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Using the scenario method in the context of health and health care – a scoping review
© Vollmar et al. 2015
Received: 16 January 2015
Accepted: 12 October 2015
Published: 16 October 2015
The scenario technique is a method for future research and for strategic planning. Today, it includes both qualitative and quantitative elements. The aims of this scoping review are to give an overview of the application of the scenario method in the fields of health care and to make suggestions for better reporting in future scenario projects.
Between January 2013 and October 2013 we conducted a systematic search in the databases Medline, Embase, PsycInfo, Eric, The Cochrane Library, Scopus, Web of Science, and Cinahl since inception for the term ‘scenario(s)’ in combination with other terms, e.g. method, model, and technique. Our search was not restricted by date or language. In addition, we screened the reference lists of the included articles.
A total of 576 bibliographical records were screened. After removing duplicates and three rounds of screening, 41 articles covering 38 different scenario projects were included for the final analysis. Nine of the included articles addressed disease related issues, led by mental health and dementia (n = 4), and followed by cancer (n = 3). Five scenario projects focused on public health issues at an organizational level and five focused on the labor market for different health care professionals. In addition, four projects dealt with health care ‘in general’, four with the field of biotechnology and personalized medicine, and additional four with other technology developments. Some of the scenario projects suffered from poor reporting of methodological aspects.
Despite its potential, use of the scenario method seems to be published rarely in comparison to other methods such as the Delphi-technique, at least in the field of health care. This might be due to the complexity of the methodological approach. Individual project methods and activities vary widely and are poorly reported. Improved criteria are required for reporting of scenario project methods. With improved standards and greater transparency, the scenario method will be a good tool for scientific health care planning and strategic decision-making in public health.
Strategic decision-making processes in the field of health care and public health have always been a point of critical discussion between the stakeholders involved. In particular, prospective planning of financial resources for epidemiologically relevant and cost intensive diseases, like dementia, is often challenging. In such cases tools to support stakeholders in the field of evidence-based decision-making have become quite important . Tools often used in strategic decision-making in public health are consensus processes e.g. the Delphi technique [2, 3]. These approaches use rounds of questionnaire surveys where information and results are fed back to panel members between each round . According to a recent review by Diamond and colleagues, 98 % of Delphi studies claimed to assess consensus . Other methods used by policy makers in the provision of health care are based on simulation modeling. In their systematic review of the “use and value of computer simulation modeling in population health and health care delivery”, Fone et al. found 182 papers using simulation techniques in the field of public health . Both the Delphi technique and simulation modeling are widely used for health care issues, but were originally developed to support forecast and foresight processes . These methods are not without critique and leave room for improvement [5, 8].
Over the last decades, the scenario method has become an additional tool in foresight activities and research. To a certain extent, it makes use of both qualitative (e.g. expert opinion and discussion) and quantitative elements (e.g. scenario calculations) [9–11].
Glenn gave the following definition: “a scenario is a story with plausible cause and effect links that connects a future condition with the present, while illustrating key decisions, events, and consequences throughout the narrative” . Scenarios are often described as outlines of possible futures, but they do not describe comprehensive pictures of the future and do not claim to be complete or correct [9, 10, 12, 13]. Although, scenarios are always hypothetical, they are not arbitrary . Additionally, the creation of scenarios presents an interdisciplinary approach to explore future issues while offering several advantages, e.g. the support of a future-oriented way of thinking by taking alternative developments into consideration [9–11]. Furthermore, it fosters systematic and structured discussion of uncertain alternative futures by the incorporation of expert knowledge. Proceeding step-by-step reduces the perceived complexity of the correlations examined, generates findings that are comprehensible , and should improve strategic decision-making [15–17]. It may be combined with other foresight methods such as the Delphi technique or road-mapping [18, 19]. Since its first appearance in the 1950s, and after a decline during the 1980s, the number of published articles using this method is again increasing .
Although less commonly used in the context of health and health care than either the Delphi technique or simulation modeling, the scenario method has also been used to support strategic decision-making in the field [13, 15–17, 21–25]. Unfortunately, information about the different scenario projects in the context of public health or health policy seems to be disparate and often not known to researchers in this field. Thus, there is a basic need to provide an overview of published scenario projects. The first aim of this review is to give such an overview of the application of the scenario method in the context of health and health care. The second aim is to make first recommendations for improved reporting in future scenario projects.
