considerable detail, often with supporting data, to discussion participants, who are asked to make recommendations that will solve the stated problem. The business case study as a method of instruction was made popular in the 1920s by instructors at Harvard Business School who adapted an approach used at Harvard Law School in which real-world cases were used in classroom discussions. Other business and law schools started compiling case studies as teaching aids for students. In a business school case study, students are not provided with the complete list of facts pertaining to the topic and are thus forced to discuss and compare their perspectives with those of their peers to recommend solutions.

In criminology , case studies typically focus on the lives of an individual or a group of individuals. These studies can provide particularly valuable insight into the personalities and motives of individual criminals, but they may suffer from a lack of objectivity on the part of the researchers (typically because of the researchers’ biases when working with people with a criminal history), and their findings may be difficult to generalize.

In sociology , the case-study method was developed by Frédéric Le Play in France during the 19th century. This approach involves a field worker staying with a family for a period of time, gathering data on the family members’ attitudes and interactions and on their income, expenditures, and physical possessions. Similar approaches have been used in anthropology . Such studies can sometimes continue for many years.

Case studies provide insight into situations that involve a specific entity or set of circumstances. They can be beneficial in helping to explain the causal relationships between quantitative indicators in a field of study, such as what drives a company’s market share. By introducing real-world examples, they also plunge the reader into an actual, concrete situation and make the concepts real rather than theoretical. They also help people study rare situations that they might not otherwise experience.

Because case studies are in a “naturalistic” environment , they are limited in terms of research design: researchers lack control over what they are studying, which means that the results often cannot be reproduced. Also, care must be taken to stay within the bounds of the research question on which the case study is focusing. Other limitations to case studies revolve around the data collected. It may be difficult, for instance, for researchers to organize the large volume of data that can emerge from the study, and their analysis of the data must be carefully thought through to produce scientifically valid insights. The research methodology used to generate these insights is as important as the insights themselves, for the latter need to be seen in the proper context. Taken out of context, they may lead to erroneous conclusions. Like all scientific studies, case studies need to be approached objectively; personal bias or opinion may skew the research methods as well as the results. ( See also confirmation bias .)

Business case studies in particular have been criticized for approaching a problem or situation from a narrow perspective. Students are expected to come up with solutions for a problem based on the data provided. However, in real life, the situation is typically reversed: business managers face a problem and must then look for data to help them solve it.

The history and evolution of case study research (JOHANSSON, 2003, p.7) [10]  

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Bringing case method teaching to high schools & colleges: U.S. History, Government, Civics & Democracy

About the project  .

The Case Method Project is an initiative formed to achieve two goals:

• Bring case method teaching to high schools and colleges
• Use this methodology to deepen students’ understanding of American democracy

Based on the highly successful experience of Harvard Business School and other graduate and professional programs that use case-based teaching, we believe the case method can be employed to strengthen high school and college education as well, ensuring a more exciting, relevant, and effective experience for students and teachers across a range of subjects. We also believe the case method can be especially effective at engaging students with topics in history and democracy and that it presents a unique opportunity to help reverse the broad decline in civic education – and civic engagement – in the United States.

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I n An Autobiography , published in 1939, R.G. Collingwood offered an arresting statement about the kind of insight possessed by the trained historian. The philosopher of history likened the difference between those who knew and understood history and those who did not to that between ‘the trained woodsman’ and ‘the ignorant traveller’ in a forest. While the latter marches along unaware of their surroundings, thinking ‘Nothing here but trees and grass’, the woodsman sees what lurks ahead. ‘Look’, he will say, ‘there is a tiger in that grass.’

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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.

Learn more about HBS Online's approach to the case method in the video below, and subscribe to our YouTube channel for more.

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 eight subject areas, including:

• Business essentials
• Leadership and management
• Entrepreneurship and innovation
• Digital transformation
• 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.

About the Author

Case Study Research Method in Psychology

Saul McLeod, PhD

Editor-in-Chief for Simply Psychology

BSc (Hons) Psychology, MRes, PhD, University of Manchester

Saul McLeod, PhD., is a qualified psychology teacher with over 18 years of experience in further and higher education. He has been published in peer-reviewed journals, including the Journal of Clinical Psychology.

Learn about our Editorial Process

Olivia Guy-Evans, MSc

Associate Editor for Simply Psychology

BSc (Hons) Psychology, MSc Psychology of Education

Olivia Guy-Evans is a writer and associate editor for Simply Psychology. She has previously worked in healthcare and educational sectors.

On This Page:

Case studies are in-depth investigations of a person, group, event, or community. Typically, data is gathered from various sources using several methods (e.g., observations & interviews).

The case study research method originated in clinical medicine (the case history, i.e., the patient’s personal history). In psychology, case studies are often confined to the study of a particular individual.

The information is mainly biographical and relates to events in the individual’s past (i.e., retrospective), as well as to significant events that are currently occurring in his or her everyday life.

The case study is not a research method, but researchers select methods of data collection and analysis that will generate material suitable for case studies.

Freud (1909a, 1909b) conducted very detailed investigations into the private lives of his patients in an attempt to both understand and help them overcome their illnesses.

This makes it clear that the case study is a method that should only be used by a psychologist, therapist, or psychiatrist, i.e., someone with a professional qualification.

There is an ethical issue of competence. Only someone qualified to diagnose and treat a person can conduct a formal case study relating to atypical (i.e., abnormal) behavior or atypical development.

 Famous Case Studies

• Anna O – One of the most famous case studies, documenting psychoanalyst Josef Breuer’s treatment of “Anna O” (real name Bertha Pappenheim) for hysteria in the late 1800s using early psychoanalytic theory.
• Little Hans – A child psychoanalysis case study published by Sigmund Freud in 1909 analyzing his five-year-old patient Herbert Graf’s house phobia as related to the Oedipus complex.
• Bruce/Brenda – Gender identity case of the boy (Bruce) whose botched circumcision led psychologist John Money to advise gender reassignment and raise him as a girl (Brenda) in the 1960s.
• Genie Wiley – Linguistics/psychological development case of the victim of extreme isolation abuse who was studied in 1970s California for effects of early language deprivation on acquiring speech later in life.
• Phineas Gage – One of the most famous neuropsychology case studies analyzes personality changes in railroad worker Phineas Gage after an 1848 brain injury involving a tamping iron piercing his skull.

Clinical Case Studies

• Studying the effectiveness of psychotherapy approaches with an individual patient
• Assessing and treating mental illnesses like depression, anxiety disorders, PTSD
• Neuropsychological cases investigating brain injuries or disorders

Child Psychology Case Studies

• Studying psychological development from birth through adolescence
• Cases of learning disabilities, autism spectrum disorders, ADHD
• Effects of trauma, abuse, deprivation on development

Types of Case Studies

• Explanatory case studies : Used to explore causation in order to find underlying principles. Helpful for doing qualitative analysis to explain presumed causal links.
• Exploratory case studies : Used to explore situations where an intervention being evaluated has no clear set of outcomes. It helps define questions and hypotheses for future research.
• Descriptive case studies : Describe an intervention or phenomenon and the real-life context in which it occurred. It is helpful for illustrating certain topics within an evaluation.
• Multiple-case studies : Used to explore differences between cases and replicate findings across cases. Helpful for comparing and contrasting specific cases.
• Intrinsic : Used to gain a better understanding of a particular case. Helpful for capturing the complexity of a single case.
• Collective : Used to explore a general phenomenon using multiple case studies. Helpful for jointly studying a group of cases in order to inquire into the phenomenon.

Where Do You Find Data for a Case Study?

There are several places to find data for a case study. The key is to gather data from multiple sources to get a complete picture of the case and corroborate facts or findings through triangulation of evidence. Most of this information is likely qualitative (i.e., verbal description rather than measurement), but the psychologist might also collect numerical data.

1. Primary sources

• Interviews – Interviewing key people related to the case to get their perspectives and insights. The interview is an extremely effective procedure for obtaining information about an individual, and it may be used to collect comments from the person’s friends, parents, employer, workmates, and others who have a good knowledge of the person, as well as to obtain facts from the person him or herself.
• Observations – Observing behaviors, interactions, processes, etc., related to the case as they unfold in real-time.
• Documents & Records – Reviewing private documents, diaries, public records, correspondence, meeting minutes, etc., relevant to the case.

2. Secondary sources

• News/Media – News coverage of events related to the case study.
• Academic articles – Journal articles, dissertations etc. that discuss the case.
• Government reports – Official data and records related to the case context.
• Books/films – Books, documentaries or films discussing the case.

3. Archival records

Searching historical archives, museum collections and databases to find relevant documents, visual/audio records related to the case history and context.

Public archives like newspapers, organizational records, photographic collections could all include potentially relevant pieces of information to shed light on attitudes, cultural perspectives, common practices and historical contexts related to psychology.

4. Organizational records

Organizational records offer the advantage of often having large datasets collected over time that can reveal or confirm psychological insights.

Of course, privacy and ethical concerns regarding confidential data must be navigated carefully.

However, with proper protocols, organizational records can provide invaluable context and empirical depth to qualitative case studies exploring the intersection of psychology and organizations.

• Organizational/industrial psychology research : Organizational records like employee surveys, turnover/retention data, policies, incident reports etc. may provide insight into topics like job satisfaction, workplace culture and dynamics, leadership issues, employee behaviors etc.
• Clinical psychology : Therapists/hospitals may grant access to anonymized medical records to study aspects like assessments, diagnoses, treatment plans etc. This could shed light on clinical practices.
• School psychology : Studies could utilize anonymized student records like test scores, grades, disciplinary issues, and counseling referrals to study child development, learning barriers, effectiveness of support programs, and more.

How do I Write a Case Study in Psychology?

Follow specified case study guidelines provided by a journal or your psychology tutor. General components of clinical case studies include: background, symptoms, assessments, diagnosis, treatment, and outcomes. Interpreting the information means the researcher decides what to include or leave out. A good case study should always clarify which information is the factual description and which is an inference or the researcher’s opinion.

