Environmental Scanning Tools for Public Health: A Step-by-Step Guide to Enhance Your Strategies

Abstract

Environmental scanning, a methodology adapted from business strategy and quality improvement, is increasingly recognized as a valuable tool within public health practice and research. Federal funding agencies and health organizations advocate for its use as a robust assessment and data collection method. Applicable across a wide spectrum of current and emerging health issues, environmental scans utilize diverse approaches to thoroughly evaluate various aspects of a problem. This involves engaging stakeholders to formulate and address critical research questions, examining relevant policies, analyzing both published academic works and gray literature, gathering and interpreting qualitative and quantitative data from primary and secondary sources, disseminating key findings to both internal and external stakeholders, and ultimately informing subsequent strategic planning and decision-making processes. To demonstrate the practical application of environmental scanning in a public health context and to highlight its inherent value for practitioners in the field, this article details a federally funded environmental scan project focused on human papillomavirus (HPV) vaccination initiatives in Kentucky.

Background

Environmental scanning is a systematic process originally developed and utilized by businesses and organizations to meticulously evaluate their internal strengths and weaknesses alongside external opportunities and threats. This comprehensive approach equips decision-makers with the capacity to collect, organize, and analyze crucial data pertaining to both their internal resources and capabilities, as well as the broader external landscape. The insights gleaned from environmental scans are instrumental in guiding strategic planning and informing key decision-making processes (1–3). In the business sector, the primary focus of environmental scanning is on acquiring pertinent and reliable information through a variety of methods. These methods encompass literature reviews, in-depth assessments of online databases, social media monitoring, policy analyses, competitor evaluations, and direct engagement with stakeholders to solicit their perspectives – including customers, board members, and staff – among other strategic approaches (3). When executed effectively, this process yields a series of evidence-based strategies that empower an organization to refine its overall strategy and enhance its operational performance (4).

In recent years, environmental scanning techniques have been increasingly adopted within public health and medicine. They serve as a valuable methodology for collecting, organizing, and analyzing information related to prevailing issues and current practices. This application aims to identify opportunities for quality improvement, establish research priorities, guide the development of targeted interventions, inform decision-makers with comprehensive insights, and ultimately contribute to improved health outcomes. Environmental scans have been successfully employed to address a diverse array of public health challenges, including chronic disease self-management (5), cancer care (2, 6–8), mental health (9–11), injury prevention (12), and quality improvement initiatives (13–16). A key characteristic of environmental scanning is its integration of multiple information-gathering strategies (2, 17, 18). These strategies encompass a range of qualitative and quantitative methods, such as focus groups, in-depth interviews, and surveys conducted with both patients and healthcare providers. Additionally, environmental scans involve thorough literature reviews, medical chart reviews, direct personal communications, reviews of internal organizational documents, and detailed policy analyses.

Environmental scans share both similarities and differences with traditional public health evaluation principles. Paralleling 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 stakeholder engagement, program description, focused program design, evidence gathering, and results dissemination (19). Furthermore, both environmental scans and the CDC’s framework emphasize the critical importance of applying lessons learned to enhance public health effectiveness and sharing these insights with relevant stakeholders. However, a key distinction lies in their primary purpose. The fundamental goal of an environmental scan is to gain a comprehensive understanding of the context, systematically collect information, and identify available resources, existing linkages, and critical gaps. In contrast, the CDC’s framework is designed to evaluate the merit, worth, or overall significance of a specific program or policy. When utilizing the CDC’s framework to evaluate a program or policy, the focus is on gathering evidence and justifying conclusions to assess performance and determine the extent to which program goals and objectives have been achieved. Conversely, environmental scan activities are centered on developing a deep understanding of both the internal and external environments surrounding a particular topic. This understanding serves as crucial input for strategic thinking, informed decision-making, and effective planning processes (2, 3).

