What are Background Questions?
Background questions are broad informational questions that improve the understanding of a topic. Researchers often use background questions to identify and understand what is known about a topic or to understand what has already been established as effective or best practice. Background questions yield a wide range of results. These results can be used to inform the components of foreground questions. The answers to background questions can be found in books, reference materials and secondary sources, like review articles, that provide an overview of a topic.
Examples of background questions:
What causes migraine headaches in women?
What are the symptoms of vitamin D deficiency?
How is mobility restored after total hip replacement?
What factors influence nursing staff retention in hospitals?
What are Foreground Questions?
Foreground questions are more focused and complex than background questions, and usually contain several concepts. Foreground questions can be used to compare two or more interventions or established practices. Foreground questions can be used to understand what the most current research in an area has focused upon. The answers to foreground questions will often be found in primary (research) articles and secondary (review) articles. PICO and alternative format questions are foreground questions.
Examples of foreground questions:
In women suffering from chronic migraines how effective are non-pharmacological or behavioral interventions?
What is the effect of vitamin D supplementation on depression?
Are water-based exercise therapies more effective than land-based exercise in restoring range-of-motion after hip replacement?
Are financial compensation strategies more effective than workplace/workload improvement strategies in retaining hospital nursing staff?
PICO(T) is a mnemonic used to describe the four elements of a good clinically oriented question:
P = Population/Problem: How would I describe the problem or a group of patients similar to mine?
I = Intervention: What main intervention, treatment, prognostic factor or exposure am I considering?
C = Comparison: Is there an alternative or usual care/treatment to compare with the intervention?
O = Outcome: What do I hope to accomplish, measure, improve or affect
In some questions, a T = Timeframe, Type of Study or Type of Question is added to the PICO framework to help find more specific evidence.
Questions are commonly either concerned with the efficacy of an therapy/intervention (such as drug treatments, clinical therapies, or lifestyle changes), diagnosis (concerning the ability of a test to accurately diagnose), or a prognosis (concerned with likelihood or risk). For alternatives to the PICO format, see the Alternative Question Formats tab.
Below are some PICO format question templates. Fill in the blanks with information from your clinical scenario:
THERAPY / INTERVENTION
In_______________, what is the effect of ________________on _______________ compared with _________________?
Examples:
In people with osteoarthritis in the feet, what is the effect of stretching exercises on reducing pain compared with rest?
In bedridden persons, what is the effect of repositioning at frequent intervals (compared to less frequent repositioning) on reducing pressure ulcers over a 90 day period?
DIAGNOSIS OR DIAGNOSTIC TEST
Are (Is) ________________ more accurate in diagnosing _______________ compared with ____________?
Examples:
Is d‐dimer assay more accurate at ruling out deep vein thrombosis compared to ultrasound?
Is 3D mammography screening more accurate in identifying breast neoplasms compared with conventional 2D mammography screening?
PROGNOSIS
Does ____________ influence ______________ in patients who have _____________?
Examples:
Does dietary carbohydrate intake influence healthy weight maintenance (BMI <25) in patients who have family history of obesity (BMI >30)?
Does vitamin D supplementatoin influence fatigue in people who have multiple sclerosis?
PREVENTION
For ___________ does the use of _________________ reduce the future risk of ____________ compared with ______________?
Examples:
For people with mild median nerve pain, does a night-time wrist brace reduce the future risk of carpal tunnel syndrome compared with no brace?
For older adults, does a yoga exercise intervention reduce the risk of falling compared with other exercise programs?
ETIOLOGY
Are ______________ who have _______________ at ______________ risk for/of ____________ compared with _____________
with/without______________?
Examples:
Are children who have been exposed to regular second hand smoke at increased risk for lung cancer compared to children without second hand smoke exposure?
MEANING
How do __________ with________ perceive ____________during ___________?
Examples:
How nurses who are preceptors perceive hospital-based training and professional development programs?
In cancer survivors, how does post-treatment status influence their perception and interpretation of quality of life after treatment?
Although PICO is a commonly used framework for asking clinical questions, it may not be the best framework for other kinds of research questions or investigations. There are many other frameworks, besides PICO, that might be used to forumlate a focused research question. A recent review article describes over a dozen alternative question frameworks. The tables below offer some explanation and examples of often used frameworks and formats for posing well-built research questions: PCC, PEO, SPIDER, SPICE, and ECLIPSE.