1. Introduction

• Provide background on the case context and why it is of interest, presenting background information like demographics, relevant history, and presenting problem.
• Compare briefly to similar published cases if applicable. Clearly state the focus/importance of the case.

2. Case Presentation

• Describe the presenting problem in detail, including symptoms, duration,and impact on daily life.
• Include client demographics like age and gender, information about social relationships, and mental health history.
• Describe all physical, emotional, and/or sensory symptoms reported by the client.
• Use patient quotes to describe the initial complaint verbatim. Follow with full-sentence summaries of relevant history details gathered, including key components that led to a working diagnosis.
• Summarize clinical exam results, namely orthopedic/neurological tests, imaging, lab tests, etc. Note actual results rather than subjective conclusions. Provide images if clearly reproducible/anonymized.
• Clearly state the working diagnosis or clinical impression before transitioning to management.

3. Management and Outcome

• Indicate the total duration of care and number of treatments given over what timeframe. Use specific names/descriptions for any therapies/interventions applied.
• Present the results of the intervention,including any quantitative or qualitative data collected.
• For outcomes, utilize visual analog scales for pain, medication usage logs, etc., if possible. Include patient self-reports of improvement/worsening of symptoms. Note the reason for discharge/end of care.

4. Discussion

• Analyze the case, exploring contributing factors, limitations of the study, and connections to existing research.
• Analyze the effectiveness of the intervention,considering factors like participant adherence, limitations of the study, and potential alternative explanations for the results.
• Identify any questions raised in the case analysis and relate insights to established theories and current research if applicable. Avoid definitive claims about physiological explanations.
• Offer clinical implications, and suggest future research directions.

5. Additional Items

• Thank specific assistants for writing support only. No patient acknowledgments.
• References should directly support any key claims or quotes included.
• Use tables/figures/images only if substantially informative. Include permissions and legends/explanatory notes.
• Provides detailed (rich qualitative) information.
• Provides insight for further research.
• Permitting investigation of otherwise impractical (or unethical) situations.

Case studies allow a researcher to investigate a topic in far more detail than might be possible if they were trying to deal with a large number of research participants (nomothetic approach) with the aim of ‘averaging’.

Because of their in-depth, multi-sided approach, case studies often shed light on aspects of human thinking and behavior that would be unethical or impractical to study in other ways.

Research that only looks into the measurable aspects of human behavior is not likely to give us insights into the subjective dimension of experience, which is important to psychoanalytic and humanistic psychologists.

Case studies are often used in exploratory research. They can help us generate new ideas (that might be tested by other methods). They are an important way of illustrating theories and can help show how different aspects of a person’s life are related to each other.

The method is, therefore, important for psychologists who adopt a holistic point of view (i.e., humanistic psychologists ).

Limitations

• Lacking scientific rigor and providing little basis for generalization of results to the wider population.
• Researchers’ own subjective feelings may influence the case study (researcher bias).
• Difficult to replicate.
• Time-consuming and expensive.
• The volume of data, together with the time restrictions in place, impacted the depth of analysis that was possible within the available resources.

Because a case study deals with only one person/event/group, we can never be sure if the case study investigated is representative of the wider body of “similar” instances. This means the conclusions drawn from a particular case may not be transferable to other settings.

Because case studies are based on the analysis of qualitative (i.e., descriptive) data , a lot depends on the psychologist’s interpretation of the information she has acquired.

This means that there is a lot of scope for Anna O , and it could be that the subjective opinions of the psychologist intrude in the assessment of what the data means.

For example, Freud has been criticized for producing case studies in which the information was sometimes distorted to fit particular behavioral theories (e.g., Little Hans ).

This is also true of Money’s interpretation of the Bruce/Brenda case study (Diamond, 1997) when he ignored evidence that went against his theory.

Breuer, J., & Freud, S. (1895).  Studies on hysteria . Standard Edition 2: London.

Curtiss, S. (1981). Genie: The case of a modern wild child .

Diamond, M., & Sigmundson, K. (1997). Sex Reassignment at Birth: Long-term Review and Clinical Implications. Archives of Pediatrics & Adolescent Medicine , 151(3), 298-304

Freud, S. (1909a). Analysis of a phobia of a five year old boy. In The Pelican Freud Library (1977), Vol 8, Case Histories 1, pages 169-306

Freud, S. (1909b). Bemerkungen über einen Fall von Zwangsneurose (Der “Rattenmann”). Jb. psychoanal. psychopathol. Forsch ., I, p. 357-421; GW, VII, p. 379-463; Notes upon a case of obsessional neurosis, SE , 10: 151-318.

Harlow J. M. (1848). Passage of an iron rod through the head.  Boston Medical and Surgical Journal, 39 , 389–393.

Harlow, J. M. (1868).  Recovery from the Passage of an Iron Bar through the Head .  Publications of the Massachusetts Medical Society. 2  (3), 327-347.

Money, J., & Ehrhardt, A. A. (1972).  Man & Woman, Boy & Girl : The Differentiation and Dimorphism of Gender Identity from Conception to Maturity. Baltimore, Maryland: Johns Hopkins University Press.

Money, J., & Tucker, P. (1975). Sexual signatures: On being a man or a woman.

Further Information

• Case Study Approach
• Case Study Method
• Enhancing the Quality of Case Studies in Health Services Research
• “We do things together” A case study of “couplehood” in dementia
• Using mixed methods for evaluating an integrative approach to cancer care: a case study

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Exploring the influence of historical storytelling on cultural heritage tourists’ revisit intention: A case study of the Mogao Grottoes in Dunhuang

Contributed equally to this work with: Feng Yuxin, Lv Xiaoyu, Tian Yunxia, Meng Weilong

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

Affiliation College of Tourism, Northwest Normal University, Lanzhou, Gansu, China

Roles Conceptualization, Data curation, Investigation, Methodology, Resources

* E-mail: [email protected]

Roles Investigation, Methodology, Writing – review & editing

Roles Investigation, Methodology, Supervision, Writing – review & editing

Affiliation College of Economics and Management, Southeast University, Nanjing, Jiangsu, China

Roles Data curation, Investigation, Methodology, Writing – review & editing

Affiliation College of Tourism, Hunan Normal University, Changsha, Hunan, China

• Feng Yuxin, 
• Qin Jianpeng, 
• Lv Xiaoyu, 
• Tian Yunxia, 
• Meng Weilong

• Published: September 19, 2024
• https://doi.org/10.1371/journal.pone.0307869
• Peer Review
• Reader Comments

The revisit intention of tourists has long been a focal point of academic inquiry. However, there is still insufficient research on the antecedents of revisit intention from the perspectives of historical storytelling, destination image and perceived value. Taking the Mogao Grottoes in Dunhuang, a UNESCO World Heritage Site, as a case study, this paper, based on stimulus–organism–response (SOR) theory, examines the impact of historical storytelling on the destination image, perceived value, and revisit intention. Additionally, it further explores the mediating role of destination image and perceived value, as well as the moderating effect of place attachment in this chain. The research findings indicate that: (1) Historical storytelling significantly enhances tourists’ perception of the tourism experience and revisit intention; (2) The study supports the mediating effect of destination image and perceived value; (3) Place attachment has a significant positive moderating effect between historical storytelling and revisit intention. Effective historical storytelling can significantly enhance destination image and perceived value, improve tourists’ participation and satisfaction in tourism, stimulate revisit intention, and promote the sustainable development of tourist destinations. These findings enrich the research content of cultural heritage tourism, providing valuable suggestions for improving the management level of cultural heritage tourism attractions and increasing visitors’ revisit intention.

Citation: Yuxin F, Jianpeng Q, Xiaoyu L, Yunxia T, Weilong M (2024) Exploring the influence of historical storytelling on cultural heritage tourists’ revisit intention: A case study of the Mogao Grottoes in Dunhuang. PLoS ONE 19(9): e0307869. https://doi.org/10.1371/journal.pone.0307869

Editor: Bo Pu, Sichuan Agricultural University, CHINA

Received: May 15, 2024; Accepted: July 14, 2024; Published: September 19, 2024

Copyright: © 2024 Yuxin 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: All relevant data are within the manuscript and its Supporting Information files.

Funding: The phased achievement of the project ‘Research on the construction of iconic long march projects within Gansu province’ funded by the Gansu Great Wall Long March National Cultural Park Construction and Development Research Center (001053108) awarded to FY. The 2023 graduate teaching case library construction project of Northwest Normal University: silk road China section cultural and tourism integration case library (2023YAL005) awarded to FY.

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

Introduction

Cultural heritage tourism is an integral component of heritage tourism. As per the resolution of the 45th session of the World Heritage Committee, by October 2023, the total number of global heritage sites expanded to 1199, comprising 993 cultural heritage sites [ 1 ]. With the increasing internal demand for high-quality development of cultural tourism and the intensifying competition among similar tourist destinations, cultural heritage tourism destinations are also facing many challenges, especially in terms of how to maintain customer numbers and competitiveness [ 2 ]. Han & Hyun (2015) found that attracting repeat visitors can make destinations more cost-effective and beneficial for the sustainable development of cultural heritage sites [ 3 ]. However, current research on cultural heritage tourism mainly focuses on the protection and development of cultural heritage itself, and there is not enough comprehensive research on tourists’ subjective behavioral intentions from the perspective of cultural heritage site visitors [ 4 ]. Therefore, it is necessary for us to study how to enhance the tourist perception and revisit intention of cultural heritage sites.