Despite its increasing adoption as an assessment tool across various healthcare settings, a universally accepted definition or standardized process for conducting environmental scans in public health practice remains lacking. In some instances, the term “environmental scan” is used informally as a broad, catch-all phrase, often used synonymously with a needs assessment (2). In other cases, it is more closely aligned with strategic planning and quality improvement initiatives (3, 7, 18, 20). Further application and critical analysis of environmental scans are essential to enhance the effectiveness of this tool and refine its related methodology (5). Recognizing the utility of environmental scans in public health practice, and acknowledging the need for more practical examples, this article aims to delineate the key steps involved in conducting an environmental scan. We will use, as a practical illustration, the environmental scan we conducted for a federally funded human papillomavirus (HPV) vaccination project in Kentucky. Our primary objective is to equip public health practitioners with the knowledge and guidance necessary to successfully apply this valuable methodology within the context of public health practice and research.

7 Steps of the Environmental Scan for Public Health Initiatives

In September 2014, eighteen cancer centers, including the University of Kentucky Markey Cancer Center, received one-year funding from the National Cancer Institute (NCI). This funding was specifically allocated to conduct environmental scans and foster collaborations with other organizations to improve HPV vaccination rates in pediatric healthcare settings (21, 22). The environmental scan design was structured around 7 key steps, a framework that is broadly applicable to numerous other public health areas.

The Kentucky Cancer Consortium has previously applied elements of the environmental scan process to address a range of public health concerns, including exposure to secondhand smoke, barriers to colorectal cancer screening, obesity, cancer prevention, and the impact of the Affordable Care Act on cancer care (23). The lessons learned from these prior experiences significantly contributed to the development and execution of our environmental scan for the HPV vaccination project. Throughout the phases of development, implementation, evaluation, and dissemination (Figure), we consistently shared our process and methodology with members of the Kentucky Cancer Consortium and academic colleagues possessing expertise in environmental scanning. This collaborative approach ensured our work was well-informed and benefited from diverse perspectives (3). The following section outlines the 7-step process we employed to conduct our environmental scan, with each step accompanied by an illustration of its implementation in the Kentucky HPV vaccination project.

Figure. 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. [A text version of this figure is also available.]

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

A crucial initial step in conducting an effective environmental scan is to designate a coordinator or a core team member who will champion the entire process, from its initial development through to the dissemination of findings (3). While the specific resources available may vary depending on the project and the organization, every environmental scan necessitates dedicated leadership and clearly defined roles and responsibilities for each member of the team. It is also essential to ensure that the project’s scope and scale 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, drew upon their extensive experience in policy development, systems and environmental change strategies, partnership cultivation, community needs assessments, strategic planning methodologies, and health communication to develop both the proposal for NCI funding and the overarching environmental scan process. A key requirement from NCI was the hiring of a full-time project coordinator (A.W.) specifically dedicated to the HPV vaccination environmental scan. This coordinator was assigned responsibility for the day-to-day implementation and management of the project.

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

Clearly defining the purpose of the environmental scan is absolutely critical. This defined purpose serves as the anchor for the entire process, ensuring focus and efficient allocation of the organization’s often limited time, resources, and energy (3, 20). While the environmental scanning process can be adaptable and flexible in its execution, establishing a firm and well-articulated purpose from the outset is essential for maintaining focus and ensuring a clearly defined scope.

Example from HPV vaccination project. The primary purpose of the HPV environmental scan was to comprehensively identify all existing public health activities, relevant research initiatives, and available information pertaining to HPV vaccination within Kentucky. Furthermore, the scan aimed to develop and strengthen connections with existing programs, synthesize the collected findings into a readily usable format for dissemination to stakeholders, and identify potential opportunities for applied research specifically focused on increasing HPV vaccination uptake rates. To guide this process, the investigative team established the following working definition:

A dynamic process of comprehensive assessment aimed at exploring HPV vaccination in a manner that makes connections not previously established and highlights barriers and facilitators not previously identified with the goal of empowering stakeholders with information for future strategic planning and decision making.

