Environmental Scanning: A Vital Tool for Strategic Planning in Health Care

Abstract

Drawing inspiration from business strategies, quality enhancement methodologies, and strategic planning frameworks, environmental scanning is increasingly recognized as a valuable asset in public health and healthcare research. Federal funding bodies and prominent health organizations advocate for its use as a crucial assessment and data collection technique. Applicable across a spectrum of contemporary and future health challenges, environmental scans employ diverse approaches to thoroughly evaluate multifaceted aspects of an issue. This involves engaging key stakeholders to formulate and address pertinent research inquiries, scrutinizing relevant policies, critically analyzing both published scholarly works and grey literature, gathering and interpreting primary and secondary qualitative and quantitative data, disseminating findings to both internal and external stakeholders, and ultimately informing subsequent planning and decision-making processes. To illustrate the practical application of environmental scanning within a healthcare context and to emphasize its significance for professionals in the field, this article delves into a federally sponsored environmental scan project focused on human papillomavirus vaccination initiatives in Kentucky.

Background

Environmental scanning is a systematic process utilized by businesses and various organizations to meticulously evaluate their internal strengths and weaknesses alongside external opportunities and threats. Decision-makers leverage environmental scans to compile, organize, and interpret data concerning their resources and limitations within both internal and external landscapes, thereby guiding strategic planning and informed decision-making (1–3). In the business realm, environmental scans prioritize the acquisition of pertinent and reliable information through diverse methods. These encompass comprehensive literature reviews, in-depth online database assessments, social media monitoring, policy analyses, competitor evaluations, and the solicitation of stakeholder perspectives, including insights from customers, board members, and staff, among other strategic approaches (3). When executed effectively, this process culminates in a series of evidence-backed responses that an organization can employ to refine its strategy and enhance overall performance (4).

In recent years, environmental scans have been increasingly adopted within public health and medicine to gather, structure, and analyze information pertaining to critical issues and prevailing practices. This application aims to identify avenues for quality improvement, establish research priorities, guide the development of effective interventions, educate decision-makers, and ultimately enhance health outcomes. Environmental scans have been instrumental in addressing a wide range of health-related topics, including chronic disease self-management (5), cancer care (2, 6–8), mental health services (9–11), injury prevention strategies (12), and quality improvement initiatives within healthcare systems (13–16). Environmental scanning integrates a multitude of information-gathering techniques (2, 17, 18), including conducting focus groups, in-depth interviews, and surveys with patients and healthcare providers, comprehensive literature reviews, meticulous medical chart audits, direct personal communications, reviews of internal organizational documents, and thorough policy analyses.

Environmental scans share both commonalities and distinctions with conventional public health evaluation principles. For instance, similar to the Centers for Disease Control and Prevention’s (CDC’s) Framework for Program Evaluation in Public Health, an environmental scan adheres to standards of utility, feasibility, propriety, and accuracy. It also incorporates standards for engaging stakeholders, defining program scope, focusing program design, gathering evidence, and disseminating results (19). Furthermore, both environmental scanning and the CDC’s framework emphasize the importance of applying lessons learned to enhance public health effectiveness and sharing these insights with relevant stakeholders. The key differentiator lies in their primary purpose. An environmental scan is designed to understand the broader context, gather comprehensive information, and pinpoint available resources, interconnections, and existing gaps. In contrast, the CDC’s framework is employed to evaluate the merit, worth, or significance of a specific program or policy. When a program or policy is assessed within the CDC framework, evidence is systematically collected, and conclusions are rigorously justified to judge performance and ascertain whether program goals and objectives have been successfully met. In essence, environmental scan activities are centered on gaining a deep understanding of the internal and external environment surrounding a particular health topic and providing valuable input for strategic thinking, informed decision-making, and effective planning (2, 3).