Historical storytelling, as a propaganda medium in the tourism process, can have a significant impact on tourists’ participation and experience [ 5 , 6 ]. Telling historical stories is considered a powerful tool to make historical events more attractive, while also effectively attracting tourists and enhancing their competitive advantage [ 7 , 8 ]. Cultural heritage sites often have a long history and unique cultural heritage, providing important cultural scenes and ample historical materials for historical storytelling. Appropriate historical storytelling can help visitors better understand the development process of cultural heritage sites and the local distinctive culture, thus establishing an emotional connection between tourists and destinations, which is crucial for enhancing tourists’ travel experience. Current research has applied historical storytelling to the tourism industry, exploring its impact on tourist emotional engagement and destination branding, and has found that it can indeed effectively enhance tourist perceptual experiences in different tourism settings [ 8 , 9 ]. Leong, Yeh, Zhou, Hung, and Huan(2024) examined the impact of historical storytelling on tourists’ perception of education, entertainment, experience, and emotional value in cultural heritage tourism sites through tour guide interaction and authentic place as intermediaries [ 6 ]. However, they failed to link these variables to travel outcomes, such as revisit intentions and word-of-mouth intentions. It is worth noting that the impact mechanism of historical storytelling on tourists’ revisit intention has not been fully explored, requiring further theoretical exploration and empirical research.

Based on the SOR theory, this study aims to explore the influence of historical storytelling on tourists’ revisit intentions in the context of cultural heritage tourism, in order to improve the quality of tourism services in scenic areas and enhance tourists’ travel experiences, increase tourists’ sense of participation and satisfaction, and stimulate tourists’ revisit intentions. This study makes a significant contribution to the field of cultural heritage tourism. Firstly, starting from historical storytelling, a research model on the influence of historical storytelling on tourists’ revisit intention was constructed, expanding the relevant research on tourists’ revisit intention, enriching the research content of cultural heritage tourism, and providing alternative perspectives for the study of cultural heritage tourism. Secondly, this study examines the mediating effect of destination image and perceived value in the model, as well as the moderating effect of place attachment. This not only helps to theoretically understand how historical storytelling influences tourists’ revisit intention, but also assists tourism destination managers in formulating appropriate development strategies, providing valuable insights for scholars and tourism practitioners.

Literature review

Stimulus–organism–response (sor) model.

The S-O-R model is derived from the behaviorist S-R model, incorporating the important role of internal states of individuals, abbreviated as the SOR model. The Stimulus-Organism-Response (SOR) theory was proposed by Mehrabian and Russell (1974), which includes stimulus, organism, and response, aiming to explore the role of external environmental stimuli in individual consumer behavior processes [ 10 ]. Stimulus refers to external factors that influence individual cognition, organism refers to internal processes that intervene between stimuli and subsequent behaviors, and response is often conceptualized as individual approach or avoidance behaviors, including repurchase and recommendation, etc [ 11 ].

Initially applied in environmental psychology to study consumer purchasing behavior, the theory gradually expanded to investigate tourist consumption behavior, effectively explaining consumer behavior in most tourism contexts [ 12 ]. In recent years, a considerable number of scholars have embarked on research endeavors, leveraging this theory to investigate tourists’ consumption behaviors and behavioral intentions. Liao et al. (2023), based on the SOR theory, analyzed the relationship between the types of reference group influence, perceived value, and health tourism intention, finding that both informational influence and utilitarian influence within reference group influence positively affect health tourism intention, with perceived value serving as a significant mediator between reference group influence and health tourism intention [ 13 ]. Therefore, this paper is based on the applicability of SOR theory, using the SOR framework as the theoretical foundation for the research.

In cultural heritage tourism research, scholars often focus on tourists’ behavioral intentions and discuss their influencing factors [ 14 ]. However, historical storytelling as a factor influencing tourist behavioral intentions, has received less attention. Therefore, it is necessary to further study the impact of historical storytelling on the tourism experience and revisit intentions of tourists at cultural heritage sites. Based on this, applying the SOR model to this study, for cultural heritage tourism destination visitors, historical storytelling is established as "stimulus" and revisit intention is established as "response". Additionally, some scholars have found that destination image and perceived value can serve as mediating mechanisms behind the behavioral intentions of tourists at cultural heritage sites [ 15 , 16 ]. Therefore, this mediating mechanism influencing the behavioral intentions of tourists at cultural heritage sites can be used (as an organism) to further validate the applicability of the SOR framework. Furthermore, some scholars have introduced place attachment as a moderating variable to explore its moderating effect on tourist behavioral intentions, and have found that place attachment has a significant moderating effect between tourist satisfaction and revisit intentions [ 17 ]. In summary, this study, based on the SOR theoretical model, considers historical storytelling as the "stimulus", destination image and tourist perceived value as the "organism", and tourist revisit intentions as the "response" to analyze the impact of historical storytelling on the revisit intentions of tourists at cultural heritage sites.

Historical storytelling

Storytelling is a social phenomenon influenced by psychology, sociology, marketing, tourism, and behavioral sciences. Palombini (2017) defines storytelling as the narration of events that happen to certain individuals, leading to changes in the situation [ 18 ]. Building upon this, historical storytelling can be simply understood as the telling of historical events related to surrounding objects in appropriate settings. As scholars delve deeper into the study of historical storytelling, some have started to apply them in tourism research, aiming to enhance tourists’ understanding of destinations, improve their perceived value, and stimulate their interest in travel [ 5 ]. Go and Govers (2012) found that storytelling greatly attracts tourists emotionally and cognitively, positively impacting their engagement and satisfaction [ 19 ]. In cultural heritage tourism, historical storytelling involves telling stories, anecdotes, and interesting facts related to cultural heritage vividly and engagingly. It is worth noting that Palombini (2017) emphasizes that storytelling in cultural heritage focuses on imparting specific knowledge about the historical events, cultural values, and social background of the depicted cultural heritage [ 18 ]. Against the backdrop of the flourishing development of cultural heritage tourism, tourists’ perception of the cultural heritage determines their cognitive image and value judgment of the destination, subsequently influencing their behavioral intentions. Historical storytelling serves as a crucial means to enhance tourists’ cultural perception.

In recent years, scholarly interest in storytelling has proliferated across diverse disciplines, including politics, communication, cognitive science, anthropology, organizational behavior, and marketing, with a particular resonance in the domain of marketing [ 20 ]. Currently, the tourism industry and academia seem to widely acknowledge that storytelling is an effective communication tool that can attract potential tourists and promote and differentiate destinations [ 21 ]. Recent research endeavors have delved into various aspects of storytelling, encompassing theoretical frameworks, research methodologies, and the impact of storytelling on destination image and tourist experiences. Zhang and Ramyah (2024) conducted a comprehensive literature review on the role of storytelling in destination marketing, revealing that scholars predominantly employ Heider’s Balance Theory and Narrative Transportation Theory in their investigations, with the latter gaining more traction in recent years [ 20 ]. Furthermore, it is observed that a majority of researchers favor qualitative approaches in studying storytelling, significantly outnumbering quantitative studies.

Furthermore, the examination of storytelling’s influence on tourism destination image and visitor experience has consistently piqued the interest of researchers. For instance, Jo, Cha and Kim(2022) collected data from 259 tourists who experienced historical storytelling during their travels in South Korea, examining the influence of tourism storytelling on the tourism destination brand value, lovemarks, and relationship strength [ 22 ]. Gemar, Sánchez-Teba and Soler(2022) utilized survey-based methods and count models to assess tourists’ perceptions of historical storytelling, destination image, and their intention to engage in cultural activities [ 23 ]. Furthermore, scholars have employed qualitative methodologies, such as interviews and observations, to explore the experiences and interpretations of tourists engaged with cultural heritage storytelling [ 2 ].

It is worth noting that recently some scholars have begun to explore the application of digital storytelling in the tourism industry. For example, Paiva et al. (2023) used a gaming experiment to find that digital storytelling can not only evoke people’s perception of environmental degradation, stimulate ecological anxiety, sadness, and loneliness, but also connect these emotions with views on sustainable actions and future practices [ 24 ].

Destination image

The destination image has a crucial role in influencing tourists’ perception and opinions of the destination, playing a significant role in tourist behavior and travel purchase decisions [ 25 ]. Since the 1960s, the concept of image has been utilized in social and environmental psychology, consumer behavior research, and marketing, representing individuals’ perception of objects, events, and behaviors driven by impressions, sensations, and beliefs [ 26 ]. When applied in the context of tourism, it is commonly referred to as "product brand image" or "destination image." In recent years, scholars have undertaken extensive research on tourist destination image, which can primarily be categorized into three aspects: the definition and dimensional constructs of destination image, the influencing factors of destination image, and its impact on tourists’ behavioral intentions.

Most scholars have studied the definition of destination image from the perspective of individual tourists, but there is still no unified definition in current research. Crompton (1979) defines destination image as the sum of a person’s trust, thoughts, and impressions of the destination [ 26 ]. Some scholars also consider destination image as a synthesis of people’s perceptions, impressions, beliefs, and viewpoints of the destination [ 27 ]. In addition, the dimensional division of destination image has always been a topic of interest to researchers, such as dividing it into single-dimensional, two-dimensional, three-dimensional, etc. Pike and Ryan (2004) believe that describing the destination image from the two dimensions of cognitive image and affective image can better capture the destination image. Cognitive image refers to tourists’ objective cognition and views of the tourism destination, while affective image encompasses tourists’ emotions towards the destination [ 28 , 29 ].

Some scholars have discussed the factors influencing destination image. Balogu and McCleary (1999) categorized the influencing factors of destination image into personal factors and stimulus factors [ 30 ]. Building on this, Beelli and Martin (2004) expanded their research and summarized the influencing factors of destination image as individual factors and information sources, with personal factors typically including demographic variables, travel motivations, and destination familiarity; while information source factors are generally divided into first-hand information sources (experience and sensation) and second-hand information sources (social media and official websites, etc.) [ 31 ]. Of note, Wang et al. (2024) utilized innovation system theory and qualitative methods to explore the influencing factors and formation process of Cultural Inheritance-Based Innovation (CIBI) in Heritage Tourism Destinations (HTD), finding that CIBI is influenced by multilevel factors of the environment, government, enterprises, and public, encompassing basic innovation management conditions and sociocultural constraints [ 4 ].

