The use of experimental vignette studies to identify drivers of variations in the delivery of health care: a Scoping review
Open accessAbstract
Background: Identifying how unwarranted variations in healthcare delivery arise is challenging. Experimental vignette studies can help, by isolating and manipulating potential drivers of differences in care. There is a lack of methodological and practical guidance on how to design and conduct these studies robustly. The aim of this study was to locate, methodologically assess, and synthesise the contribution of experimental vignette studies to the identification of drivers of unwarranted variations in healthcare delivery. Methods: We used a scoping review approach. We searched MEDLINE, Embase, Web of Science and CINAHL databases (2007–2019) using terms relating to vignettes and variations in healthcare. We screened title/abstracts and full text to identify studies using experimental vignettes to examine drivers of variations in healthcare delivery. Included papers were assessed against a methodological framework synthesised from vignette study design recommendations within and beyond healthcare. Results: We located 21 eligible studies. Study participants were almost exclusively clinicians (18/21). Vignettes were delivered via text ( n = 6), pictures (n = 6), video (n = 6) or interactively, using face-to-face, telephone or online simulated consultations ( n = 3). Few studies evaluated the credibility of vignettes, and many had flaws in their wider study design. Ten were of good methodological quality. Studies contributed to understanding variations in care, most commonly by testing hypotheses that could not be examined directly using real patients. Conclusions: Experimental vignette studies can be an important methodological tool for identifying how unwarranted variations in care can arise. Flaws in study design or conduct can limit their credibility or produce biased results. Their full potential has yet to be realised.
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Vignette studies are an effective way of exploring people's beliefs, perceptions, attitudes, behaviour and biases.
“In addition, vignette studies are an effective way of exploring people’s beliefs, perceptions, attitudes, behaviour and biases.95–98”
From Health professionals implicit bias of patients with low socioeconomic status (SES) and its effects on clinical decision-making: a scoping review (2024) · cites this paper as [95]
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Consideration of Psychosocial Factors in Acute Low Back Pain by Physical Therapists
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“While both methods have strengths and weaknesses, well-designed vignette studies may have advantages in certain scenarios [67].”
MethodIva, B., & Maja, O.-H. (2023) · Basic & Clinical Pharmacology & Toxicology · doi:10.1111/bcpt.13899 · Cited by 6 · see citing works
“22 Case vignettes can be a valuable method for researching variations in clinical decision making, and a useful teaching tool as well, 23,24 especially in settings unaccus-tomed to a clinical approach such as deprescribing.”
Methodvan Bree, E. M., van Gestel, L. C., Visser, E. H., Aardoom, J. J., Brakema, E. A., & Adriaanse, M. A. (2025) · The Lancet Planetary Health · doi:10.1016/j.lanplh.2025.101328 · Cited by 7 · see citing works
Evaluating Large Language Models on Social Signal Sensitivity: An Appraisal Theory Approach
Wu, Z., Dutt, R., & Rose, C. (2024) · HUCLLM · doi:10.18653/v1/2024.hucllm-1.6 · Cited by 5
“Our investigation employs an experimental approach grounded in the vignette study paradigm (Converse et al., 2015; Veloski et al., 2005; Sheringham et al., 2021).”
The Role of Open Education and Faculty Gender in Shaping Student Perceptions
Clinton-Lisell, V., & Kelly, A. E. (2024) · Open Praxis · doi:10.55982/openpraxis.16.4.733 · Cited by 5 · see citing works
Yarnell, C. J., Paranthaman, A., Reardon, P. M., Angriman, F., Bassi, T. G., Bellani, G., Brochard, L. J., de Grooth, H., Dragoi, L., Gaus, S., et al. (2024) · Critical Care Medicine · doi:10.1097/ccm.0000000000006494 · Cited by 10 · see citing works
“We designed a factorial vignette-based survey (33–35).”
Improving health service design and delivery for men: does gender targeting matter?
Friend, J. M., & Alden, D. L. (2024) · Journal of Services Marketing · doi:10.1108/jsm-11-2023-0408 · Cited by 4 · see citing works
Yarnell, C., Paranthaman, A., Reardon, P., Angriman, F., Bassi, T., Bellani, G., Brochard, L., de Grooth, H., Dragoi, L., Goligher, E., et al. (2024) · medRxiv · doi:10.1101/2024.04.16.24305906 · Cited by 4
Natterøy, C. S., Tveit, B., & Raustøl, A. (2024) · Nordic journal of nursing research · doi:10.1177/20571585241267741 · Cited by 2 · see citing works
“27 We used the checklist Standard for Reporting Qualitative Research (SRQP) 28 when reporting this study (Supplementary fi le).”