Despite its growing acceptance as an assessment tool across various healthcare contexts, environmental scanning still lacks a universally accepted definition or standardized process within public health practice. In some instances, the term “environmental scan” is used loosely, often interchangeably with “needs assessment” (2). In other cases, it is more closely aligned with strategic planning and quality improvement endeavors (3, 7, 18, 20). Further practical application and critical evaluation of environmental scans are essential to refine the effectiveness of this tool and its associated methodologies (5). Recognizing the inherent value of environmental scans in public health practice and acknowledging the need for more concrete, real-world examples, this article aims to delineate the essential steps involved in conducting an environmental scan. We will use a case study of an environmental scan we conducted for a federally funded human papillomavirus (HPV) vaccination project in Kentucky to illustrate these steps. Our primary objective is to equip public health professionals with the knowledge and guidance necessary to successfully implement this methodology in their own public health practice and research initiatives.

7 Steps to Conduct an Effective Environmental Scan for Health Care Initiatives

In September 2014, a significant initiative saw eighteen cancer centers, including the esteemed University of Kentucky Markey Cancer Center, receive one-year grants from the National Cancer Institute (NCI). This funding was specifically allocated to conduct environmental scans and foster collaborations with diverse organizations to boost HPV vaccination rates within pediatric healthcare settings (21, 22). The design of this environmental scan was structured around seven key steps, a framework readily adaptable to numerous other public health domains.

The Kentucky Cancer Consortium has effectively employed elements of the environmental scan process to address a range of pressing public health concerns. These include mitigating exposure to secondhand smoke, overcoming barriers to colorectal cancer screening, tackling the challenges of obesity and cancer, and assessing the multifaceted impact of the Affordable Care Act on cancer care delivery (23). The valuable lessons gleaned from these prior experiences significantly contributed to the design and execution of our environmental scan specifically focused on the HPV vaccination project. Throughout the various phases of development, implementation, evaluation, and dissemination (as depicted in Figure 1), we consistently shared our evolving process and methodological insights with members of the Kentucky Cancer Consortium and academic peers possessing expertise in environmental scanning, ensuring our work was well-informed and robust (3). The following section outlines the seven-step framework we employed to conduct our environmental scan, with each step accompanied by a practical illustration of its implementation within the Kentucky HPV vaccination project.

Figure 1. Timeline for developing and implementing an environmental scan for Kentucky’s human papillomavirus (HPV) project, July 2014–December 2015. Abbreviations: KY, Kentucky; NCI, National Cancer Institute; RFP, request for proposal.

Step 1: Leverage Existing Expertise to Define Project Leadership and Capacity

A crucial initial step in conducting an effective environmental scan is to designate a dedicated coordinator or a core team member who will champion the entire process, from its initial conceptualization to the final dissemination of findings (3). While the resources available may vary depending on the project scope and organizational context, it is imperative that every environmental scan is underpinned by committed leadership and clearly defined roles and responsibilities for each team member involved. Furthermore, the project’s scope and scale must be carefully considered to ensure they are realistically aligned with the organization’s existing capacity and resources.

Example from HPV vaccination project: Two project leaders (R.C.V. and J.R.K), each bringing complementary expertise in public health and cancer control, collaboratively drew upon their extensive experience in policy development, systems and environmental change initiatives, partnership cultivation, community needs assessments, strategic planning methodologies, and health communication strategies to develop the proposal for NCI funding and to shape the overall environmental scan process. A key requirement stipulated by the NCI was the hiring of a full-time coordinator (A.W.) specifically dedicated to the HPV vaccination environmental scan. This coordinator was entrusted with the responsibility of overseeing the day-to-day implementation of the project.

Step 2: Clearly Define the Focal Area and Purpose of the Environmental Scan

Establishing a clear and concise purpose for the environmental scan is paramount. This purpose serves as the bedrock of the entire process, ensuring that the organization’s limited time, resources, and energy are strategically directed (3, 20). While the environmental scanning process inherently possesses a degree of flexibility, a well-defined purpose acts as a compass, keeping the scan laser-focused and its scope clearly delineated.