Many scholars have also studied the impact of destination image on tourists’ behavioral intentions, dividing it into three stages: pre-travel, during travel, and post-travel. We find that most scholars primarily focus on the influence of destination image on tourists’ post-travel behavioral intentions [ 15 ]. Gavurova et al. (2023) investigate the impact of tourism destination image on travelers’ behavioral intentions from a transportation perspective, utilizing cluster analysis and regression analysis to quantify the relationship between road transport development indicators and visitor spending, revealing that traffic conditions significantly influence visitors’ willingness to pay [ 32 ]. Yang et al. (2024) explored the heterogeneous effects of different tourism advertising styles on cultural heritage sites. The study found that compared to direct tourism advertising, metaphorical tourism advertising can shape a more attractive image of the tourist destination, thus stimulating stronger visitation intentions among cultural heritage site visitors [ 14 ].

Perceived value

Perceived value is an important concept and theory in researching consumer experience and experience quality. The concept of perceived value was first proposed by American service marketing scholar Zeithaml (1988) in the field of marketing. He believes that perceived value is the overall feeling that customers have after consuming a certain product or service, evaluating the input and output [ 33 ]. In recent years, scholars have studied various aspects of tourist perceived value, including the concept of perceived value, dimensions of perceived value, and its impact on tourist behavioral intentions, continuously expanding and improving the theory of tourism perceived value.

Due to the different understandings of perceived value among scholars, there is diversity in the definition of perceived value. Its definition can mainly be analyzed and discussed from perspectives such as cost and benefit, input and output ratio [ 34 , 35 ]. Sáncheztal (2006) suggests that the concept of perceived value can be regarded as a multidimensional structure, which has been widely applied in academia [ 36 ]. This approach enables us to overcome some of the issues associated with understanding perceived value using traditional methods, particularly the excessive focus on economic utility [ 33 ]. Furthermore, Scholars have divided perceived value into different dimensions according to their research needs, such as single-dimensional, two-dimensional, and three-dimensional, without a clearly unified method for dimensional division. For example, the two-dimensional scale proposed by Grewal et al. (1998) is highly representative [ 37 ]. They divided the dimensions of perceived value from the perspective of transaction processes into transaction value and acquisition value, which is considered a reliable and effective measurement method [ 38 ].

Tourist perceived value is the subjective evaluation made by tourists regarding the services and products obtained during the travel process, which can exert a positive effect on aspects such as tourist satisfaction and behavioral intentions [ 39 , 40 ]. Furthermore, it also influences both the pre-purchase and post-purchase stages. Empirical research conducted by many scholars has demonstrated that high levels of tourist perceived value can positively affect their revisit intention. For example, Peng et al. (2023) explored the impact mechanism of tourists’ perceived happiness on the revisit intention to traditional Chinese medicine cultural tourism destinations based on attachment theory [ 2 ]. Through empirical research, it was found that when tourists perceive a higher level of happiness at cultural heritage sites, their revisit intention is significantly enhanced. Yao et al. (2020) took the case of Meizhou Island, the birthplace of China’s first world-class intangible cultural heritage—Mazu belief, to explore the significant positive impact of tourist perceived value on revisit intention, with place attachment playing a partial mediating role [ 40 ].

Revisit intention

Tourist revisit intention is one of the key indicators for sustainable development in the tourism industry. Firstly, compared to first-time visitors, repeat visitors tend to have a greater economic contribution to the tourism destination because of their increased interest in the destination, leading them to invest more time and effort, as well as purchase more tourism products and services, thereby extending the life cycle of the tourism destination to some extent [ 41 , 42 ]. Secondly, from the perspective of tourist consumption behavior, retaining an existing customer is much cheaper than acquiring a new one [ 43 ]. Consequently, scholars have conducted extensive research on how to enhance tourist loyalty and stimulate revisit intention, categorizing tourist loyalty into attitudinal loyalty and behavioral loyalty, with revisit intention being a critical manifestation of tourist behavioral loyalty [ 44 , 45 ].

Tourists’ revisit intention reflects the intention that tourists may want to visit a tourist place again, and this revisit intention can be transformed into actual revisit behavior under certain conditions [ 44 ]. In terms of research content, early studies identified factors influencing revisit intentions primarily as tourists’ income, age, and occupation, among other external conditions. Chen and Huang (2010), based on network text analysis and in-depth interviews, empirically researched the motives for revisiting among tourists in Xiamen city [ 46 ]. They concluded that factors such as age, occupation, and monthly income significantly influence tourists’ revisit intention. It is worth noting that many early scholars overlooked internal factors such as psychological processes during tourists’ travel experiences. Subsequently, scholars gradually recognized the importance of psychological factors such as travel motivation, satisfaction, destination image, and travel involvement in influencing tourists’ revisit intention. In current research on tourists’ revisit intention, scholars primarily focus on aspects such as motivation [ 47 ], satisfaction [ 48 ], destination image [ 15 ], and perceived value [ 40 ], among others. It has been found that these factors positively promote tourists’ revisit intention.

In addition, in terms of research methodology, scholars commonly employ traditional quantitative analysis methods to investigate tourists’ revisit intentions, such as Structural Equation Modeling and Logistic Regression analysis [ 2 , 49 ]. However, these models assume that the variables do not affect each other, which may lead to omissions and deficiencies in the research.

In general, scholars have extensively studied the factors influencing tourists’ revisit intention, and it has been found that the revisit intention is the result of a cumulative effect based on multiple factors, necessitating consideration of various influences. The influence of external characteristics tends to be secondary in comparison to the role of emotional factors. Therefore, it is necessary to prioritize the perceptions and tourism experiences of visitors, conducting in-depth analyses of their practical needs and psychological motivations, in order to effectively enhance their revisit intention. For example, Rasoolimanesh et al. (2021) used the case study of the world heritage city of Kashan in Iran to empirically investigate how visitor participation, authenticity, and destination image directly or indirectly affect heritage site visitors’ revisit intention and electronic word-of-mouth (eWOM) intention through memorable tourism experiences (MTE) [ 50 ].

Place attachment

In the 1970s, geographer Tuan (1974) first proposed the concept of "topophilia" to summarize the emotional connection between individuals and specific material spaces, including perceptions, values, and worldviews [ 51 ]. He conducted preliminary research on this concept, which laid the theoretical foundation for place attachment. Originating from environmental psychology, the theory of place attachment gradually became an important concept in disciplines such as geography, tourism studies, and urban and rural planning, gaining widespread attention. As research on place attachment deepened, many scholars applied it to tourism studies, analyzing and exploring the emotional connections between people and places by treating place attachment as an independent variable, a mediating variable, or a moderating variable. Dang and Weiss (2021) conducted a systematic literature review examining the relationship between place attachment and behavioral intentions [ 52 ]. Through qualitative analysis, they found that many scholars have empirically demonstrated the significant impact of place attachment on factors such as willingness to pay, loyalty, risk coping behavior, pro-environmental behavior, and pro-tourism behavior.

In recent years, research on place attachment in the tourism industry has mainly focused on dimensions and their impact on visitor satisfaction, loyalty, and behavioral intentions. Most scholars believe that place attachment is a multidimensional concept, thus various methods of dimension division research have been proposed, such as single-dimensional, two-dimensional, and three-dimensional, etc., but there is still no clear-cut division method. However, it is worth noting that Williams et al. (1992) proposed a division of place attachment into two dimensions: place dependence and place identity. Place identity emphasizes emotional connection, while place dependence leans towards people’s reliance on the functional aspects of a place. This two-dimensional model has been validated and acknowledged by the academic community [ 53 ].

In addition, many tourism scholars have found that place attachment has a direct or indirect positive relationship with tourists’ satisfaction, loyalty, and behavioral intentions. This study focuses on the impact of place attachment on tourists’ revisit intention. Place attachment refers to the special emotions that people have towards a place due to various factors, and this special emotion is an important influencing factor in forming tourists’ revisit intention, playing a facilitating role in their decision-making process [ 54 ]. At the same time, cultural heritage sites are more likely to evoke special emotions in tourists due to their unique historical, cultural, and emotional values, thereby fostering a sense of place attachment and stimulating revisit intentions [ 2 , 40 ].

Hypotheses development

In conclusion, scholars have been conducting in-depth research on historical storytelling and revisit intentions, and have made certain research achievements, providing a theoretical basis and guidance for the development of this study.

Storytelling is ubiquitous in every aspect of life, as it can help people connect with each other and cultivate empathy, leading individuals to attempt to "feel the world in the same way as the characters in the story" [ 55 , 56 ]. In the digital age, historical storytelling is considered an effective means to enhance the reputation of destinations [ 57 ]. When tourism service personnel tell historical stories at cultural heritage sites, they create immersive and memorable experiences for tourists, connecting them with the local social and cultural context, providing higher quality tourism services, and helping tourists better understand the destination, stimulating their interest in tourism, and increasing their participation and satisfaction [ 6 ]. Revisit intention usually refers to the likelihood of tourists returning to the destination, with factors influencing revisit intention mainly including satisfaction, destination image, perceived value, etc. [ 58 ]. Although the presence of historical storytelling is not among the numerous influencing factors, existing research has found that historical storytelling has a positive impact on the tourist experience and perceived value of cultural heritage sites [ 6 ]. Therefore, this study believes that telling historical stories at cultural heritage sites can provide visitors with a better tourism experience, enhance visitors’ cognitive image, perceived value, and revisit intention. Thus, this study proposes the following hypotheses:

• H1: Historical storytelling positively influences the destination image.
• H2: Historical storytelling positively influences tourists’ perceived value.
• H3: Historical storytelling positively influences tourists’ revisit intention.