‘scenarios’ in epidemiology when used only as projections (e.g. ‘population ageing’, defined as an increase in the percentage of elderly persons in the population) ,
publications unrelated to health or health care ,
Subjects of the scenario projects
Year of publication
Focus/title of the project
Time horizon [approx. in years]
Number of scenarios
2 x 1988
Aging in the Netherlands
Dementia in the Netherlands
Leufkens et al. 
Future of Medicine
Cancer diseases in the Netherlands
Cardio-vascular diseases in the Netherlands
Accident mortality and unintentional injuries in the Netherlands
Leadership practices and organizational demands
Venable et al. 
University of Alabama
Local public health departments
Institute for Health Care Marketing
Health care organization (case example: future opportunities of American Transitional Care, Inc.)
Harmsen et al. 
Aarhus School of Business
Danish food industry
Islei et al. 
Leufkens et al. 
Department of Pharmaco-epidemiology & Pharmacotherapy
Ling & Hadridge 
Neiner et al. 
National Center for Chronic Disease Prevention and Health Promotion
Public health (specifically to illustrate a health department’s desire to address chronic disease prevention and control)
Allen Memorial Hospital
Life Science Strategy Consulting
Van Lente et al. 
University of Utrecht
Biotechnology in Europe
Bezold & Beck 
Bierbooms et al. 
What types of residence should be organized for people with mental health problems?
Buchan & Seccombe 
Queen Margaret University
Future supply of registered nursing staff, midwives and health visitors in the National Health Service (NHS)
Carlsen et al. 
Defense Research Agency
Local adaptation to climate change (health aspects)
2 x 2005
International Campaign to Revitalise Academic Medicine (ICRAM)
Eberl & Schnepp 
The German Nurses Association
Family health nursing in Germany
7 reduced to 5
Enzmann et al. 
Society of Chairs of Academic Radiology Departments (SCARD)
Field of radiology
Gnatzy & Moser 
EBS Business School, Deutschland
Evolving health insurance industry in rural India
Gregório et al. 
WHO Collaborating Centre for Health Workforce Policy and Planning
Personalized medicine on the example of dementia
Ma & Seid 
Disease management in the US
My wellbeing project
Life control especially related to health and personal wellbeing using ICT-tools
Nguyen et al. 
Centre for Public Health and Ecosystem Research
Niewöhner et al. 
Max-Delbrueck-Center for Molecular Medicine (MDC)
Relationship between biomedicine and economy in Germany
Retèl et al. 
Netherlands Cancer Institute
Developments in technology assessment (e.g. clinical implementation of the 70-gene signature for breast cancer)
10 reduced to 5
Rhea & Bettles 
Academy of Nutrition & Dietetics
Dietetics workforce supply and demand
Rydström & Törnberg 
External influences on cervical cancer incidence and mortality
Suk & Semenza 
European Centre for Disease Prevention and Control (ECDC)
Future infectious disease threats to Europe
Vollmar et al. 
German Center for Neuro-degenerative Diseases (DZNE)
Health care for people with dementia in Germany
Wiek et al. 
Institute for Environmental Decisions (IED)
Possible future developments of nanotechnology in Switzerland
The main topics of the scenario projects differed in many ways. Most of them addressed disease related issues (n = 9), led by mental health and dementia (n = 4) [13, 21, 29, 69, 70] and cancer (n = 3) [58, 64, 74]. Only one scenario project each reported on cardio-vascular diseases  and infectious diseases .
Five scenario projects dealt with public health issues on an organizational level [24, 30, 53, 61, 76] and five on the labor market of different health care professionals [16, 23, 55, 60, 77], with two of them focusing on the pharmacy profession [16, 60].
In addition, four projects dealt with health care ‘in general’ [22, 63, 72, 78], four with other technology developments [57, 62, 64, 66], and an additional four with the field of biotechnology and personalized medicine [29, 59, 65, 71].
Three projects were concerned with the pharmaceutical industry and drug development [54, 56, 79]. We could identify only one scenario project each about the food industry , aging issues [73, 81], ‘recommendations’ for a developing country , academic medicine [82, 83], and the influence of climate change (on health) .
Eleven scenario projects (Table 1) were from North America, 25 from Europe (one of them with a topic about India ), one from Vietnam  and one had an international focus [82, 83]. More than half of the projects (n = 21) were published in the last ten years, eight between 1995 and 2004 and nine before 1995. Of these nine, six projects [67–70, 73, 74, 79, 81] were part of a national program in the Netherlands. During this program the study group for future scenarios in health care (STG/STC) developed several scenarios for certain health issues from the mid-1980s to the mid-1990s for the Dutch government [48, 73, 85]. In this review we considered (as mentioned in our inclusion/exclusion criteria) only those program projects which were published in scientific journals (n = 8) [67–70, 73, 74, 79, 81]. A full list of all topics covered by the STG/STC program can be found in the program description of Schreuder .