Example from HPV vaccination project: The overarching purpose of the HPV environmental scan was meticulously defined as follows: to comprehensively identify all existing public health initiatives, ongoing research endeavors, and pertinent information sources related to HPV vaccination within Kentucky. Furthermore, it aimed to establish or strengthen connections with existing programs, synthesize the gathered findings into a readily usable format for effective dissemination to stakeholders, and proactively identify opportunities for applied research aimed at measurably increasing HPV vaccination uptake rates. To guide this endeavor, the investigative team formulated the following working definition:

“Environmental scanning is a dynamic process of comprehensive assessment purposefully designed to explore HPV vaccination in a manner that uncovers previously unrecognized connections and highlights both barriers and facilitators that were not previously identified. The ultimate goal is to empower stakeholders with actionable information to inform future strategic planning and decision-making processes.”

Step 3: Develop and Adhere to a Realistic Timeline with Incremental Milestones

Project timelines are often dictated by funding agencies or, in their absence, by organizational leadership. If the environmental scan is self-initiated and not governed by external funding constraints, it is crucial to establish a well-defined timeline from the outset. Strategic planning of environmental scan activities is essential to optimize the process and maintain project momentum. For instance, if surveys or qualitative interviews are integral components of the environmental scan, sufficient time must be allocated for key tasks. This includes developing robust survey instruments and interview guides, conducting thorough pilot testing of these instruments, securing necessary approvals from institutional review boards, effectively recruiting participants, diligently collecting and analyzing data, and finally, synthesizing and interpreting the collected data to derive meaningful insights.

Example from HPV vaccination project: Our project operated under a one-year timeline mandated by the NCI. This externally imposed timeline proved instrumental in prioritizing the various components of the scan and ensuring efficient resource allocation. Certain components required specific timing dictated by stakeholder availability and schedules. For example, the Kentucky HPV Initiatives Team convened bimonthly, necessitating that we align certain activities with their meeting schedule. Our project plan incorporated the completion of both quantitative and qualitative data collection within the one-year timeframe (as depicted in Figure 1). The time allocated for the provider survey, which was deployed in August 2015, encompassed a series of essential activities: collaborative development of the survey instrument in conjunction with other funded cancer centers, submission and attainment of university institutional review board approval, pilot testing of survey constructs and preliminary questions with six clinicians to ensure clarity and relevance, collection of responses from a diverse group of 231 healthcare professionals including physicians, mid-level clinicians, nurses, and pharmacists, and rigorous analysis of the preliminary data to identify initial trends and insights.

Step 4: Determine the Scope of Information to be Collected for the Environmental Scan

Initiate a comprehensive brainstorming session to identify all pertinent topics and potential resources that could inform the environmental scan (2, 3, 7, 18, 20). While it is acknowledged that not all desired information may ultimately be accessible, it is crucial to initially cast a wide net and include everything that, ideally, should be incorporated into the scan. It is more advantageous to discover that certain information is unavailable than to inadvertently overlook potentially critical data points. Unlike Step 2, the list of information items identified in this step is intended to be dynamic and iterative, evolving as opportunities to engage with stakeholders emerge and new resources are uncovered throughout the scanning process.

Example from HPV vaccination project: The HPV vaccination project commenced with the identification of several broad areas of inquiry related to HPV vaccination activities within Kentucky. These initial areas included: an examination of state cancer registry and immunization data, a review of media coverage surrounding HPV vaccination, an analysis of the policy landscape, an assessment of the public health practice and research environments, a comprehensive literature review, an update to the Kentucky Cancer Action Plan, a comparative analysis of HPV vaccination initiatives in other states, the conduct of 14 key informant interviews to gather expert perspectives, and the identification of priority areas for future research. As the environmental scan progressed, it became evident that certain topics yielded richer and more robust information than others. For instance, the Kentucky Department for Public Health’s Division of Immunization had secured CDC funding to implement a multimedia campaign promoting HPV vaccination during the back-to-school season. Conversely, in other instances, project staff had to proactively seek out less conventional data sources. For example, the Kentucky Immunization Registry’s system was not designed to mandate the entry of HPV vaccination data. Consequently, alternative data sources were explored to construct a comprehensive picture of HPV vaccination trends in Kentucky. This included leveraging data from the CDC’s Comprehensive Clinical Assessment Software Application (CoCASA), a valuable tool for evaluating immunization coverage and practices within clinics and other settings where immunizations are administered.