The image of a tourism destination reflects tourists’ overall perception and impression of the destination, and a good destination image can effectively stimulate tourists’ willingness to visit and influence their travel decisions [ 15 ]. Zhang and Hou (2014) conducted an empirical study using the case of Hongcun, a World Cultural Heritage site in Anhui province, which elucidated that tourists’ positive perceptions of a destination’s image significantly encourage revisit intention [ 59 ]. Furthermore, Lai et al. (2020) used Australia as an example to predict the behavioral intentions of potential Chinese tourists by combining cognitive and affective components of food imagery. The results showed that cognitive food imagery was more predictive of tourist behavioral intentions than affective imagery [ 60 ]. Therefore, this study focuses primarily on the impact of destination cognitive imagery on tourists’ travel experiences and behavioral intentions.

In addition, many scholars have recently studied the relationship between destination image and tourist perceived value. Through empirical research, they have found that destination image has a significant impact on perceived value, with destinations having a favorable image often exhibiting higher perceived value [ 61 ]. Gu and Cui (2023) used Hangzhou, which possesses three world cultural heritage sites, as a case study and found that tourists’ cognition of world cultural heritage significantly influences their perceived quality and perceived value [ 62 ]. Therefore, this study proposes the following hypothesis:

• H4: The image of a tourist destination positively influences tourists’ revisit intention.
• H5: The destination image of tourism positively influences tourists’ perceived value.

Based on the aforementioned literature review, we discern a positive influence of tourists’ perceived value on their revisit intentions, an effect that persists within the context of cultural heritage tourism [ 2 ]. For example, Han (2015) takes the Ling Shan Buddhist cultural leisure resort in Wuxi as an example, and through empirical research, it is found that perceived value is the antecedent variable of satisfaction and behavioral intention, and the perceived value of cultural tourist destinations will directly affect their behavioral willingness [ 63 ]. Therefore, this study proposes the following hypotheses:

• H6: Tourist perceived value positively influences tourist revisit intention.

Based on the previous assumptions, this study attempts to delve into the potential chain-mediated effects in the research model. Existing literature has analyzed the relationship between destination image, perceived value, and tourists’ revisit intention, revealing that perceived value plays a mediating role between destination image and tourists’ revisit intention [ 64 ]. Meanwhile, many scholars tend to focus only on the overall perceived value when exploring the mediating role of perceived value between destination image and behavioral intention [ 16 , 40 ]. Therefore, this study mainly focuses on the role of overall perceived value in the model.

Xu and Li (2018) studied the mechanism of the effect of destination image in Xinjiang, China on tourists’ behavioral intentions, finding that perceived value plays a crucial role in the impact mechanism of destination image perception on tourists’ behavioral intentions [ 16 ]. However, this relationship has not yet been fully explored in the specific context of cultural heritage tourism. This study argues that historical storytelling can effectively enhance tourists’ perception and views of a destination, thereby enabling tourists to experience higher value and ultimately strengthening their revisit intention. Therefore, this study considers historical storytelling as the antecedent variable, destination image and perceived value as the mediating variables, and revisit intention as the outcome variable, to delve into the potential chain-mediated effects. Thus, this study proposes the following hypotheses:

• H7: The destination image plays an intermediary role between historical storytelling and tourists’ revisit intention.
• H8: Tourist perceived value plays an intermediary role between historical storytelling and tourists’ revisit intention.
• H9: The destination image and tourist perceived value play a mediating role in the relationship between historical storytelling and tourists’ revisit intention.

Furthermore, based on the literature review above, we can find that place attachment has a significant impact on the revisit intention [ 63 ]. It is worth noting that Yun and Liu (2023) introduced place attachment as a moderating factor into the research framework, and found that place attachment can moderate the impact of perceived distance on tourists’ behavioral intentions [ 65 ]. Furthermore, they discovered that perceived value mediates the moderating effect of place attachment on tourists.

Place attachment is the connection formed between individuals and places through interaction, which can influence tourists’ emotions and behaviors towards tourism destinations [ 52 ]. In cultural heritage tourism, this attachment may become more profound and intricate due to the unique character and historical significance of the cultural heritage sites [ 2 ]. Therefore, this study believes that different levels of place attachment will moderate tourists’ revisit intention. This study suggests that when tourists have a high level of place attachment to the destination, historical storytelling will make it easier for them to develop a desire to revisit, and the mediating effect of destination image and perceived value between historical storytelling and revisit intention will also be strengthened. Therefore, this study proposes the following hypothesis:

• H10: Place attachment plays a positive moderating role in the impact of historical storytelling on the revisit intention.
• H11: Place attachment positively moderates the mediating role of destination image between historical storytelling and revisit intention in tourism.
• H12: Place attachment positively moderates the mediating role of perceived value in historical storytelling and revisit intentions for tourists.

In conclusion, based on the above analysis and reasoning, this study has constructed a research model from the perspective of the SOR framework, which includes historical storytelling, destination image, perceived value, place attachment, and revisit intention ( Fig 1 ). Furthermore, in this research model, destination image and perceived value play a mediating role, while place attachment has a moderating effect.

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https://doi.org/10.1371/journal.pone.0307869.g001

Methodology

Research scope and object.

This study takes the Mogao Grottoes in Dunhuang, a UNESCO World Heritage site, as a case study. Popularly known as the Thousand Buddha Caves, the Mogao Grottoes are hailed as the "most valuable cultural discovery of the 20th century" and the "Eastern Louvre". They are the largest and most abundant Buddhist art site in the world, possessing significant historical and cultural value as well as tourism value. Meanwhile, the Dunhuang Mogao Grottoes serve as a microcosm of the evolution of Chinese cave art, representing the longest-lasting, most rich in content, artistically exquisite, well-preserved, and most influential grotto group in China [ 66 ]. In 1987, the Mogao Grottoes were designated as one of the first World Cultural Heritage sites in China, enjoying high international recognition and attracting a large number of visitors for sightseeing. This can provide a representative sample for empirical research on the tourist experience and revisit intentions of cultural heritage sites.

In Dunhuang, where the tourism industry accounts for a significant proportion of the tertiary sector at 63.33%, the Mogao Grottoes undoubtedly serve as the cornerstone of its tourism brand. The development of Mogao Grottoes tourism directly determines the prosperity or decline of Dunhuang’s tourism economy. According to statistics from the cultural and tourism department of Dunhuang City, in 2023, the Dunhuang tourism industry, centered around the Mogao Grottoes, received a total of 16.82 million visitors and achieved tourism revenue of 15.6 billion yuan, both reaching historical highs [ 67 ]. In recent years, the Dunhuang Research Institute has further developed cultural experiential projects to enhance the Dunhuang tourism experience and attract more visitors. For example, the digital Dunhuang project "Seeking Dunhuang" combines advanced game technologies such as 3D modeling and VR virtual reality scenes to lead visitors to "travel through" historical time and "explore" the thousand-year-old Dunhuang. Compared with other cultural heritage sites, the Mogao Grottoes have experienced thousands of years of history, where various cultures from ancient and modern times, both domestic and foreign, converge and blend. This long and ancient history provides an important cultural backdrop and ample historical materials for historical storytelling, as well as facilitates our study of the impact of historical storytelling on tourists’ travel experiences and revisit intentions.

Construct measurement and questionnaires

This study employed a questionnaire survey comprising two parts. The first part aimed to collect respondents’ basic information. The second part aimed to measure levels of various constructs. Historical storytelling consisted of four items aimed at assessing the persuasive level of local historical storytelling in Mogao Grottoes [ 6 , 68 ]. Destination image included seven items aimed at gauging tourists’ perceptions of various aspects of the tourist destination [ 69 , 70 ]. Perceived value consisted of three items aimed at evaluating the overall assessment of tourists on the tourism process [ 48 , 71 ]. Place attachment comprised six items aimed at measuring the emotional connection between people and places [ 53 ]. Revisit intentions by tourists included three items aimed at assessing tourists’ intention to revisit the Mogao Grottoes scenic area [ 2 , 72 ]. These items were formatted using a 7-point Likert scale, where 1 indicated low levels and 7 indicated high levels. The questionnaire’s five latent variables totaled 23 items. Considering the quality and effectiveness of the questionnaire, investigators conducted a survey in advance on 51 tourists who had experienced historical storytelling at the Mogao Grottoes in Dunhuang. Based on the analysis results, one item with a low factor loading in the destination image was removed, resulting in the formal survey questionnaire on the intention of revisiting the Mogao Grottoes. Please refer to the S1 Appendix for the questionnaire.

Data collection and analysis

This study employs a convenience sampling method to conduct a survey on visitors at the Mogao Grottoes scenic area. This non-probability sampling strategy is deemed cost-effective and suitable for an on-site tourist survey in behavioral science research [ 73 ]. While the target population and survey locations were intentionally chosen, the sampling process was spontaneous, which will reduce research bias [ 74 ]. The data collection for this questionnaire is mainly based on the self-completion method. This study obtained data from two channels, online and offline. Firstly, the researchers distributed survey questionnaires to local tourists randomly at the Mogao Grottoes in Dunhuang during the peak tourist season. Data collection was conducted during two time periods to ensure the diversity of the data, from October 1, 2023 to October 3, 2023, and from January 1, 2024 to January 3, 2024. A total of 244 questionnaires were distributed and all were collected. Secondly, from February 3, 2024 to March 3, 2024, researchers distributed online survey questionnaires through the Wenjuanxing platform and received a total of 107 completed questionnaires. After excluding 26 incomplete questionnaires, a total of 325 valid surveys were obtained, representing an effective response rate of 92.6%. There is no consensus among scholars regarding the selection of sample size. Comrey (1978) suggests that the minimum sample size should be at least 200, while Nunaly (1978) suggests that the sample size should be at least ten times the number of variables [ 75 , 76 ]. Therefore, the 325 samples in this study meet the requirements of the above scholars, ensuring the accuracy and reliability of the model. This study used statistical software SPSS 26.0 and AMOS 26.0 to analyze the data from a total of 325 questionnaires collected online and offline.