MethodQuirke, M., Alexander, D., Masterson, K., Greene, J., Walsh, C., Leroy, P., Berry, J., Polikoff, L., & Brenner, M. (2022) · BMC Medical Research Methodology · doi:10.1186/s12874-022-01653-2 · Cited by 4
“To briefly summarise its core structure, the factorial survey is a type of experimental vignette-based methodology [16] which takes the form of an ‘experiment within a survey’ [17, 18].”
Bunting, S. R., Calabrese, S., Spigner, S. T., Goetz, T. G., Morrison, S., Zucker, S., Ritchie, T. D., Garber, S. S., & Batteson, T. J. (2022) · LGBT Health · doi:10.1089/lgbt.2021.0023 · Cited by 4
“37,38 By systematically varying fictional patients’ sexual orientation in identical clinical scenarios, insights about how social biases could impact the care of these patients can be gleaned.”
Mathis, M. R., Mirizzi, K., Burns, C., Janda, A. M., Mentz, G. B., Aaronson, K. D., Wu, Z., Likosky, D., Pagani, F. D., Kheterpal, S., et al. (2025) · BMJ Open · doi:10.1136/bmjopen-2025-100306 · Cited by 3 · see citing works
D'Huyvetter, P., & Verbruggen, M. (2024) · European Journal of Work and Organizational Psychology · doi:10.1080/1359432x.2024.2439831 · Cited by 4 · see citing works
“…are by definition hypothetical (Atzmüller & Steiner, 2010), but have, overall, vignettes a good internal validity and are therefore often used to explore situations of complex decision-making as well as their underlying cognitive processes (Aguinis & Bradley, 2014; Sheringham et al., 2021).”
Visser, E. H., Brakema, E., Slootweg, I., Vos, H., & Adriaanse, M. (2024) · medRxiv · doi:10.3399/bjgpo.2025.0041 · Cited by 3 · see citing works
“32 However, our primary interest was in the relative differences between types of advice, rather than their absolute value.”
Clinical decision-making on lung cancer investigations in primary care: a vignette study
Mitchinson, L., von Wagner, C., Blyth, A., Shah, H., Rafiq, M., Merriel, S. W. D., Barclay, M., Lyratzopoulos, G., Hamilton, W., Abel, G. A., et al. (2024) · BMJ Open · doi:10.1136/bmjopen-2023-082495 · Cited by 3
Maas, V. S., & Shi, B. (2024) · SSRN Electronic Journal · doi:10.2139/ssrn.4864031 · Cited by 3 · see citing works
The Use of Speculative Fiction in Future-Focused Health Care Research
Groeneveld, S., Wentzel, J., Laurens, M. C., van Gemert-Pijnen, L. V., Verdaasdonk, R., van Os-Medendorp, H., & den Ouden, M. (2026) · Journal of Medical Internet Research · doi:10.2196/89699 · Cited by 2 · see citing works
“Using existing stories or cultural references can reduce development time, but it also requires careful assessment of the material’s quality and suitability, a concern that aligns with methodological discussions in vignette studies [34].”
Multiple Suggested Care Alternatives and Decision-Making of Primary Care Physicians
Altinger, G., Maher, C. G., Jones, C. M. P., Collins, J., Linder, J. A., Bell, K. J. L., Lin, C.-W. C., Tracy, M., Boroumand, F., & Traeger, A. (2025) · JAMA Network Open · doi:10.1001/jamanetworkopen.2025.42949 · Cited by 2 · see citing works
Influence of race and gender on variability in clinical decision-making in neurology
Paynter, R. A., Bozinov, N., Hawa, S., & Simard, J. F. (2025) · Scientific Reports · doi:10.1038/s41598-025-00726-8 · Cited by 2 · see citing works
Urban, M. M., Sullivan, K. A., & Purser, K. (2024) · Psychiatry Psychology and Law · doi:10.1080/13218719.2024.2330046 · Cited by 3 · see citing works
“A second aim was to investigate a possible mechanism for this effect as per previous recommendations (Sheringham et al., 2021).”