Step 5: Identify and Proactively Engage Key Stakeholders

Stakeholders, and crucially, their willingness to actively participate in the environmental scan, are the linchpin of its ultimate success. Develop a diverse and iterative list of individuals and organizations possessing relevant information pertaining to each topic identified in Step 4. Stakeholders can play a pivotal role in expanding the initial list of topics by recommending additional stakeholders or connecting project staff members to their networks, effectively employing a snowball sampling approach.

Before initiating contact with stakeholders, it is essential to clearly define what information or input is being sought from them. Develop a structured plan for conversations with participants, whether it involves a pre-defined set of questions, specific requests for data or documents, or clearly articulated action items. Be prepared to address stakeholder inquiries about the topic under investigation and the environmental scan process itself, as well as any funding requirements or project parameters. Meticulously document all suggestions and insights shared by stakeholders, even if their immediate relevance is not readily apparent. These seemingly peripheral suggestions may prove to be invaluable as the project progresses. Furthermore, consider what can be offered in return for stakeholders’ valuable participation, such as providing them with early access to the final environmental scan results or offering promotional materials related to their organizations or initiatives.

Example from HPV vaccination project: During the NCI grant application phase, we proactively sought and secured letters of support from key local and state partners. These letters served as powerful endorsements and facilitated the establishment of early buy-in from established stakeholders. For instance, the project coordinator had cultivated a prior working relationship with the Kentucky Department for Public Health and had established professional rapport with individuals within its immunization branch. This pre-existing connection proved invaluable, as the immunization branch subsequently introduced us to a network of stakeholders who were previously unknown to the HPV vaccination project team. The stakeholder list rapidly expanded to encompass local immunization coalitions, a practice-based pharmacy research network, and pediatricians practicing in rural Appalachian Kentucky who had demonstrated success in promoting HPV vaccination within their communities.

We ensured that stakeholders received a concise introduction to the environmental scan, clearly outlining its objectives and anticipated outcomes. We also collaboratively devised a plan to ensure the most efficient and respectful utilization of their time and expertise. Some stakeholders, demonstrating their commitment to the project’s goals, invited us to actively participate in their ongoing public health activities. For example, the Kentucky College Health Association extended an invitation to the project coordinator to present at their annual meeting, focusing on the critical topic of HPV vaccination. A mini-grant secured through the University of Kentucky’s Appalachian Center enabled the team to offer incentives (in the form of $75 gift cards) to the pediatricians identified as successful HPV vaccinators, encouraging their participation in in-depth qualitative interviews. These six interviews proved to be exceptionally valuable, providing rich qualitative data that significantly enriched the environmental scan. Furthermore, a grant from the American Cancer Society provided the resources to collaborate with the University of Kentucky’s Center for the Advancement of Pharmacy Practice and a local pharmacy chain operating in Appalachian Kentucky. This partnership aimed to extend HPV vaccination promotion efforts beyond traditional medical settings and into community pharmacies, enhancing accessibility and reach.

Step 6: Analyze and Synthesize Environmental Scan Results into a Concise Summary Report

Conduct a rigorous analysis of all data collected throughout the environmental scan process, and systematically triangulate the data in accordance with the pre-defined environmental scan plan (18, 20, 24). Thoroughly document both quantitative and qualitative findings derived from survey instruments, key informant interviews, policy and media assessments, and comprehensive literature reviews. Subsequently, synthesize these diverse results into meaningful conclusions that directly address the focal area of the environmental scan (3). Crucially, identify evidence-based research priorities or intervention target areas that emerge from the synthesized findings. Utilize the results to inform subsequent decision-making processes and to develop a robust action plan. This action plan should strategically guide future public health research or practice projects and empower partners to collaboratively move forward in addressing the identified needs and opportunities.