Respondent profile

In the 325 samples, there were 138 males and 187 females. Among the respondents, 228 were aged between 26 and 40, while 65 were aged between 41 and 60. In terms of education, 261 respondents had a bachelor’s degree, and 46 had a master’s degree or higher. Regarding monthly income, 164 respondents had a monthly income between 5000 and 10000 RMB, while 82 had a monthly income between 10001 and 20000 RMB. It can be observed that visitors to the Mogao Grottoes generally have higher incomes. Additionally, only 102 respondents had visited the Mogao Grottoes before, accounting for 31.4% of the total. Therefore, research on visitors’ revisit intention is crucial for the future development of Mogao Grottoes tourism. For detailed information on the respondents, please refer to Table 1 .

https://doi.org/10.1371/journal.pone.0307869.t001

Data reliability and validity

By examining the specific indicators of each item in the model, the reliability and validity of the model can be measured. First, the reliability of the model can be assessed by examining the value of Cronbach’s Alpha. Nunnally (1978) suggested that a Cronbach’s Alpha value greater than 0.7 indicates acceptable reliability, while a value greater than 0.8 indicates good reliability [ 76 ]. As shown in Table 2 , the Alpha values of each latent variable range from 0.778 to 0.936, indicating relatively good reliability of the scale. Secondly, the convergent validity of the model can be evaluated by examining the factor loading, composite reliability (CR), and average variance extracted (AVE) of each latent variable. According to the standards proposed by Fornell and Larcker (1981), a CR value greater than 0.6 and an AVE value greater than 0.5 indicate an acceptable level of convergent validity [ 77 ]. Pearce and Lee (2005) suggested that in addition to meeting the former criteria, the standardized factor loading of all measurement items should be greater than 0.6 to meet the standard [ 78 ]. As shown in Table 2 , the factor loading, CR, and AVE values of each latent variable all meet the standards, indicating good convergent validity of the scale.

https://doi.org/10.1371/journal.pone.0307869.t002

In addition, discriminant validity testing of all latent variables can evaluate the discriminant validity of the model. According to the standards proposed by Fornell and Larcker (1981), the square root of the average variance extracted (AVE) should be greater than the inter-variable correlations [ 77 ]. As shown in Table 3 below, the square root of the AVE for each latent variable on the diagonal is greater than the correlations between the corresponding variables, indicating good discriminant validity of the scale.

https://doi.org/10.1371/journal.pone.0307869.t003

Structural model and hypotheses test

Main effect analysis..

This study used AMOS 26.0 to test the model fit and path relationships. As shown in Table 4 , according to the standards proposed by Wu (2009), CMIN/DF (chi-square degrees of freedom ratio) = 1.711, within the range of 1–3, RMSEA (root mean square error of approximation) = 0.047, within the excellent range of <0.05 [ 79 ]. Additionally, the test results of GFI, NFI, and RFI indicators all reached excellent levels of above 0.9. Therefore, the results of model fit testing indicate that the model in this study has a good fit.

https://doi.org/10.1371/journal.pone.0307869.t004

Next, as shown in Table 5 , historical storytelling has a significant positive impact on the destination image (β = 0.707, p<0.001), perceived value (β = 0.493, p<0.001), and revisit intention (β = 0.254, p<0.001). Additionally, the destination image has a significant positive impact on the perceived value (β = 0.315, p<0.001) and revisit intention (β = 0.246, p<0.001). Finally, the perceived value has a significant positive impact on the revisit intention (β = 0.303, p<0.001). Therefore, this study assumes that hypotheses H1-H6 are all valid.

https://doi.org/10.1371/journal.pone.0307869.t005

Mediation effect analysis.

This study further explores the chained mediation effect of destination image and revisit intention in the model. In testing the mediation effect, MacKinnon et al. (2004) argue that the bootstrapping method is superior to the causal steps test and the Sobel test [ 80 ]. According to Hayes (2009), if the confidence interval between the upper and lower limits does not include zero, then the mediation effect is significant [ 81 ]. As shown in Table 6 , firstly, destination image significantly mediates the relationship between historical storytelling and revisit intention (β = 0.174, p<0.05); secondly, perceived value significantly mediates the relationship between historical storytelling and revisit intention (β = 0.149, p<0.05); finally, historical storytelling significantly influences revisit intention through the chained mediation of destination image and perceived value (β = 0.067, p<0.05). Therefore, this study assumes that H7-H9 are all supported.

https://doi.org/10.1371/journal.pone.0307869.t006

Moderating effect analysis.

According to Edwards and Lambert (2007), the regression coefficients were tested using model 89 from the PROCESS 4.1 plugin in SPSS 26.0. The interaction effects between the moderator variable and the mediator variable were examined using the bootstrapping method, and the changes in the mediated effect after moderation were ultimately determined [ 82 ]. As shown in Table 7 , after controlling for age, education, monthly income, and visit frequency, the study found that place attachment positively moderated the relationship between historical storytelling and revisit intention (b = 0.171, p<0.05). The interaction term of destination image and place attachment (b = 0.046, p>0.05) and the interaction term of perceived value and place attachment (b = -0.156, p>0.05) do not have a significant impact on revisit intention. Therefore, H10 was supported, while H11 and H12 were not supported. Furthermore, the previous visit to the destination had a significant impact on tourists’ revisit intention.

https://doi.org/10.1371/journal.pone.0307869.t007

In order to further analyze the moderating effect of different levels of place attachment on the relationship between historical storytelling and revisit intentions, this study conducted a simple slope analysis. As shown in Fig 2 , when there is a high sense of place attachment (b = 0.256, p<0.01), the positive impact of historical storytelling on revisit intentions is significant, while when there is a low sense of place attachment (b = 0.068, p>0.05), the positive effect is not significant. This finding further supports H10.

https://doi.org/10.1371/journal.pone.0307869.g002

Conclusion and prospects

Conclusion and discussion.

This study explores the chain mediation effect between historical storytelling and revisit intention through the mediating variables of destination image and perceived value. Building on this, further analysis was conducted on the moderating effect of place attachment on revisit intentions across different paths. In conclusion, the results of this study provide valuable insights into the relationships among historical storytelling, destination image, perceived value, place attachment, and revisit intention.

The main findings can be summarized into three key points. Firstly, the establishment of hypotheses H1, H2, and H3 indicates that historical storytelling can enhance the destination’s cognitive image and perceived value, stimulating tourists’ revisit intention. This is consistent with the research findings of Go and Govers (2012), who suggest that effective historical storytelling has a positive impact on tourist engagement and satisfaction [ 19 ]. Our research further demonstrates that even in the absence of explicit destination image and perceived value, historical storytelling itself can have a positive impact on revisit intentions. However, the lack of these intermediate variables would not be conducive to fully stimulating tourists’ revisit intentions. The establishment of hypotheses H7, H8, and H9 suggests that the chain-mediated effect of destination image and perceived value is beneficial for historical storytelling to better stimulate tourists’ revisit intention. This means that by shaping positive destination images and enhancing perceived value, historical storytelling can more effectively stimulate tourists’ revisit intention.

Secondly, this study explores the relationship between destination image, perceived value, and revisit intention. Based on the hypotheses H4, H5, and H6, the study found that a better destination cognitive image is conducive to enhancing tourists’ perceived value. The destination’s cognitive image and perceived value will have a significant positive impact on tourists’ revisit intention, which is consistent with the findings of Xu and Li. Xu and Li (2018) found that perceived value plays a crucial role in the impact of destination cognitive image on tourists’ behavioral intentions [ 16 ]. Through empirical research using this model, it was found that this relationship also holds true in cultural heritage tourism. Furthermore, this study found that compared to destination image, perceived value has a greater impact on revisit intention.

Finally, according to the established hypothesis H10, place attachment plays a significant positive moderating role between historical storytelling and revisit intention. This study was conducted in the context of cultural heritage tourism, revealing that the impact of historical storytelling on revisit intention varies across different levels of place attachment. When tourists have a higher level of place attachment, the influence of historical storytelling on their revisit intention is strengthened. The non-confirmation of Hypotheses H11 and H12 suggests that place attachment does not exert a significant moderating influence on the mediating effect of destination cognitive image and perceived value in the relationship between historical storytelling and revisit intention. This indicates that in cultural heritage tourism, place attachment is an important factor influencing tourists’ revisit intention, but its role is mainly reflected in directly enhancing the attractiveness of historical storytelling to tourists, rather than indirectly affecting tourists’ revisit intention by adjusting other variables (such as destination cognitive image and perceived value). This is also similar to the research results of Hu, Wang, and Yun et al., suggesting that place attachment may have a certain moderating and promoting effect on revisit intention [ 17 , 65 , 83 ]. Wang et al. (2022) found that by introducing place attachment as a moderating variable, place attachment plays a positive moderating role in the relationship between pro-environmental behavior and revisit intention [ 83 ].

Theoretical implications

This study constructs a research model of tourists’ revisit intention based on the SOR theory, enriching and broadening the research on tourists’ revisit intention, and has certain theoretical significance. The theoretical significance of this study mainly includes the following three points.

Firstly, the construction of the model for revisiting intentions of tourists at cultural heritage tourism sites in this study contributes to the refinement of the management theory of cultural heritage tourism. Kim (2014) argued that research on tourist experiences should shift the focus from the objective attributes of destinations to the subjective interpretations of these attributes by tourists [ 84 ]. Our study extends the research on tourists’ revisit intentions by revealing the relationship between historical storytelling and tourist perceptions from the perspective of tourists’ subjective interpretations [ 2 ]. By introducing historical storytelling as an antecedent variable to enhance tourists’ perception of cultural heritage tourism, and using this as a starting point, the impact of historical storytelling on tourists’ revisit intention is discussed, enriching the research content of cultural heritage tourism.