Schnoor, K., Versluis, A., Chavannes, N. H., & Talboom-Kamp, E. P. W. A. (2023) · JMIR Human Factors · doi:10.2196/49221 · Cited by 2 · see citing works
Attitudes toward persons with epilepsy as friends: Results of a factorial survey
Walther, K., Kriwy, P., Stritzelberger, J., Graf, W., Gollwitzer, S., Lang, J., Reindl, C., Schwab, S., Welte, T., & Hamer, H. (2022) · Epilepsia · doi:10.1111/epi.17491 · Cited by 2
Sayın, Z., Cebeci, I., Sancar, M., & Okuyan, B. (2026) · International Journal of Clinical Pharmacy · doi:10.1007/s11096-026-02173-5 · Cited by 1 · see citing works
“This methodology enables a dual analysis of situational factors and individual behavioural constructs, providing a robust framework for investigating intentions toward collaborative deprescribing services [25, 29–31].”
Fousiani, K., Cremer, L. R., Çetin, M., & Raeder, S. (2026) · PLoS ONE · doi:10.1371/journal.pone.0340860 · Cited by 3 · see citing works
“This distinction allowed Study 2 to capture more generalized justice perceptions of the algorithmic manager, reducing the influence of personal biases that could arise when participants imagine themselves in the scenario [62].”
Bowman, A. R., & Room, L. M. (2025) · Pain Management · doi:10.1080/17581869.2025.2570111 · Cited by 1 · see citing works
Help Me Help You: Privacy Considerations for Third Party IoT Device Repair
Reitinger, N., He, W.-J., Bruno, C., Landau, S., Gunter, C. A., Khanafer, M., Mangar, R., & Anthony, D. L. (2025) · Proceedings on Privacy Enhancing Technologies · doi:10.56553/popets-2025-0128 · Cited by 1
“This deliberate study design is a common practice in simulating an environment for the purpose of a more precise study—as researchers often do in varying vignette conditions [3, 17, 84].”
Aoki, A., Suto, M., Nishino, K., Yamamoto, E., & Takehara, K. (2025) · Psychiatry and Clinical Neurosciences · doi:10.1002/pcn5.70211 · Cited by 1 · see citing works
Mokwenye, R. C. (2025) · Journal of Public Health Research · doi:10.1177/22799036251368446 · Cited by 1 · see citing works
“The vignette favoured a gradual entry that allowed the respondent’s feeling of intrusion to be managed sociocul-turally, 34 generating a rapport and relationship of trust between the researcher and participants.”
Eiroá‐Orosa, F. J., & Sanchez‐Moscona, C. (2025) · Open Research Europe · doi:10.12688/openreseurope.19331.1 · Cited by 1 · see citing works
Duijzer, D., de Winter, M. D., Carrier, M., Cohen, A. T., Hansen, J.-B., Kaasjager, K., Kakkar, A. K., Middeldorp, S., Sørensen, H., Visseren, F., et al. (2024) · Research and Practice in Thrombosis and Haemostasis · doi:10.1016/j.rpth.2024.102569 · Cited by 1 · see citing works
“They contained 6 unique fi ctional case vignettes meeting prede fi ned requirements for case vignette studies [15,17].”
BackgroundAgerström, J., Andréll, C., Bremer, A., Strömberg, A., Årestedt, K., & Israelsson, J. (2023) · Heart & lung : the journal of critical care · doi:10.1016/j.hrtlng.2023.09.011 · Cited by 1
The impact of non-harmonious goals on partner support and taking on opportunities
Vowels, L. M., Carnelley, K. B., Kumashiro, M., & Rowe, A. C. (2022) · Current Psychology · doi:10.1007/s12144-022-03463-7 · Cited by 2 · see citing works
Muraille, J., & Scheerder, J. (2026) · International Journal of Sport Policy and Politics · doi:10.1080/19406940.2026.2738568
Lakha, S. F., Pennefather, P., Khandwala, A., & Fels, D. I. (2026) · JMIR Formative Research · doi:10.2196/80998
“Vignettes, widely used across diverse fields such as social science, organizational research, psychology, business ethics, information studies, and nursing research, are narratives that provide insights into perceptions, beliefs, and attitudes [24,25].”
Sievert, E. D. C., Eitze, S., & Betsch, C. (2026) · British Journal of Health Psychology · doi:10.1111/bjhp.70109
“…in health care, because they allow potential drivers of perceptions and responses to be systematically varied under controlled conditions and thus serve as an efficient early-stage test bed before piloting interventions in clinical settings (Evans et al., 2015; Sheringham et al., 2021).”