Example from HPV vaccination project: As the NCI funding period neared its conclusion, project staff commenced the intensive phase of data analysis. This involved analyzing the wealth of data collected from the provider survey, identifying recurring themes and patterns emerging from the in-depth provider interviews, synthesizing the diverse information gathered from the key informant interviews, and rigorously analyzing transcripts of television programs obtained from the one-year HPV vaccination media scan. All analytical activities were deliberately aligned with the overarching objectives of the environmental scan: to formulate a comprehensive HPV vaccination research agenda, to identify effective partnership models and policy frameworks that could be replicated in other settings, and to pinpoint priority educational and interventional areas for key stakeholders to focus on in future initiatives.

Step 7: Disseminate Key Findings and Conclusions to Relevant Stakeholders

Researchers and practitioners have various avenues for delivering the final product of the environmental scan (3, 18). In some cases, the funding agency may provide a specific template to guide the summarization of data in a final report. If a template is not mandated or readily available, it is advisable to create one either at the outset of the project or towards its conclusion. In the report shared with stakeholders, explicitly address the extent to which the initial overarching research question and its subtopics were effectively answered by the environmental scan. Clearly list all informational sources consulted and utilized throughout the process. Ensure that the finalized results of the environmental scan are readily accessible to the funding agency, the organization’s leadership, and all individuals and organizations who actively participated in the process.

Example from HPV vaccination project: The NCI did not stipulate a specific final reporting template for this project, allowing for flexibility in report format and content. The format of our final report was not predetermined at the project’s inception. Instead, it organically evolved around the informational sources that were strategically identified and established in Step 4 of the scan. We disseminated the final report in both traditional paper format and as a visually engaging poster presentation to ensure accessibility for the funding agency, key stakeholders, and other interested parties. Furthermore, the environmental scan team actively engaged in knowledge dissemination by delivering six informational presentations at national, state, and local conferences, reaching a wider audience and amplifying the impact of the project’s findings.

Discussion

Environmental scanning serves as a powerful methodology for comprehensively assessing both the external and internal environments of health programs. It is equally valuable in identifying the barriers and facilitators that influence the effective resolution of health challenges within the context of a specific community or a national priority area. The insights gleaned from environmental scans can strategically inform planning and decision-making for new projects or interventions, effectively guide the direction of emerging public health activities, raise critical awareness of health disparities and other inequities, and even serve as a catalyst for initiating new projects or pursuing relevant funding opportunities (2, 17, 18). For instance, HPV vaccination, despite being recommended for over a decade, remains relatively novel in the public consciousness and is significantly underutilized in Kentucky and across the nation for the primary prevention of HPV-related cancers (25–27). The environmental scan approach proved to be a strategically insightful and creatively effective method for the NCI to gain a comprehensive, big-picture understanding of the diverse HPV vaccination activities underway within the catchment areas of 18 designated cancer centers. Collectively, the 18 individual environmental scans provided the NCI and each grantee institution with strategically vital, localized information. This information shed light on the interconnections between cancer centers, immunization programs, and public health coalitions and initiatives aimed at promoting HPV vaccination. Furthermore, the scans facilitated the identification of novel collaborations specifically designed to enhance HPV vaccination uptake through applied research endeavors. Ultimately, these scans informed both research and practice agendas, all with the overarching goal of measurably reducing the incidence of HPV-related diseases.

Prior to embarking on an environmental scan, it is essential to establish a clear working definition of what constitutes an “environmental scan” within the specific context of the project (2). This definition should encompass detailed yet adaptable steps to ensure the desired outcomes are achieved. The entire process must be sufficiently fluid to accommodate modifications suggested by valuable information gleaned from stakeholders and to effectively address new questions that inevitably arise during the scanning process.

Perhaps the most critical step in the entire environmental scan process is to proactively determine how the findings will be effectively utilized (18, 20). The final product of the scan, whether it takes the form of a comprehensive hardcopy report or a compelling presentation, should be widely disseminated to all relevant stakeholders, including those who generously contributed their time and expertise by providing information for the environmental scan. Ideally, the final product will serve as a catalyst, generating concrete research priorities, pinpointing existing funding gaps, creating tangible opportunities for effective interventions, and identifying new partnerships that warrant cultivation and strengthening. Kentucky’s final report and accompanying poster presentation, both of which were made readily available to the NCI and key stakeholders, effectively highlighted the pressing need for robust HPV vaccination data, energized existing partners and fostered the engagement of new collaborators, and generated a prioritized list of research areas. These research priorities included the development and implementation of a pharmacy-based vaccination study and the strategic utilization of community–clinical linkages to enhance HPV vaccination rates.