PCC (Population, Concept, Context)
This framework is the appropriate for scoping reviews and can be applied to qualitative or quantitative topics.
Example PCC question: How do elementary school nurses in Minnesota assess a student’s ability to carry their own asthma inhaler?
| Population | Group of people relevant to the review question | Elementary school nurses |
| Concept | Intervention, phenomena or outcome of interest | Evaluation methods of student readiness to carry inhaler |
| Context | Specific setting |
Minnesota |
PEO (Population/Problem/Patient, Exposure, Outcome)
PEO is applied to qualitative research questions and useful when researching a potential outcome or correlation of a condition or exposure.
Example PEO question: Does social media usage of more than 2 hours per day worsen the self-assessed mental health of adolescents aged 12-18 in the United States?
| Population | Group of people relevant to the review question | Adolescents (age 12-18) in the U.S. |
| Exposure | Exposure to a risk factor, condition, illness, screening, or service | Social media usage greater than 2 hours per day |
| Outcome | What, in relation to the issue, is being examined? | Self-assessed mental health |
SPIDER (Sample, Phenomenon of Interest, Design, Evaluation, Research type)
SPIDER is a framework suitable for qualitative or mixed methods research questions that focuses on samples of populations, rather than patients or entire populations.
Example SPIDER question: What are the self-perceptions of competency of newly hired nursing graduates (RN) participating in a nurse mentorship program?
| Sample | Group of people being studied | Newly hired nursing graduates (RN) |
| Phenomenon of Interest | Hypothesized reason for behavior or choice | participation in nurse mentoring program |
| Design | How the study is conceived or data collected? | interviews |
| Evaluation | Outcome measure(s) | self-perception of competency |
| Research type | Methodology (qualitative, quantitative or mixed) | qualitative |
SPICE (Setting, Perspective, Intervention/exposure/interest, Comparison, Evaluation)
SPICE is a framework suitable for qualitative topics that evaluate the outcome(s) of a service, project, or intervention.
Example SPICE question: At the ElderCottage long term care facility, does a staff-led, facility-wide nighttime noice reduction protocol improve the self-reported sleep quality of residents, more than the designated quiet zones on each unit.
| Setting | Context for the question (where) | ElderCottage long term care facility |
| Perspective | The perspective of users or stakeholders being studied (who) | residents |
| Intervention/Exposure/Interest | The service, intervention, or action taken (what) | Staff-led, facility-wide noise reduction at night protocol |
| Comparison | Alternative action or outcome | quiet zones on the units |
| Evaluation | The result or measurement of the success of the intervention | improved resident sleep quality |
ECLIPSE (Expectation, Client group, Location, Impact, Professionals, SErvice)
The ECLIPSE framework is often applied to qualitative research that examines policy, administration or management.
Example ECLIPSE question:Is the current early mobilization program on the orthopedic surgery unit improving the patient quality of life and autonomy at discharge?
| Client group | Population the service is aiming to serve (who) | adult lower-extremity surgical patients |
| Location | Setting | hospital ortho post-surgical unit |
| Impact | Measurement of change | improved patient quality of life/autonomy at discharge |
| Professionals | Providers of the service | nurses and physical therapy staff |
| SErvice | Program or service being studied | early mobilization program |
In the table below, we model how to move from a PICO or alternative format question to a search strategy.
We start by forming our question, then generate keywords and synonyms for search terms, and then use Boolean operators (AND and OR) to map out a search strategy.
The P (patient or population) and the I (intervention or treatment or phenomenon of interest or interest, etc.) are generally searched first.
The C (comparison) and O (outcome) are less often included in a search.
For this example, our patients are older adults who may find an intervention to assist with food safety helpful so that they may continue to live safely and healthfully in their homes.
PICO: In older adults, what is the effect of a food safety educational intervention on improving food handling and general nutritional status.
You will likely need to modify your search strategy as you search the databases and discover additional search terms, terms that cause many false-hits, and search results that are not as planned. Searching is an iterative process.
Copy the search strategy into a database, linking synonym terms with OR and the different question aspects or facets with AND.
Start searching with P and I (or alternative intervention/phenomenon of interest facet) and add additional question aspects as needed.
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