Using the scenario method in the context of health and health care – a scoping review

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 [1]. 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 [4]. According to a recent review by Diamond and colleagues, 98 % of Delphi studies claimed to assess consensus [5]. 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 [6]. Both the Delphi technique and simulation modeling are widely used for health care issues, but were originally developed to support forecast and foresight processes [7]. 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” [9]. 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 [10]. 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 [14], 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 [20].

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.

We conducted our scoping review [26] on the basis of the enhanced recent recommendations of Arksey and O’Malley [27] by Levac and colleagues [28] and presented the results of our search strategy in a flowchart (Fig. 1). Between January 2013 and October 2013 we conducted a systematic search in the following: Medline, Embase, PsycInfo, Eric, The Cochrane Library, Scopus, Web of Science, and CINAHL. An initial search was carried out in January 2013 and an additional search was made in October 2013. The word ‘scenario’ was searched in combination with other terms, e.g. method, model, technique, etc. (see Additional files 1 and 2). In an additional step, the reference lists were tracked backwards for further relevant publications not listed in the databases mentioned above (Fig. 1). We also included in our review manuscripts which were recommended by authors or experts in the field [16, 29]. We also scanned articles suggested by the ´related citations in PubMed’ option for the three most recently published articles [16, 21, 30]. Our search was not restricted by date or language. After screening the title, and, if available, the abstract, all articles that both dealt with the scenario method and addressed issues related to health or health care were included for full text screening. This full screening was performed by two reviewers (HCV, MR) with the following exclusion criteria. Discrepancies were discussed between the two reviewers to achieve consensus. In the case of a possible disagreement a third author (TO) was designated (not required).

Articles were excluded in which the term ‘scenario’ was used only to refer to a possible (future) event [31, 32]. Other exclusion criteria were:

Our search resulted in the identification of a total of 576 bibliographical records. Charting of the data was undertaken independently by two authors (HCV, MR). After removing duplicates, 379 references remained, which, after thorough title and abstract screening, left 67 selected references for possible inclusion (Fig. 1). After full-text screening, 21 publications were excluded because they did not fit the criteria previously determined. From these 46 articles describing the scenario method in use, a total of 41 remained after a final step of exclusion (Fig. 1). Reasons for exclusion were as follows: description of a whole national scenario program (see below) [48], only an abstract of an included project [46], only a simulation modeling project without the description of the scenarios [49], one background paper of an included project with no direct link to the scenarios [50], and one article with no scenario project [51]. The final 41 publications described a total number of 38 different scenario projects. As the studies were quite heterogeneous and included a variety of perspectives, it was decided to classify them by using the following categories (according to Schnaars): year, institution, country, focus, time horizon, number of developed scenarios (Table 1) [52]. We also had discussed to include details of the used methods (e.g. qualitative, quantitative, or both), however in many studies the methods were not adequately described, so we decided not to expand this point. Table 1 gives an overview of the subjects of the included scenario projects, most of them with a time horizon from 10 to 20 years (n = 28), two with a 5 year- [13, 53] and one with a 50 year-perspective [54]. In seven projects the adopted time horizon was not mentioned [24, 55‐60]. The background of the participating experts was not always adequately reported. The reported background of the experts ranged from “leading health futurists” [61], “members of scientific expert societies and/or staff associations” [55, 62], “experienced managers” [56], “RAND health researchers” [63], “genomic experts and breast cancer specialists” [64], “younger citizens” [65], to “secondary school pupils and university students” [29] or “community members” [30]. Only two projects explicitly stated the background of the experts in a table [16, 66]. Five projects reported a combination of the scenario method with a Delphi technique to reach consensus among participating experts [18, 64, 67‐71]. One project was published in Dutch [70] and one in German [55]. All others were published in English. The number of developed scenarios ranged from one [72] to 19 [73] scenarios, but most frequently the numbers of scenarios were three (n = 10), four (n = 9) or five (n = 6) (Table 1).

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 [80], the opportunities of nanotechnology in Switzerland [66], or the relationship between biomedicine and the economy in Germany [65]). One project even came from the Swedish Defense Research Agency (FOI) with tailor-made scenarios for local adaptation to climate change [84]. 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 [24]. 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”) [24]. 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 [53]) to global challenges (e.g. future infectious disease threats to Europe [75]). 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” [16]. 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 [82], text descriptions [78], pictures [83], or short stories called storylines [21]). Although there is no definite response to the question of how many scenarios are optimal in the scenario planning literature [87], 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 [88], but do not describe comprehensive pictures of the future and do not claim to be complete or correct [10]. 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].

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 [104].