The scenario method has been used for a wide spectrum of strategic issues and different applications, starting with military planning in the 1960s [9–11, 52, 86, 87]. Despite its potential, use of the scenario method seems to have been published rarely in comparison to other methods such as the Delphi-technique, at least in the field of health care since the 1980s [40, 48, 88]. Our scoping review could identify 41 relevant publications in scientific journals representing 38 scenario projects. There were a lot of different perspectives as indicated by the wide range of participating institutions and experts (Table 1). The scenario projects addressed not only public health problems, but also strategic issues for business decisions (e.g. the future of the Danish food industry , the opportunities of nanotechnology in Switzerland , or the relationship between biomedicine and the economy in Germany ). One project even came from the Swedish Defense Research Agency (FOI) with tailor-made scenarios for local adaptation to climate change . Nevertheless, this project addressed (among other things) the effects of a heat wave on the health care sector, which is definitely an important topic for public health researchers. One project described three fictive scenarios as examples for the scenario method itself . We decided to include this “project” because it addressed a relevant public health issue (“using a health department’s desire to address chronic disease prevention and control”) . Most of the projects were developed after the year 2000 and addressed a wide range of topics, from regional institutional perspectives (e.g. local public health departments ) to global challenges (e.g. future infectious disease threats to Europe ). Many of the scenario projects in this review provide a framework for determining actions in research, as well as in public policy-making, e.g. it could be the basis for discussing a national dementia plan [21, 69, 70] or for developing a strategy to ‘revitalize’ academic medicine [82, 83]. None of the projects has been designated as unsuccessful by the authors, which could be either a sign of the method’s strength or of publication bias. In fact, Gregório and colleagues stated: “The use of scenario analysis in a strategic thinking process has demonstrated to be of value while planning for future resources and other policy issues” . Several of these scenario projects were classified as helpful for strategic planning and also for enabling the incorporation of expert knowledge (the qualitative ‘human factor’) [13, 48, 53]. Additionally, several projects used quantitative approaches to calculate the scenarios [21, 23, 56]. The resulting scenarios were illustrated in many different ways or combinations (e.g. tables , text descriptions , pictures , or short stories called storylines ). Although there is no definite response to the question of how many scenarios are optimal in the scenario planning literature , three to five scenarios are considered appropriate by most of the researchers [86, 87]. This number also occurred most frequently in our review. Scenarios can be described as outlines of possible variations of the future , but do not describe comprehensive pictures of the future and do not claim to be complete or correct . Sometimes doubts with respect to the reliability of the scenarios may arise because the methods are not clearly described [15, 54, 78, 82, 83, 89]. Compared to conventional methodological reporting, i.e. in clinical studies, the method in scenario projects should be described as precisely as possible due to the process-oriented character of scenario development. This includes the selection of the experts, the applied software tools, the use of additional literature sources, and also the method’s use in combination with other methods, like the Delphi technique [67–71].
Although this review is quite comprehensive with respect to the scenario method in the field of health or health care, there are some limitations (partly inherent to the scenario method, see below) which should be mentioned. First of all, despite our detailed search strategy, it was difficult to accurately identify appropriate scenario projects. This issue is summarized by Glenn’s statement: “scenario is the most abused term in futures research” . Bishop and colleagues added: “even the most basic vocabulary is used every which way in this field . We provided some examples of this issue in the Methods section (reasons for exclusion). Even when an article’s title seems to be clear, one cannot be certain that the article deals with a scenario project [31, 90]. Furthermore, there is no clear-cut scenario method. Unlike classical epidemiological research, many variants of the method exist and, according to our findings, are applied in various projects [9, 10, 48, 87, 88]. An additional difficulty is that these different variants of the method have not remained stable. For example, there has been a notable shift from quantitative to more qualitative or mixed method approaches, as evidenced by statements like “Scenario-projects are primarily simulation” , “scenario analysis is essentially a qualitative technique” , “we have used […], the qualitative scenario method, in order to assess and rank possible influencing factors” . According to Glenn, “often projections are confused with scenarios” . Another limitation is that only 11 publications were identified from searches in the databases used in this review. The remaining 30 publications were found by screening the reference lists, on the internet, and through recommendations from experts in the field. It was also apparent that only a few scenario projects have been published in scientific journals (by researchers), whereas a substantial number of project reports have been published as grey literature by government institutions [25, 91], non-government organizations [47, 92] or private (commercial/consulting) firms [92, 93]. So, it should be taken into consideration that some of the scenario projects have not been developed by scientific experts, but rather came from non-scientific institutions or clinical organizations (with little awareness of scientific research techniques) [55, 62, 72]). Additionally, some included scenario projects [21, 29] have also been published in more detailed reports  or books .
