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Step 1: Ask

Clinical problems often don't arise as perfectly formulated questions - they are complex and have many different aspects to consider. However, without a clear question it can be difficult to find the information you need to inform your practice.

The first step of the EBP process is to convert your problem into a structured and answerable clinical question.

Types of clinical questions

There are two main types of clinical questions: background questions and foreground questions. Knowing whether you are asking a foreground or background question will help you decide where to search for information.

Drag the vertical bar below to reveal information about clinical question types.

Watch the videos below to learn more about developing a clinical question.

Terry Shaneyfelt 2012, Developing answerable clinical questions
Running time: 5:52 minutes

Types of foreground questions

There are five different types of foreground questions, each focusing on a different action in response to the clinical problem: therapy or intervention; prognosis; harm/etiology; diagnosis; and prevention.

Select the headings below to read more about types of foreground questions.

If you are asking What should I do to help my patient? you are asking a therapy or intervention question.

Therapy questions explore potential interventions that could be used to treat or manage a patient's condition. They are used to evaluate the effectiveness of different medications, physical therapy, surgical procedures, lifestyle changes, etc.

If you are asking What will happen to my patient in the future? you are asking a prognosis question.

Prognosis questions explore the likelihood of particular outcomes for patients with particular disorders. They are used to predict the patient's expected development and anticipate any future complications.

If you are asking Why has this happened to my patient? you are asking a harm or etiology question.

Harm/etiology questions explore the causes and likelihood of a health care problem. They are used to find the origin of a patient's condition so that decisions about their care can be made.

If you are asking How should I determine if my patient has a particular condition? you are asking a diagnosis question.

Diagnosis questions compare the accuracy and safety of diagnostic tests against the standard method. They are used to determine which test will be the most accurate in confirming or excluding a particular condition.

If you are asking How can I prevent a specific outcome for my patient? you are asking a prevention question.


Prevention questions explore ways to reduce the likeihood of particular condition or disease. They are used to reduce the chance of disease by identifying and modifying risk factors.

Each type of question is best answered by different types of research studies. Knowing which type of question you are asking will help you decide which resources you need to locate. You can learn more about this in Step 2: Acquire (Search). 

Building your foreground question

The PICO framework can help you convert your clinical problem into an answerable question. 

You can use the PICO framework to break your problem down into four components which describe the population, the intervention or treatment, the comparison treatment (if required), and the outcome you want to investigate. You can use these components first to build your question and later as keywords when searching for information.

Select the plus symbols below to learn more about each PICO element.

You can practice identifying PICO elements in example case studies here:

Once you have identified your PICO elements you need to bring them together to create a well formulated question. It doesn't matter in which order you use the PICO elements as long as it make a clear question. The following worksheet contains templates to help you turn your PICO elements into an answerable question:

George, a 34-year-old male, is a non-smoker and has no chronic medical problems. He is seeing his GP today because he is suffering from back pain. He retired from professional rugby five years ago. He had an injury on his lower back earlier in his sports career and had back pain which was completely cured within a year by chiropractic treatment. He owns an online business and is active on social media. He has tried using heat packs and taking over-the-counter pain relievers with no improvement.

For this example, you want to investigate treating George's back pain with muscle relaxants but you're not sure how effective they are in comparison to using opioid medication. You are asking an intervention question.

The table below shows the relevant clinical information for each PICO element.

PICO element Relevant clinical information
P:  Population/patient/problem a 34 year old male with no chronic medical conditions experiencing back pain
 I: Intervention using muscle relaxants
C: Comparison using opioids
O: Outcome relieving back pain

Now you need to bring all the PICO elements together into a question. It doesn't matter in which order you use the PICO elements as long as it makes a clear question. For example, the intervention question for our clinical example is:

In 34 year old males with no chronic medical conditions experiencing
back pain
 (P), how do muscle relaxants (I) compared to opioids (C) 
affect back pain (O)?

Here are some different frameworks you may want to use:

PICO(T) Population (patient), Intervention, Comparison (control) and Outcome. Add a Timeframe if required. Used particularly for treatment type questions.
PECO(T) A variation of PICO where E= Exposure and T=Timeframe if required.
PIPOH Developed in the context of practice guideline adaptation. Includes P= Professionals/Patients, O= Outcome and H= Healthcare Setting.
SPICE S= Setting (where), P= Perspective (for whom), I= Intervention (what), C= Comparison (compared with what), E= Evaluation (Booth 2006).
SPIDER S= Sample, P= Phenomenon of interest, D= Design, E= Evaluation, R= Research type. Useful for qualitative or mixed method studies (Cooke, Smith and Booth 2012).
ECLIPSE E= Expectations, C= Client group, L= Location, I= Impact, P= Profession, SE= Service (Wildridge & Bell 2002).
PESTLE P= Political, E= Economic, SSocial, TTechnological, E= Environmental, L= Legal (CIPD 2010).

Watch the videos below to learn more about using PICO to build your question.

Cushing/Whitney Medical Library 2019, Framing questions with PICO
Running time: 4:11 minutes

Binghamton University Libraries 2017, PICO: a model for evidence based research,
Running time: 8:40 minutes

Clinical scenario

You can practice converting a clinical problem into each type of foreground question in the interactive activity below. 

 Please expand the window for the best viewing experience.

Test your knowledge