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Health (Nursing, Medicine, Allied Health)

Guide to research sources and tools for locating health evidence in books, journals, databases.

Defining the Question: Foreground & Background Questions

In order to most appropriately choose an information resource and craft a search strategy, it is necessary to consider what kind of question you are asking: a specific, narrow "foreground" question, or a broader background question that will help give context to your research?

Foreground Questions

A "foreground" question in health research is one that is relatively specific, and is usually best addressed by locating primary research evidence. 

Using a structured question framework can help you clearly define the concepts or variables that make up the specific research question. 

 Across most frameworks, you’ll often be considering:

  • a who (who was studied - a population or sample)
  • a what (what was done or examined - an intervention, an exposure, a policy, a program, a phenomenon)
  • a how ([how] did the [what] affect the [who] - an outcome, an effect). 

PICO is the most common framework for developing a clinical research question, but multiple question frameworks exist.

PICO (Problem/Population, Intervention, Comparison, Outcome)

Appropriate for: clinical questions, often addressing the effect of an intervention/therapy/treatment

Example: For adolescents with type II diabetes (P) does the use of telehealth consultations (I) compared to in-person consultations (C) improve blood sugar control (O)?

Description and example of PICO question framework.
Element Description Example
Population / problem Who is the group of people being studied?  adolescents with T2D


What is the intervention being investigated? (independent variable) telehealth consultations
Comparison To what is the intervention being compared? in person consultations
Outcome What are the desired outcomes of the intervention? (dependent variable) blood sugar control
Framing Different Types of Clinical Questions with PICO

Different types of clinical questions are suited to different syntaxes and phrasings, but all will clearly define the PICO elements.  The definitions and frames below may be helpful for organizing your question:


Questions addressing how a clinical issue, illness, or disability is treated.

"In__________________(P), how does__________________(I) compared to_________________(C) affect______________(O)?"


Questions that address the causes or origin of disease, the factors which produce or predispose toward a certain disease or disorder.

"Are_________________(P), who have_________________(I) compared with those without_________________(C) at_________________risk for/of_________________(O) over_________________(T)?" 


Questions addressing the act or process of identifying or determining the nature and cause of a disease or injury through evaluation.

In_________________(P) are/is_________________(I) compared with_________________(C) more accurate in diagnosing_________________(O)?


Questions addressing the prediction of the course of a disease.

In_________________(P), how does_________________(I) compared to_________________ (C) influence_________________(O)?


Questions addressing how one experiences a phenomenon or why we need to approach practice differently.

"How do_________________(P) with_________________(I) perceive_________________(O)?" 

Adapted from: Melnyk, B. M., & Fineout-Overholt, E. (2011). Evidence-based practice in nursing & healthcare: A guide to best practice. Philadelphia: Wolters Kluwer/Lippincott Williams & Wilkins.

Beyond PICO: Other Types of Question Frameworks

PICO is a useful framework for clinical research questions, but may not be appropriate for all kinds of reviews.  Also consider:

PEO (Population, Exposure, Outcome)

Appropriate for: describing association between particular exposures/risk factors and outcomes

Example: How do preparation programs (E) influence the development of teaching competence (O) among novice nurse educators (P)?

Description and example of PEO question framework.
Element Description Example
Population  Who is the group of people being studied?  novice nurse educators


What is the population being exposed to (independent variable)? preparation programs
Outcome What is the outcome that may be affected by the exposure (dependent variable)? teaching competence
SPIDER (Sample, Phenomenon of Interest, Design, Evaluation, Research Type)

Appropriate for: questions of experience or perspectives (questions that may be addressed by qualitative or mixed methods research)

Example: What are the experiences and perspectives (E) of undergraduate nursing students (S) in clinical placements within prison healthcare settings(PI)?

Description and example of SPIDER question framework.
Element Description Example
Sample  Who is the group of people being studied? undergraduate nursing students

Phenomenon of


What are the reasons for behavior and decisions? clinical placements in prison healthcare settings
Design How has the research been collected (e.g., interview, survey)? interview and surveys
Evaluation What is the outcome being impacted? attitudes, experiences and reflections on learning
Research type What type of research? qualitative, quantitative or mixed methods
SPICE (Setting, Perspective, Intervention/phenomenon of Interest, Comparison, Evaluation)

Appropriate for: evaluating the outcomes of a service, project, or intervention

Example: What are the impacts and best practices for workplace (S) transition support programs (I) for the retention (E) of newly-hired, new graduate nurses (P)?

Description and example of SPIDER question framework.
Element Description Example
Setting What is the context for the question? (Where?) nursing workplaces (healthcare settings)


For whom is this intervention/program/service designed (users, potential users, stakeholders)? new graduate nurses
Intervention/Interest/Exposure What action is taken for the users, potential users, or stakeholders? long term transition support programs (residency/mentorship)
Comparison What are the alternative interventions? no or limited transition support / orientation
Evaluation What is the results of the intervention or service/how is success measured? retention of newly hired nurses
PCC (Problem/population, Concept, Context)

Appropriate for: broader (scoping) questions

Example: How do nursing schools (Context) teach, measure, and maintain nursing students' (P) technological literacy (Concept))throughout their educational programs?

Description and example of SPIDER question framework.
Element Description Example
Population/Problem What are the important characteristics of the participants, or the problem of focus? nursing students


What is the core concept being examined by the review? technological literacy
Context What is the context for the question? (Could include geographic location, or details about the setting of interest)? nursing schools

Background Questions

To craft a strong and reasonable foreground research question, it is important to have a firm understanding of the concepts of interest.  As such, it is often necessary to ask background questions, which ask for more general, foundational knowledge about a disorder, disease, patient population, policy issue, etc. 

For example, consider the PICO question outlined above:

"For adolescents with type II diabetes does the use of telehealth consultations compared to in-person consultations improve blood sugar control?

To best make sense of the literature that might address this PICO question, you would also need a deep understanding of background questions like:

  • What are the unique barriers or challenges related to blood sugar management in adolescents with TII diabetes?
  • What are the measures of effective blood sugar control?
  • What kinds of interventions would fall under the umbrella of 'telehealth'?
  • What are the qualitative differences in patient experience in telehealth versus in-person interactions with healthcare providers?