Step 3: Develop and Adhere to a Project Timeline with Incremental Goals

Project timelines may be predetermined, often dictated by a funding agency or, in other cases, established by organizational leadership. If the environmental scan is being organized independently, without external mandates, it is crucial to establish a realistic and well-defined timeline right from the project’s inception. Strategic planning of environmental scan activities is essential to optimize the overall process and maintain project momentum. For instance, if surveys or qualitative interviews are integral components of the environmental scan, it is vital to allocate sufficient time for each stage. This includes time for developing the survey instrument and interview guides, conducting pilot testing to refine the instruments, securing necessary approvals from institutional review boards, recruiting participants, meticulously collecting and analyzing the data, and finally, synthesizing and interpreting the findings.

Example from HPV vaccination project. Our project’s one-year timeline was set by the NCI funding guidelines. Having this predefined timeline was instrumental in prioritizing the various components of the environmental scan and ensuring timely progress. Certain components required alignment with stakeholder schedules; for example, the Kentucky HPV Initiatives Team held bimonthly meetings, necessitating the scheduling of some of our activities accordingly. Our plan included completing both quantitative and qualitative data collection within the one-year timeframe (Figure). The time allocated for the provider survey, which was launched in August 2015, encompassed several key activities: developing the survey instrument in collaboration with other NCI-funded cancer centers, submitting an application and obtaining approval from the university’s institutional review board, conducting pilot testing of survey constructs and preliminary questions with 6 clinicians, collecting responses from 231 physicians, mid-level clinicians, nurses, and pharmacists, and performing preliminary data analysis.

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

Initiate a brainstorming session to identify all relevant topics and potential resources that could contribute valuable information to the environmental scan (2, 3, 7, 18, 20). While it is acknowledged that not all desired information may ultimately be accessible, it is important to initially cast a wide net and include everything that ideally should be part of the scan. It is more beneficial to discover that certain information is unavailable than to risk overlooking potentially crucial insights due to an overly narrow initial scope. In contrast to Step 2, the list of information items in this step is intended to be dynamic and iterative, evolving as stakeholder engagement opportunities develop and new resources are identified throughout the process.

Example from HPV vaccination project. The project commenced with several broad areas of inquiry related to HPV vaccination activities in Kentucky. These initial areas included: an analysis of state cancer registry and immunization data, a review of media coverage related to HPV vaccination, an assessment of the policy environment, an examination of public health practice and research environments, a comprehensive literature review, an update of the Kentucky Cancer Action Plan, a review of HPV vaccination initiatives in other states, 14 key informant interviews, and the identification of priority areas for future research. As the environmental scan progressed, certain topics emerged as being more data-rich and readily accessible than others. For instance, the Kentucky Department for Public Health’s Division of Immunization was awarded CDC funding to implement a multimedia campaign promoting HPV vaccination during the back-to-school season, providing a valuable source of information. In other instances, project staff had to actively seek out less conventional data sources. For example, the Kentucky Immunization Registry, at the time, did not mandate the entry of HPV vaccination data into its system. Consequently, alternative data sources were utilized to develop a comprehensive understanding of HPV vaccination trends in Kentucky. This included accessing data from the CDC’s Comprehensive Clinical Assessment Software Application, a specialized tool designed for evaluating immunization coverage and practices within clinics and other immunization service delivery sites.

Step 5: Identify and Actively Engage Key Stakeholders

Stakeholders, and critically, their willingness to actively participate in the environmental scan, are paramount to its overall success. Develop a comprehensive and iterative list of individuals or organizations possessing relevant information pertaining to each topic identified in Step 4. Stakeholders can play a crucial role in expanding the initial list of topics by recommending additional contacts or directly connecting project staff members to other pertinent stakeholders, effectively employing a “snowball” approach to stakeholder identification and engagement.