Decision against reviewing grey literature
The “Pisa Declaration on Policy Development for Grey Literature Resources” , a Cochrane report , and the enhanced Arksey and O´Malley framework [27, 28] all recommend including grey literature to validate the results of a research-based literature search. However, Levac and colleagues also point out the cost-to-benefit ratio consideration: “Balancing breadth and comprehensiveness of the scoping study with feasibility of resources can be challenging” .
Firstly, although non-peer reviewed publications have the potential to provide valuable insights in this area, the quality of methods applied to data collection, analysis and interpretation may vary substantially . We conducted an exploratory search on the internet before we used a systematic search approach. We randomly surveyed the reports and found a very heterogeneous quality. Although there were a few reports reflecting high scientific quality (e.g. [25, 99]) we also identified reports of lesser quality and reports with minimal to non-existent descriptions of the methods used . Notably, one can be assumed that reports from commercial/consulting firms [92, 93] try to avoid detailed and transparent description of the scenario preparation process in order to protect proprietary data and the nature of their business model.
Secondly, in order to confirm that our results could be replicated, we wanted to ensure that all studies had been subjected to some form of peer-review. In order to still allow a maximal amount of comprehensiveness, we conducted a systematic search for literature in the mentioned databases and also in the reference lists of the identified literature (backward tracking).
Thirdly, there is still a lack of persistent identifiers and open standards of metadata for grey literature, which complicates the identification of relevant publications.
Fourthly, the large number of existing scenario projects addressed in reports (e.g. [25, 91, 93, 94, 99–101]) made it impossible to handle a comprehensive search with our limited resources. Because of that, the effort associated with a comprehensive search for grey literature would be disproportionate to the resulting benefits. For example, the study group for future scenarios in health care (STG/STC) listed 29 published books for their program alone . For this program we identified eight scenario project articles published in scientific journals [67–70, 73, 74, 79, 81].
For these reasons, we think a subsequent integration of grey literature would not have led to new and stronger results for our research aims.
Limitations of the scenario method itself
Proposed key methodological criteria to report in scenario projects
Aim of the scenario project
• Does the word “scenario project (planning, approach…)” appear in the title along with the topic of primary interest?
• Is the topic of interest clearly described?
• What are the proposed implications?
• Are the target groups and/or stakeholders specified?
• Is there a clear time horizon?
Framework of the scenario project
• Are the preconditions and presuppositions well described?
• Is the process of developing the areas of influence, key factors, and future projections adequately described?
• Who is involved (description of scenario development team and participants/experts)?
• Is the background of participants/experts clear?
• How will participants/experts be selected or excluded?
Methodological approach of the scenario project
• Is the specific scenario technique used (e.g. only narrative, consistence analysis, cross-impact analysis) well described?
• If any, is the mathematical approach well described?
• How is the mathematical approach transformed/implemented in software (if applicable)?
• Is there any combination with other methods like the Delphi technique?
• Is the presentation of the scenario development process adequate?
• Are the scenarios presented in a sound manner (to the specified target groups/stakeholders)?
Impact of the scenario project
• Are there any recommendations for different target groups/stakeholders?
• What are the next steps after the scenario project?
In recent years, more scenario projects relating to health and health care have been published in scientific journals than ever before. This review provides a comprehensive overview of the use of the scenario method in the field of public health and health policy research. The scenario method has been classified as most helpful for strategic issues by several authors of the projects. However, there is no ‘one” scenario method. There is a wide spectrum of strategic aims covered by heterogeneous variants of the scenario method.
To establish the scientific use of scenario methods, uniform qualitative reporting would be useful, based on the GRAMMS criteria, for example .
We thank Karla Bergerhoff, MD, Cochrane Metabolic and Endocrine Disorders Group (CMED), Medical Faculty, Heinrich-Heine-University Düsseldorf for her helpful support during research. We also thank Nancy Myers, BA, for her language support.
Research reported in this publication was supported only by the institutions of the authors.
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