Secondly, this paper further explores the chain mediation effect of destination cognitive image and perceived value as multiple mediators between historical storytelling and tourists’ revisit intention. The hypothesized chain mediation effect is validated, indicating that historical storytelling significantly influence tourists’ revisit intention through the chain mediation effect of destination cognitive image and perceived value. This study expands the understanding of the multiple pathway relationship between historical storytelling and tourists’ revisit intention, providing alternative perspectives for cultural heritage tourism research.

Finally, many scholars currently consider place attachment as a mediating variable in different tourism contexts, confirming its positive correlation with tourists’ revisit intention [ 2 , 85 ]. Our study treats place attachment as a moderating variable and examines its impact on tourists’ revisit intention in this research. From the empirical findings of our study, place attachment as a moderating variable only exerts a moderating effect between historical storytelling and tourists’ revisit intention, while it does not significantly moderate the mediating role of destination image and perceived value between historical storytelling and tourists’ revisit intention. Therefore, this study concludes the influence of place attachment on tourists’ revisit intention across different paths in the model. Additionally, this research partially addresses the deficiency in current revisit intention studies by considering moderating variables.

Management implications

The results of this study have certain management implications for the development of the Mogao Grottoes tourism industry. It can not only guide tourism practitioners and destination managers to enhance visitor experiences and increase perceived value through specific strategies, but also provide certain references and insights for other cultural heritage sites.

The practical significance of this study mainly includes three points. First, through the results of this study, we found that historical storytelling has a significant impact on enhancing tourists’ revisit intention. Therefore, in the development of cultural heritage tourism, it is important to thoroughly collect and research various local historical stories, such as religious legends, mythological stories, biographies, fables, and court life. These stories should then be cleverly combined with tourist experiences through tour guides, digital technology, and virtual reality (VR)/augmented reality (AR) techniques or more innovative means. This will showcase the destination’s rich historical significance and cultural heritage to tourists, allowing them to immerse themselves in the cultural experience, enhance their satisfaction, and strive for a broader development space in the tourism market. For the Mogao Grottoes scenic area, first of all, it is necessary for the local government and the scenic area management department to establish a professional team responsible for collecting, researching, and verifying various local stories and historical legends; secondly, not only should professional training be provided to tour guides so that they can vividly and accurately tell the local historical stories, but efforts should also be made to develop the Mogao Grottoes tourism app to provide story interpretation, AR experiences, and other functions; finally, through economic incentive measures and honor selection, local residents should be encouraged to participate in the inheritance and storytelling of historical stories, in order to enhance the authenticity and interactivity of the tourist experience.

Secondly, according to this study, we found that destination cognitive image and perceived value have a significant chain-mediated effect between historical storytelling and tourists’ revisit intentions. Furthermore, destination cognitive image and perceived value themselves have a significant positive impact on tourists’ revisit intentions. This finding emphasizes the importance of integrating historical storytelling and destination image building in destination management. Therefore, destination managers can develop tourism products and upgrade scenic areas based on tourists’ consumption preferences and purchasing behavior, aiming to enhance tourists’ destination cognitive image and perceived value, thus improving the quality of scenic area services and revenue, and extending the tourism life cycle of the Dunhuang Mogao Grottoes scenic area. Specifically, the Mogao Grottoes tourist site could conduct in-depth market research to comprehend the distinct needs and preferences of various visitor segments. Based on the research outcomes, it could devise a diversified range of tourism products. For instance, targeting young tourists, innovative projects integrating technology and interactive experiences could be developed, such as Augmented Reality (AR) tours and Virtual Reality (VR) experiences, offering them an immersive and novel experience. For art and culture enthusiasts, tour packages centered around Dunhuang murals could be introduced, combining art appreciation, cultural lectures, and hands-on workshops, enabling visitors to gain a more profound understanding of Dunhuang’s art heritage. At the same time, it is important to strengthen the level of scenic area services and create a high-quality tourism service environment. By analyzing the strengths and weaknesses in the marketing and service management of the Mogao Grottoes tourism scenic area, and summarizing corresponding optimization strategies, the level of tourism scenic area service management can be improved, and its brand competitiveness can be enhanced. For example, the management department should increase funding and upgrade the infrastructure of the scenic area, such as improving restroom facilities, adding rest areas, and providing more information signs, in order to enhance the comfort of tourists during their visits. In addition, it is necessary to establish a standardized complaint handling process based on feedback from tourists, clearly defining the steps of complaint reception, recording, investigation, response, and feedback, to ensure transparency in the process and let tourists know how their complaints will be addressed.

Finally, the research results also emphasize the significant moderating role of place attachment between historical storytelling and tourists’ revisit intention. This requires cultural heritage sites to pay attention to cultivating visitors’ place attachment emotions in the management and development process, in order to promote visitors’ tourism experience, satisfaction, and revisit intention, and thus promote the sustainable development of cultural heritage tourism. Managers should pay particular attention to showcasing the unique culture of Mogao Grottoes and its distinctive tourism products in tourists’ travel experiences, allowing them to obtain a one-of-a-kind tourism experience and creating a competitive advantage through differentiation. As a representative of Dunhuang culture, Mogao Grottoes possesses abundant historical and cultural heritage resources. Integrating this unique cultural resource into tourists’ travel experiences is conducive to fostering a sense of connection between people and the land, enhancing tourists’ emotional attachment to the place, and thereby stimulating their revisit intention. First, the scenic area can design a series of cultural experience activities, such as Dunhuang mural copying, Silk Road history lectures, Dunhuang dance workshops, etc., to allow visitors to personally experience the unique charm of Dunhuang culture; secondly, managers can make full use of social media platforms to encourage visitors to share their experiences and stories at the Mogao Grottoes, and enhance visitors’ attachment to the Mogao Grottoes through user-generated content; finally, the Mogao Grottoes can also provide personalized services for visitors, such as inviting them to attend the opening of new exhibitions and cultural lectures at the Mogao Grottoes, or offering special discounts to returning visitors, allowing visitors to feel the special attention of the Mogao Grottoes to them, effectively enhancing visitors’ emotional attachment to the Mogao Grottoes and stimulating their revisit intention.

Limitations and future research directions

The findings of this study provide relevant insights and perspectives on the relationships between historical storytelling, destination image, perceived value, place attachment, and tourists’ revisit intention. However, there are still some limitations.

Firstly, in terms of research methods. The questionnaire data obtained in this study mainly relies on self-administered surveys by tourists. Given that the responses to the survey may be influenced by participants’ cultural background, regional of origin, educational background, mood, cognition, and experiences, the answers provided by the respondents are inherently constrained to some extent. In future research, it could be beneficial to consider incorporating more objective data collection methods to enhance the reliability of the study. For example, using structured interviews to have face-to-face communication with tourists, delving deeper into their perspectives and opinions; or employing observational methods to collect data by directly observing tourists’ behaviors and phenomena; additionally, combining big data analysis by utilizing existing datasets and data mining techniques to gather information.

Secondly, in terms of research content. This study mainly focuses on the destination cognitive image and tourists’ overall perceived value, without conducting in-depth analysis on other dimensions of destination image and perceived value. The aim is to explore the influence of historical storytelling on the tourist experience and revisit intention of cultural heritage site visitors from a macro perspective. In future research, further exploration can be conducted on the emotional image and overall image within the destination image, as well as other dimensions such as transaction value and acquisition value in perceived value, in order to reveal the influence of historical storytelling on destination image and tourist perceived value from a more micro perspective. Furthermore, this study examined the moderating effect of place attachment, and found that it does not have a significant moderating effect on the mediating role of destination cognitive image and perceived value. In future research, other related moderating variables such as tourism involvement, gender, emotions, and novelty-seeking motivation can be explored.

Finally, in terms of the research subject. This study takes the famous World Cultural Heritage site, the Mogao Grottoes in Dunhuang, as a case study for empirical research. Its long history and innovative tourism experience projects are likely to further enhance the effectiveness of historical storytelling, which may limit the generalization of the research findings to other cultural heritage sites. In future research, further exploration can be conducted on the impact of historical storytelling on tourists’ travel experiences and revisiting intentions at other cultural heritage sites, in order to explore potential variations in the effectiveness of these strategies.

Supporting information

S1 appendix..

https://doi.org/10.1371/journal.pone.0307869.s001

https://doi.org/10.1371/journal.pone.0307869.s002

Acknowledgments

Sincere gratitude is extended to the anonymous expert reviewers for their time and effort invested in the paper review process. The valuable suggestions provided by the reviewers regarding the research framework, method selection, and result analysis have greatly benefited this study.

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• Management of a rare case of lymphangioleiomyomatosis complicated by recurrent pneumothorax
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• Kyle Jordan Fletke 1 ,
• Nicole Taylor 2 and
• Nirev Shah 3
• 1 Family and Community Medicine , University of Maryland School of Medicine , Baltimore , Maryland , USA
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A female of reproductive age presents to the emergency department with progressive dyspnoea due to pneumothorax. She has a history of lymphangioleiomyomatosis (LAM) diagnosed by lung biopsy 15 years ago following incidental finding of pneumothorax. Despite various procedural and medicinal treatments, she continued to have recurrent pneumothorax, with three hospital admissions over the preceding 3 months. LAM is a rare cystic lung disease affecting the lymphatic system, which most commonly affects women of childbearing age. It can be diagnosed via imaging or tissue biopsy (gold standard). Treatment can be difficult, and it often requires highly specialised care by pulmonologists and often confers significant limitations to patients’ independence and quality of life. Family physicians are often part of multidisciplinary team to provide care to patients with rare chronic conditions.