Stenlund, A., Ängerud, K. H., Lilja, M., Otten, J., & Jutterström, L. (2026) · Nursing Open · doi:10.1002/nop2.70828
“Hypothetical cases are used because they are perceived as less threatening than asking HCPs for their opinions or experiences in handling similar situations (Sheringham et al. 2021).”
Dina, V., Țenț, P. A., Maghiar, A.-T., Bodog, R. F., Grecu, T., Cretu, O. M., Maghiar, L., Bodog, F., Căiță, G. A., Şandor, M. I., et al. (2026) · Healthcare · doi:10.3390/healthcare14183030
“This is a standard limitation of vignette methodology [61,62], and the remedies lie outside the present design: replication among patients actually scheduled for facial reconstructive surgery, and ultimately observation of consent decisions where such systems are in use.”
van Bruggen, S. V., de Vreeze, L. D., Lameijer, C., Bloemers, F., & Terwee, C. (2026) · Quality of Life Research · doi:10.1007/s11136-026-04367-w
Sagan, A., Kringos, D., Maeseneer, J. D., Vackerberg, N., Permanand, G., Kowalska-Bobko, I., Fernandes, Ó. B., & Allen, L. (2026) · The Lancet Primary Care · doi:10.1016/j.lanprc.2026.100198
Han, Y., Ouyang, W., Qiao, Z., & Du, H. (2026) · Displays · doi:10.1016/j.displa.2026.103668
Holloway, A., & Kisley, M. (2026) · Frontiers in Psychology · doi:10.3389/fpsyg.2026.1857104
“Sheringham et al. (2021) noted that vignettes may reduce the possible influence of observational biases by standardizing the message into written words.”
Baumer, T., Gupta, S., Davies, T. W., Tomassini, S., Harrogate, S., Ramesh, A., Cloke, T., Taylor, C., Lim, C., Barnes, J., et al. (2026) · Anaesthesia Reports · doi:10.1002/anr3.70071
van Hoorn, R. C., van Gestel, L. C., Harteveld-Griffioen, D., Petrignani, M. W. F., Kersten, C., Muskens, M., Vols, L., Borgdorff, H., van der Meer, I. M., Adriaanse, M. A., et al. (2026) · BMC Public Health · doi:10.1186/s12889-026-28252-w
“Moreover, the value of hypothetical scenarios has been demonstrated in other research [34, 35, 60, 61].”
Bridging the Gap to Universal Health Care: An Evaluation of PhilHealth Konsulta Primary Care Model
Alisbo, A. R., & Castillo, C. I. D. (2026) · International Journal For Multidisciplinary Research · doi:10.36948/ijfmr.2026.v08i03.81130
Exploring provider attitudes towards digital therapeutics for diabetes and depression
Kane, O., Ferryman, K., & Kass, N. (2026) · Scientific Reports · doi:10.1038/s41598-026-54183-y
“Vignettes are helpful methods for experimentation, establishing research questions and unveiling ways of thinking that may not otherwise be possible to explore 37 .”
Adis, N. S., & Zolkefli, Y. (2026) · INTERNATIONAL JOURNAL OF CARE SCHOLARS · doi:10.31436/ijcs.v9i2.470
“Vignettes encouraged open discussion on sensitive topics while allowing participants to respond based on their understanding (11).”
Wolswinkel, J. T., van Lenthe, I., Maurits, J., Aarts, J. W., Bekkers, R., Eikelder, M. T. T., Stroeken, Y., Beltman, J., ter Kuile, M. T., Lok, C. A. R., et al. (2026) · International Journal of Gynecological Cancer · doi:10.1016/j.ijgc.2026.104802
Zakher, M., & Wassif, H. (2026) · doi:10.51952/9781447377207
Crick, J., Almonroeder, T., & Widenhoefer, T. (2026) · Physiotherapy Theory and Practice · doi:10.1080/09593985.2026.2672019
Martisella, M., Marquis, M., Stypulkowski, A., Payot, A., Bourque, C. J., & Bouthillier, M.-É. (2026) · Paediatrics & Child Health · doi:10.1093/pch/pxag016
Bryant, J., Mansfield, E., Ries, N., Mackenzie, L., Webster, P., Kuhne, C., Leigh, L., & Boyes, A. W. (2026) · Journal of Elder Abuse & Neglect · doi:10.1080/08946566.2026.2636518
“…in health and social research to examine clinical decision-making in a controlled and standardized manner, allowing researchers to assess practitioner responses to sensitive, complex, or ethically challenging scenarios that are difficult to observe directly in practice (Sheringham et al., 2021).”