Prior to reaching out to stakeholders, it is essential to clearly define what information or input is needed from them. Develop a structured plan for conversations with participants, whether this takes the form of a set of pre-determined questions, specific requests for data or documents, or clearly defined action items. Be prepared to address any questions stakeholders may have about the topic of the environmental scan, the overall process, and the funding requirements of the project. Meticulously document all suggestions and recommendations offered by stakeholders, even if their immediate relevance is not apparent. These seemingly minor suggestions may prove to be highly valuable as the project progresses. Finally, consider offering something in return for stakeholders’ participation, such as access to the final environmental scan results or relevant promotional materials.

Example from HPV vaccination project. During the NCI application process, we proactively collected letters of support from key local and state partners. These letters served to establish early buy-in and support from established stakeholders. For example, the project coordinator had prior professional experience working with the Kentucky Department for Public Health, fostering a strong professional rapport with its immunization branch. In turn, the immunization branch facilitated connections to stakeholders who were previously unknown to the vaccination project team. This network effect rapidly expanded our stakeholder list to include local immunization coalitions, a practice-based pharmacy research network, and pediatricians practicing in rural Appalachian Kentucky who had demonstrated success in HPV vaccination initiatives.

We ensured that stakeholders were provided with a concise introduction to the environmental scan, its objectives, and its intended outcomes. We also developed a clear plan to maximize the efficient use of their time and expertise. Some stakeholders actively invited our participation in their ongoing public health activities. For instance, the Kentucky College Health Association invited the project coordinator to present at their annual meeting on the topic of HPV vaccination. A mini-grant secured through the University of Kentucky’s Appalachian Center allowed the team to incentivize (with $75 gift cards) pediatricians identified as successful HPV vaccinators to participate in in-depth, qualitative interviews. These six interviews provided invaluable insights for the environmental scan. Furthermore, a grant from the American Cancer Society enabled us to collaborate with the University of Kentucky’s Center for the Advancement of Pharmacy Practice and a local pharmacy chain in Appalachian Kentucky to promote HPV vaccination beyond the traditional medical home setting, expanding the reach of our intervention efforts.

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

Thoroughly analyze all data collected throughout the environmental scan process and triangulate the data from various sources as outlined in the environmental scan plan (18, 20, 24). Systematically document both quantitative and qualitative findings derived from survey instruments, key informant interviews, policy and media assessments, and comprehensive literature reviews. Synthesize these results into meaningful and actionable conclusions directly relevant to the defined focus area of the scan (3). Furthermore, identify evidence-based research priorities or key intervention target areas that emerge from the analysis. Utilize the synthesized results to inform subsequent decision-making steps and to develop a robust action plan. This action plan should guide future public health research or practice projects and empower stakeholders to move forward collaboratively and effectively.

Example from HPV vaccination project. As the funding period neared its conclusion, project staff commenced the process of analyzing data collected from the provider survey, identifying recurring themes and key insights from the in-depth provider interviews, synthesizing information gathered from the key informant interviews, and analyzing transcripts of television programs obtained from the one-year HPV vaccination media scan. All of these analytical activities were purposefully conducted with the overarching objectives of developing a targeted HPV vaccination research agenda, identifying effective partnerships and successful policies that could be replicated in other contexts, and ascertaining priority educational and interventional areas for key stakeholders to focus on moving forward.

Step 7: Disseminate Results and Conclusions to Key Stakeholders

Researchers and practitioners have various options for presenting the final product of an environmental scan (3, 18). For example, the funding agency may provide a specific template or format for summarizing data in a final report. If a template is not mandated, or if no such template is provided, it is advisable to create one either at the project’s outset or towards its conclusion. In the report prepared for stakeholders, clearly address the extent to which the initial, overarching research question and its subtopics have been answered, and provide a comprehensive list of all informational sources utilized during the scan. Ensure that the results of the environmental scan are readily accessible to the funding agency, the organization’s leadership, and all individuals and groups who actively participated in the process.