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Lymphangioleiomyomatosis (LAM) is a rare cystic lung disease, which can occur sporadically or in conjunction with tuberous sclerosis complex (TSC). 1 The estimated prevalence of LAM is 3–7 cases per million women, with an estimated 15% of cases associated with tuberous sclerosis complex. 2 Tuberous sclerosis complex can be diagnosed with the identification of either a TSC1 or TSC2 pathogenic mutation or from clinical diagnostic criteria. 3 LAM primarily affects the lung parenchyma but can affect other organs, including the kidneys, brain and liver. 4 The most common presenting symptom is dyspnoea, which can easily be mistaken for more common diagnoses like asthma or Chronic Obstructive Pulmonary Disease (COPD) in the emergency department or primary care setting. 5 Interdisciplinary management of rare diseases, such as LAM, is required to assist primary care physicians in the diagnosis and treatment of such illnesses.

Case presentation

A female in her 30s presented to the emergency department experiencing progressive dyspnoea, non-productive cough and left-sided chest pain. This was her third presentation during a 3-month period, with multiple prior pneumothoraxes resolved following chest tube placement over the past 15 years. She has a medical history of sporadic-LAM (S-LAM) and allergic rhinitis, and no significant family history of cardiopulmonary disease. Her social history includes one alcoholic unit per week and no history of tobacco, vaping or other inhaled substances. Her vital signs were significant for tachycardia with a pulse of 112 beats per minute, tachypnoea of 22 breaths per minute and an oxygen saturation (SpO2) of 89% in room air. Her physical exam was notable for diminished breath sounds on the left side without wheezes, rales or crackles. Chest radiograph demonstrated a new left-sided pneumothorax and stable loculated pneumothorax on the right side with underlying cystic lung disease. An interventional pulmonologist was consulted for acute management of her spontaneous pneumothorax. CT chest after placement of left-sided pigtail catheter showed small residual left-sided pneumothorax in the medial posterior pleural space with stable loculated right pneumothorax ( figure 1 ). Cardiac enzymes were negative, and ECG demonstrated normal sinus rhythm with right atrial enlargement.

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Coronal view CT chest.

Investigations

The patient was first diagnosed with sporadic LAM 15 years ago. A CT abdomen and pelvis without contrast was suggested to evaluate abdominal pain and it showed a haemorrhagic exophytic left renal mass and incidental finding of right pneumothorax. Subsequent CT chest showed diffuse scattered cystic changes with well-defined walls. No other lung abnormalities were noted. Given the persistence of the patient’s pneumothorax and concern for LAM, a lung biopsy was performed during a video-assisted thoracic surgery (VATS) procedure. Immunostaining was focally positive for HMB-45 and Desmin and negative for Mart-1, which is consistent with the diagnosis of LAM. An ophthalmologist evaluated the patient during initial hospitalisation and did not find stigmata of TSC. Brain MRI was also obtained to evaluate intracranial tumours and was found to be normal other than a non-specific right frontal subcortical white matter hyperintense focus.

Pulmonary function tests demonstrated a forced expiratory volume in one second/forced vital capacity (FEV1/FVC) ratio of 71%, FVC of 2.91 L (69% predicted), FEV1 of 2.05 L (61% predicted and decreased from 2.5 L previously), total lung capacity of 4.4 L (83% predicted) and a diffusion capacity of carbon monoxide of 18.9 mL/mm Hg/min (71% predicted).

An echocardiogram revealed that the left ventricle was found to be decreased in size (consistent with decreased filling), with normal wall thickness, wall motion and left ventricular diastolic filling. The left ventricular ejection fraction was 70%. The right ventricle was normal in size, with normal systolic function and trace tricuspid regurgitation. Right ventricular systolic pressure was not calculated.

The patient has not undergone genetic testing for TSC. However, she does not have additional clinical stigmata of TSC. The left renal mass present on the CT on initial presentation 15 years ago was consistent with angiomyolipoma (a finding in LAM) versus clear cell – cell carcinoma. The patient underwent embolisation of this lesion. This lesion was never biopsied but remained stable in size on subsequent imaging, confirming the presence of malignancy less likely. The diagnostic criterion for LAM requires the presence of ≥2 angiomyolipoma, which this patient does not meet. Additionally, a combination of two major clinical features (LAM and angiomyolipomas) without other features does not meet the criteria for definite diagnosis of TSC. Therefore, the patient does not meet the clinical diagnostic criteria for definite diagnosis of TSC. 3

Differential diagnosis

Although the patient’s history of LAM was the most likely cause for her pneumothorax, it is imperative to consider other causes of her pneumothorax to prevent future events. Typically, the differential for pneumothorax is divided into three categories. 6 The first is trauma, often from blunt or penetrating chest trauma such as a motor vehicle accident. The second is iatrogenic, caused by a healthcare procedure such as a central line insertion. The third is spontaneous, in which no specific cause is identified. A subcategory of spontaneous pneumothorax is secondary in which the patient has an underlying lung condition. Cystic lung diseases, such as LAM, pulmonary Langerhans cell histiocytosis, Birt-Hogg-Dube syndrome, amyloidosis and lymphocytic interstitial pneumonia, can increase risk of spontaneous pneumothorax. 7

The absence of recent trauma or healthcare procedures, no smoking or vaping history and imaging studies negative for other lung pathologies make pathology other than LAM to be the unlikely cause of this patient’s recurrent pneumothorax. This is supported by the definitive diagnoses of LAM by positive biopsy and CT findings of multiple thin-walled cysts, consistent with LAM.

The patient was managed in the acute setting with placement of an anterolateral left-sided chest tube. The chest tube was slowly transitioned from suction to water seal and then removed following resolution of her pneumothorax. No significant changes were made to her medication regimen at the time of discharge.

Outcome and follow-up

The patient underwent a doxycycline pleurodesis and later a betadine pleurodesis with resolution of her pneumothorax. She was able to return to her daily life, though with continued reduced exercise tolerance. 2 months after hospitalisation, repeat pulmonary function tests demonstrated reduced lung function. She was unable to join clinical trials for LAM due to her recent pneumothoraxes. Sirolimus, an established pharmacotherapy for LAM, was suggested by the pulmonology team to stabilise her pulmonary function though it was initially deferred per patient’s preference due to the concerns for side effects. After experiencing a recurrent spontaneous pneumothorax (the fifth one of the year), sirolimus, an established therapy for LAM which affects the mTOR pathway, was initiated. 8 Follow-up pulmonary function testing and CT scan demonstrated that her pulmonary disease was stable following initiation of the daily sirolimus. She has not had a recurrent pneumothorax in over 1 year.

LAM is a rare cystic lung disease affecting the lungs and lymphatic system. It can occur either in combination with tuberous sclerosis or alone. 1 It mainly affects women of childbearing age and is characterised by pulmonary cystic changes, recurrent spontaneous pneumothorax and chylous pleural effusions, and can proceed to progressive respiratory failure. 9 It can also include abdominal manifestations such as lymphadenopathy, lymphatic masses and angiomyolipomas, which may cause abdominal pain. Throughout the disease process, LAM cells (smooth muscle) accumulate in the lungs, resulting in cystic changes and progressive loss of healthy lung tissue. LAM cells also accumulate in the lymphatics, resulting in the thickening of lymphatic vessel lumen and cystic dilation. 10 Diagnosis is often delayed but can be achieved by obtaining pulmonary function tests and CT scan imaging of the chest. Pulmonary function tests typically demonstrate airflow obstruction (often with a bronchodilator response), normal total lung capacity and decreased diffusion capacity. 11 CT scans will demonstrate many thin-walled cysts throughout the lungs. 10 If CT findings and other typical manifestations of LAM are present, then tissue biopsy is often not needed for diagnosis. The diagnostic gold standard is a lung/lymphatics biopsy demonstrating LAM cells or nodular infiltration by abnormal smooth muscle cells and specific immunohistochemical staining for smooth muscle marker and melanoma-related antigen HMB45. 12 Treatment includes managing acute symptoms of pneumothorax, typically with chest tube placement. It can also include pleurodesis to help reduce spontaneous pneumothorax frequency. Sirolimus, an immune modulator acting on the mTOR pathway which is responsible for part of the pathophysiology of LAM, has been shown to be an effective therapy for stabilising lung function. 8 Ultimately, some patients require lung transplant.

Patient’s perspective

Living with Llymphangioleiomyomatosis (LAM) for the past 14 years has been a profound journey, one that has tested my resilience as an individual. Throughout this journey, my spiritual connection with God has deepened, providing me with strength and comfort as I navigate the challenges of this chronic illness.

Despite the lifestyle changes and uncertainties, I am immensely grateful and feel blessed to be alive today. I am incredibly thankful for the exceptional care and support provided by the medical professionals. Their collaborative approach and dedication to my well-being have played a pivotal role in managing my condition and achieving the best possible outcomes.

Acknowledgement is also due to the LAM Foundation, whose tireless efforts in research, fundraising, and information dissemination have significantly contributed to advancing understanding and treatment options for LAM. Their commitment to organizing conferences and forums has been instrumental in fostering a supportive community and providing access to valuable resources.

Lastly, I want to express my heartfelt gratitude to my family and friends for their unwavering love and support throughout this journey. Their encouragement and presence have been invaluable in helping me face the challenges of LAM with courage and optimism.

Learning points

It is important for primary care physicians to be aware of rare diseases as to be able toso they can direct patients to appropriate specialists and ongoing clinical trials to improve outcomes.

Lymphangioleiomyomatosis is a rare cystic lung disease that should be considered in young women of childbearing agoe who have spontaneous pneumothorax or progressive pulmonary decline of unclear origin.

Sirolimus can be considered for the treatment of LAM in patients with recurrent respiratory symptoms, including pneumothorax.

Ethics statements

Patient consent for publication.

Consent obtained directly from patient(s).

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Contributors All the authors participated in the clinical care of the patient, contributed to the writing of the manuscript and edited clinical images. They also gave final approval of the manuscript.

Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

Case reports provide a valuable learning resource for the scientific community and can indicate areas of interest for future research. They should not be used in isolation to guide treatment choices or public health policy.

Competing interests None declared.

Provenance and peer review Not commissioned; externally peer reviewed.

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