Our description of the environmental scan process has at least two inherent limitations that warrant acknowledgment. Firstly, a universally accepted standard definition for environmental scanning or a consistently applied approach to its implementation does not yet exist within the field of public health (2, 18). This inherent ambiguity represents a limitation of the process itself, and it is anticipated that both the definition and the methodological process will continue to evolve as more public health organizations and practitioners increasingly adopt this valuable tool. Over time, the specific process outlined in this article may become either more or less directly applicable as the field matures and best practices emerge. Secondly, our environmental scan was conducted within a specific set of contextual circumstances. It benefited from federal agency funding and support, the dedication of a full-time project coordinator, pre-established relationships with key informants, and a defined one-year project timeline. It is important to recognize that the seven steps described in this article may not be directly generalizable to all other public health environments, particularly those with different resource constraints or organizational structures. Notwithstanding these limitations, these environmental scan steps, or thoughtfully adapted versions thereof, hold significant potential for application to a wide spectrum of public health questions and diverse areas of research and practice.

Acknowledgments

The Kentucky HPV vaccination environmental scan was generously supported by an administrative supplement from the National Cancer Institute to the University of Kentucky Markey Cancer Center (3P30CA177558-02S2; Evers, principal investigator).

Author Information

Corresponding Author: Robin C. Vanderpool, DrPH, University of Kentucky College of Public Health and University of Kentucky Markey Cancer Center, 2365 Harrodsburg Rd, Ste A230, Lexington, KY 40504-2281. Telephone: 859-218-2102. Email: robin@kcr.uky.edu.

Author Affiliations: Amanda Wilburn, Jennifer R. Knight, University of Kentucky College of Public Health and University of Kentucky Markey Cancer Center, Lexington, Kentucky.