Example from HPV vaccination project. The NCI did not specify a particular final reporting template for this project. Consequently, the format of the final report was not predetermined at the project’s start. Instead, it organically evolved around the informational sources that were established in Step 4 of the environmental scan process. We made the final report available in both paper and poster presentation formats to the funding agency, key stakeholders, and other interested parties. In addition, the environmental scan team delivered six informational presentations at national, state, and local conferences to further disseminate the findings and reach a broader audience.

Discussion

An environmental scan serves as a powerful tool for comprehensively assessing both the external and internal environments of public health programs. It is also highly effective in identifying barriers and facilitators that influence the successful resolution of health problems within a specific community or in relation to a national health priority area. The insights gained from an environmental scan can significantly inform strategic planning and decision-making processes for projects or interventions. It can guide the strategic direction of new public health initiatives, raise critical awareness of health disparities or other inequities, or serve as a catalyst for initiating new projects or funding opportunities (2, 17, 18). For instance, HPV vaccination, despite being recommended for over a decade, remains a relatively new concept in public consciousness and is significantly underutilized in Kentucky and across the nation for the prevention of HPV-related cancers (25–27). The environmental scan approach proved to be a strategic and innovative method for the NCI to gain a comprehensive, “big-picture” perspective of HPV vaccination activities within the catchment areas of 18 designated cancer centers. Collectively, these 18 environmental scans provided the NCI and each grantee institution with valuable, localized information regarding the interconnectedness of cancer, immunization, and public health coalitions and programs focused on promoting HPV vaccination. They also identified emerging collaborations aimed at enhancing HPV vaccination uptake through applied research initiatives and informed both research and practice agendas, all with the overarching goal of reducing the incidence of HPV-related diseases.

Before embarking on an environmental scan, it is essential to establish a clear and practical working definition of what constitutes an environmental scan within the specific context of the project (2). This definition should outline detailed yet adaptable steps to achieve the desired outcomes. The overall process must be sufficiently fluid to accommodate changes suggested by information gleaned from stakeholders and to address new questions that may arise during the scan.

Perhaps the most critical step in conducting an environmental scan is to proactively determine how the results will be utilized (18, 20). The final product, whether it be a formal hardcopy report or a presentation, should be widely shared with all relevant stakeholders, including those who contributed information to the environmental scan. Ideally, the final product will serve as a catalyst for generating new research priorities, identifying critical funding gaps, creating opportunities for effective interventions, and fostering the development of new partnerships for future collaboration. Kentucky’s final report and poster presentation, disseminated to the NCI and key stakeholders, effectively highlighted the pressing need for robust HPV vaccination data, energized existing partners and identified new potential collaborators, and generated a prioritized list of research areas, including conducting a pharmacy-based vaccination study and leveraging community–clinical linkages to promote HPV vaccination more effectively.

Our description of environmental scanning methodology has at least two primary limitations. First, a universally accepted standard definition or consistent methodological approach for environmental scans is currently lacking within the field of public health (2, 18). This inherent ambiguity represents a limitation of the process itself. The definition and process of environmental scanning will likely continue to evolve as more public health organizations and practitioners adopt and adapt this tool. Over time, the 7-step process described in this article may become either more or less universally applicable. Second, our specific environmental scan was conducted within a particular set of circumstances: it benefited from dedicated federal funding and support, a full-time project coordinator, pre-existing relationships with key informants, and a defined one-year timeline. The 7-step process outlined in this article may not be directly generalizable to all other public health environments, particularly those with significantly different resource levels or time constraints. Regardless of these limitations, the core principles and steps of environmental scanning, or adapted versions thereof, hold significant potential for application to a wide range of public health questions and diverse areas of research and practice.

Acknowledgments

The Kentucky HPV vaccination environmental scan was 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: [email protected].

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