Background vs. Foreground Questions

When to use PICO ...

Background questions concern general knowledge. These types of questions generally have only 2 parts:
1) A question root (who, what, when, where, how, why) and
2) a disorder, test, treatment, or other aspect of health care.

Often these questions can best be answered by using a textbook or consulting a clinical database.

Example Background Question: What are the best interventions to prevent accidental falls in the elderly?

Foreground questions are specific knowledge questions that affect clinical decisions, including a broad range of biologic, psychological, and sociologic issues. These are the questions that generally require a search of the primary medical literature and that are best suited to the PICO format.

PICO Search

PICO

What is the P.I.C.O. Model?

Defining a clinical question in terms of the specific patient problem aids the searcher in finding clinically relevant evidence in the literature.

Essentially, PICO is a focused search strategy.

P-I-C-O Model for Clinical Questions

P	Patient, Population, or Problem	How would I describe a group of patients similar to mine?
I	Intervention, Prognostic Factor, or Exposure	Which main intervention, prognostic factor, or exposure am I considering?
C	Comparison or Intervention (if appropriate)	What is the main alternative to compare with the intervention?
O	Outcome you would like to measure or achieve	What can I hope to accomplish, measure, improve, or affect?
T	Time Interval	What is the time interval to achieve desired outcomes?
	What type of question are you asking?	Diagnosis, Etiology/Harm, Therapy, Prognosis, Prevention
	Type of study you want to find	What would be the best study design/methodology?

Table based on: Evidence Based Medicine: PICO. UIC Library.

Example PICO Questions

Therapy / Intervention Example : In the elderly (P), does aspirin (I) reduce the risk of heart attacks (O)?

Intervention Example : In hospitalized adults (P), how does a Rapid Response Team (I) affect the number of cardiac arrests (O) and unplanned admissions to the ICU (O) during a 3-month period?

Diagnosis Example : In healthcare settings, does screening for intimate partner/domestic violence (I) improve quality-of-life (O) for women (P)?

Meaning Example : How do family caregivers (P) with relatives receiving hospice care (I) receive the loss of their loved one (O) during end-of-life (T)?

Comparative Intervention / Therapy Example : In patients with dementia who are agitated (P), how does baby doll therapy (I) compared with Risperdone drug therapy (C) affect behavior outbursts (O) within 1 month (T)?

Other question development frameworks

PICO is a helpful framework for clinical research questions, but may not be the best for other types of research questions. Did you know there are at least 25 other question frameworks besides variations of PICO? Frameworks like PEO, SPIDER, SPICE, ECLIPSE, and others can help you formulate a focused research question. The table and example below were created by the Medical University of South Carolina (MUSC) Libraries.

PEO

The PEO question framework is useful for qualitative research topics. PEO questions identify three concepts: population, exposure, and outcome.

Element	Definition	Example
Population	Who is my question focused on?	mothers
Exposure	What is the issue I am interested in?	postnatal depression
Outcome	What, in relation to the issue, do I want to examine?	daily living experiences

Research question: What are the daily living experiences of mothers with postnatal depression?

SPIDER

The SPIDER question framework is useful for qualitative or mixed methods research topics focused on "samples" rather than populations.

SPIDER questions identify five concepts: sample, phenomenon of interest, design, evaluation,and research type.

Element	Definition	Example
Sample	Who is the group of people being studied?	young parents
Phenomenon of Interest	What are the reasons for behavior and decisions?	attendance at antenatal education classes
Design	How has the research been collected (e.g., interview, survey)?	interviews
Evaluation	What is the outcome being impacted?	experiences
Research type	What type of research (qualitative or mixed methods)?	qualitative studies

Research question: What are the experiences of young parents in attendance at antenatal education classes?

SPICE

The SPICE question framework is useful for qualitative research topics evaluating the outcomes of a service, project, or intervention. SPICE questions identify five concepts: setting, perspective, intervention/exposure/interest, comparison, and evaluation.

Element	Definition	Example
Setting	Setting is the context for the question (where).	South Carolina
Perspective	Perspective is the users, potential users, or stakeholders of the service (for whom).	teenagers
Intervention / Interest / Exposure	Intervention is the action taken for the users, potential users, or stakeholders (what).	provision of Quit Kits to support smoking cessation
Comparison	Comparison is the alternative actions or outcomes (compared to what).	no support or "cold turkey"
Evaluation	Evaluation is the result or measurement that will determine the success of the intervention (what is the result, how well).	number of successful attempts to give up smoking with Quit Kits compared to number of successful attempts with no support

Research question: For teenagers in South Carolina, what is the effect of provision of Quit Kits to support smoking cessation on number of successful attempts to give up smoking compared to no support ("cold turkey")?