References

1. Morrison JL. Environmental scanning. In: Whitely MA, Porter JD, Fenske RH, editors. A primer for new institutional researchers. Tallahassee (FL): The Association for Institutional Research; 1992. p. 86–99.
2. Rowel R, Moore ND, Nowrojee S, Memiah P, Bronner Y. The utility of the environmental scan for public health practice: lessons from an urban program to increase cancer screening. J Natl Med Assoc 2005;97(4):527–34. PubMed
3. Thinking Futures. Holtham Hill (Australia): Doing an environmental scanning: an overview guide; 2012. http://www.sswm.info/sites/default/files/reference_attachments/CONWAY%202012%20Doing%20Environmental%20Scanning.pdf. Accessed June 8, 2016.
4. Society for Human Resource Management. Alexandria (VA): Society for Human Resource Management; 2016. https://www.shrm.org. Accessed April 2, 2016.
5. Liddy C, Mill K. An environmental scan of policies in support of chronic disease self-management in Canada. Chronic Dis Inj Can 2014;34(1):55–63. PubMed
6. Blasi PR, King D, Henrikson NB. HPV vaccine public awareness campaigns: an environmental scan. Health Promot Pract 2015;16(6):897–905. CrossRef PubMed
7. Centers for Disease Control and Prevention. Increasing quality colorectal cancer screening: an action guide for working with health systems. Atlanta (GA): Centers for Disease Control and Prevention, US Department of Health and Human Services; 2013.
8. Patel J, Salit IE, Berry MJ, de Pokomandy A, Nathan M, Fishman F, et al. Environmental scan of anal cancer screening practices: worldwide survey results. Cancer Med 2014;3(4):1052–61. CrossRef PubMed
9. Mazade NA, Glover RW, Hutchings GP. Environmental scan 2000: issues facing state mental health agencies. Adm Policy Ment Health 2000;27(4):167–81. CrossRef PubMed
10. Reitmanova S, Gustafson DL. Primary mental health care information and services for St. John’s visible minority immigrants: gaps and opportunities. Issues Ment Health Nurs 2009;30(10):615–23. CrossRef PubMed
11. Mazade NA, Glover RW. State mental health policy: critical priorities confronting state mental health agencies. Psychiatr Serv 2007;58(9):1148–50. CrossRef PubMed
12. Kalula SZ, Scott V, Dowd A, Brodrick K. Falls and fall prevention programmes in developing countries: environmental scan for the adaptation of the Canadian Falls prevention curriculum for developing countries. J Safety Res 2011;42(6):461–72. CrossRef PubMed
13. Sorensen AV, Bernard SL. Accelerating what works: using qualitative research methods in developing a change package for a learning collaborative. Jt Comm J Qual Patient Saf 2012;38(2):89–95. PubMed
14. Weidmer BA, Brach C, Hays RD. Development and evaluation of CAHPS survey items assessing how well healthcare providers address health literacy. Med Care 2012;50(9, Suppl 2):S3–11. CrossRef PubMed
15. Sibbald SL, McPherson C, Kothari A. Ontario primary care reform and quality improvement activities: an environmental scan. BMC Health Serv Res 2013;13(1):209. CrossRef PubMed
16. Anas R, Stiff J, Speller B, Foster N, Bell R, McLaughlin V, et al. Raising the bar: using program evaluation for quality improvement. Healthc Manage Forum 2013;26(4):191–5. CrossRef PubMed
17. Graham P, Evitts T, Thomas-MacLean R. Environmental scans: how useful are they for primary care research? Can Fam Physician 2008;54(7):1022–3. PubMed
18. National Association of County and City Health Officials. Developing a local health department strategic plan: a how-to guide. http://www.naccho.org/uploads/downloadable-resources/Programs/Public-Health-Infrastructure/StrategicPlanningGuideFinal.pdf. Accessed June 20, 2016.
19. Centers for Disease Control and Prevention. CDC evaluation framework. Atlanta (GA): Centers for Disease Control and Prevention; 2016. http://www.cdc.gov/eval/framework/. Accessed June 5, 2015.
20. Public Health Foundation. The ABCs of plan-do-check-act (PDCA). Washington (DC): Public Health Foundation. http://www.phf.org/resourcestools/Pages/The_ABCs_of_PDCA.aspx. Accessed June 20, 2016.
21. National Cancer Institute, Division of Cancer Control and Population Sciences. Administrative supplements for NCI-designated cancer centers to support collaborations to enhance HPV vaccination in pediatric settings: a summary report. Silver Spring (MD): Nova Research Company; 2016.
22. National Cancer Institute. HPV vaccine uptake in cancer centers. Bethesda (MD): National Cancer Institute; 2015. http://healthcaredelivery.cancer.gov/hpvuptake/. Accessed April 2, 2016.
23. Kentucky Cancer Consortium. Lexington (KY): KCC Communications. http://www.kycancerc.org/. Access June 5, 2016.
24. Guion LA. A 10-step process for environmental scanning. J Ext 2010;48(4) http://www.joe.org/joe/2010august/iw2.php.
25. Holman DM, Benard V, Roland KB, Watson M, Liddon N, Stokley S. Barriers to human papillomavirus vaccination among US adolescents: a systematic review of the literature. JAMA Pediatr 2014;168(1):76–82. CrossRef PubMed
26. Daniel-Ulloa J, Gilbert PA, Parker EA. Human papillomavirus vaccination in the United States: uneven uptake by gender, race/ethnicity, and sexual orientation. Am J Public Health 2016;106(4):746–7. CrossRef PubMed
27. Reagan-Steiner S, Yankey D, Jeyarajah J, Elam-Evans LD, Singleton JA, Curtis CR, et al. National, regional, state, and selected local area vaccination coverage among adolescents aged 13–17 years — United States, 2014. MMWR Morb Mortal Wkly Rep 2015;64(29):784–92. CrossRef PubMed