Duality of AI-based interaction systems in organisations: bridging among human and machine
Hammes, M., Thiemann, D., Gorba, D., & Kalwa, V. (2026) · Behaviour and Information Technology · doi:10.1080/0144929x.2026.2614041 · Cited by 1 · see citing works
“Yet, vignettes may not fully capture the complexity of real-world scenarios and interactions with AI systems, and their effects also depend on the participants’ literacy and reactivity (Evans et al. 2015; Sheringham, Kuhn, and Burt 2021).”
Employee decision-making: the role of egoism and altruism in corporate spending behavior
Elhajjar, S., Yacoub, L., & Borna, S. (2025) · International Journal of Ethics and Systems · doi:10.1108/ijoes-07-2025-0407
Ethnicity and clinical empathy in primary care consultations: a web-based experiment
He, Q., Du, R., Belgi, S., Neil, G. J., Everitt, H. A., & Bishop, F. L. (2025) · BJGP open · doi:10.3399/bjgpo.2025.0084
Park, J. S., Lee, J.-S., & Do, Y. K. (2025) · Journal of Evaluation In Clinical Practice · doi:10.1111/jep.70208
“First, patient decision ‐ making in hypothetical vignettes may not accurately reflect real ‐ world decisions, raising concerns about the validity of our results [30, 31].”
Disparities in Healthcare Providers’ Substance Use Detection Practices for Pregnant Patients
Lijewski, V., Straub, H., Klie, K. A., Hwang, S. S., & Sheeder, J. (2025) · Journal of Racial and Ethnic Health Disparities · doi:10.1007/s40615-025-02523-5
“Often referred to as a “hybrid” approach between conventional surveys and observations of real-life practice, vignette studies provide characteristics of both the high internal validity of experiments and the high external validity of survey research [39, 41].”
Heaviside, H. J., & Watkins, L. (2025) · Studies in Higher Education · doi:10.1080/03075079.2025.2500695
“Historically, vignettes have been presented in textual form, whereby participants are presented with a hypothetical written scenario (Aruguete, Slater, and Mwaikinda 2017; Oldfield, Manley, and Thelwell 2020; Sheringham, Kihn, and Burt 2021).”
Vinsjevik, M. C. G., & Øen, K. G. (2024) · Global Qualitative Nursing Research · doi:10.1177/23333936241274061
“Using vignettes, respondents could recognize themselves in concrete, practical situations, which may have led to more engagement and comprehensive answers to the questionnaire (Hughes & Huby, 2002; Sheringham et al., 2021).”
BackgroundGreene, C., Barry, B., & Claudy, M. (2026) · Cambridge Forum on AI Law and Governance · doi:10.1017/cfl.2026.10052 · Cited by 1 · see citing works
- Authors
- Sheringham, J., Kuhn, I., & Burt, J.
- Affiliations
- University College London (GB)
- University of Cambridge (GB)
- Corresponding author
- Sheringham, Jessica
- Venue
- BMC Medical Research Methodology
- Published
- 2021-04-22
- Volume
- 21
- Issue
- 1
- Pages
- 81-81
- ISSN
- 1471-2288 (ISSN-L)
- PMC
- PMC8061048
- OpenAlex
- W3155534442
- Cited by
- 82
- References
- 79
- Citations by year
- 2026: 22 · 2025: 20 · 2024: 24 · 2023: 10 · 2022: 6
- FWCI
- 11.24
- Type
- journal article
- Language
- en
- Open access
- gold
- doi.org
- Locations
- BMC Medical Research Methodology (publishedVersion, cc-by)
- PubMed Central (publishedVersion, cc-by)
- PubMed (publishedVersion)
- DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
- UCL Discovery (University College London) (submittedVersion)
- Apollo (University of Cambridge) (submittedVersion)
- Apollo (University of Cambridge) (submittedVersion, cc-by)
- Apollo
- Topics
- Health Sciences › Health Professions › General Health Professions › Healthcare cost, quality, practices
- Health Sciences › Health Professions › General Health Professions › Health Policy Implementation Science
- Health Sciences › Medicine › Family Practice › Clinical Reasoning and Diagnostic Skills
- Keywords
- health care delivery, methodological quality, simulated consultations, clinician behavior, study design flaws
- MeSH terms
- Delivery of Health Care, Humans, Referral and Consultation, Telephone, MEDLINE, Text Messaging
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