ECLIPSE

The ECLIPSE framework is useful for qualitative research topics investigating the outcomes of a policy or service. ECLIPSE questions identify six concepts: expectation, client group, location, impact, professionals, and service.

Element	Definition	Example
Expectation	What are you looking to improve or change? What is the information going to be used for?	to increase access to wireless internet in the hospital
Client group	Who is the service or policy aimed at?	patients and families
Location	Where is the service or policy located?	hospitals
I mpact	What is the change in service or policy that the researcher is investigating?	clients have easy access to free internet
Professionals	Who is involved in providing or improving the service or policy?	IT, hospital administration
Service	What kind of service or policy is this?	provision of free wireless internet to patients

Research question: How can I increase access to wireless internet for hospital patients?

Other Question Formats for Different Types of Reviews

From: What kind of systematic review should I conduct? A proposed typology and guidance for systematic reviewers in the medical and health sciences

Review Type	Aim	Question Format	Question Example
Effectiveness	To evaluate the effectiveness of a certain treatment/practice in terms of its impact on outcomes	Population, Intervention, Comparator/s, Outcomes (PICO) [23]	What is the effectiveness of exercise for treating depression in adults compared to no treatment or a comparison treatment? [69]
Experiential (Qualitative)	To investigate the experience or meaningfulness of a particular phenomenon	Population, Phenomena of Interest, Context (PICo) [13]	What is the experience of undergoing high technology medical imaging (such as Magnetic Resonance Imaging) in adult patients in high income countries? [70]
Costs/Economic Evaluation	To determine the costs associated with a particular approach/treatment strategy, particularly in terms of cost effectiveness or benefit	Population, Intervention, Comparator/s, Outcomes, Context (PICOC) [14]	What is the cost effectiveness of self-monitoring of blood glucose in type 2 diabetes mellitus in high income countries? [71]
Prevalence and/or Incidence	To determine the prevalence and/or incidence of a certain condition	Condition, Context, Population (CoCoPop) [15]	What is the prevalence/incidence of claustrophobia and claustrophobic reactions in adult patients undergoing MRI? [72]
Diagnostic Test Accuracy	To determine how well a diagnostic test works in terms of its sensitivity and specificity for a particular diagnosis	Population, Index Test, Reference Test, Diagnosis of Interest (PIRD) [16]	What is the diagnostic test accuracy of nutritional tools (such as the Malnutrition Screening Tool) compared to the Patient Generated Subjective Global Assessment amongst patients with colorectal cancer to identify undernutrition? [73]
Etiology and/or Risk	To determine the association between particular exposures/risk factors and outcomes	Population, Exposure, Outcome (PEO) [17]	Are adults exposed to radon at risk for developing lung cancer? [74]
Expert opinion/policy	To review and synthesize current expert opinion, text or policy on a certain phenomena	Population, Intervention or Phenomena of Interest, Context (PICo) [18]	What are the policy strategies to reduce maternal mortality in pregnant and birthing women in Cambodia, Thailand, Malaysia and Sri Lanka? [75]
Psychometric	To evaluate the psychometric properties of a certain test, normally to determine how the reliability and validity of a particular test or assessment.	Construct of interest or the name of the measurement instrument(s), Population, Type of measurement instrument, Measurement properties [31, 32]	What is the reliability, validity, responsiveness and interpretability of methods (manual muscle testing, isokinetic dynamometry, hand held dynamometry) to assess muscle strength in adults? [76]
Prognostic	To determine the overall prognosis for a condition, the link between specific prognostic factors and an outcome and/or prognostic/prediction models and prognostic tests.	Population, Prognostic Factors (or models of interest), Outcome (PFO) [20, 34,35,36]	In adults with low back pain, what is the association between individual recovery expectations and disability outcomes? [77]
Methodology	To examine and investigate current research methods and potentially their impact on research quality.	Types of Studies, Types of Data, Types of Methods, Outcomes [39] (SDMO)	What is the effect of masked (blind) peer review for quantitative studies in terms of the study quality as reported in published reports? (question modified from Jefferson 2007) [40]

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