1. The document discusses the differences between background and foreground questions and provides examples. Background questions are broad while foreground questions are more focused on a specific problem. 2. It also discusses formulating a good study question using the PICO format which includes the Patient/Problem, Intervention, Comparison, and Outcome. 3. Key steps in formulating a study question are ensuring it is related to the problem and will facilitate precise searching for an answer.

1. Formulation of Study Question
Amr Albanna, MD, MSc

2. Objectives
1. To understand the difference between
“background” and “foreground” questions.
2. To have a systematic way for searching and
presenting background information related to
your research topic.
3. To be able to formulate a PICO (or PICOT) format
question.
4. To understand the importance of formulating a
good study question for planning your research
study.

3. How are these questions different?
• Do statins improve survival after acute
myocardial infarction?
• In patients with first acute myocardial
infarction, does early administration of
statins lead to higher survival rates as
compared to placebo?

4. How are these questions different?
• Does watching TV cause obesity?
• In school children, is increased TV viewing
associated with an increased incidence of
obesity measured using body mass index?

5. How are these questions different?
• How does polymerase chain reaction (PCR)
work?
• In patients suspected to have pulmonary
tuberculosis, is PCR more sensitive and
specific than culture?

6. Types of Questions
Guyatt et al. Users Guides to the Medical Literature. Chicago: AMA Press, 2002

7. Background questions
• General (broad) question
• Resources:
– Textbooks
– Narrative reviews (Opinion articles)

8. Background
1. The overall burden of health-care related
disorder/issue (current situation).
2. Specific problems related to this disorder (e.g.
diagnosis, associated problems, complications,
treatment).
3. Unanswered questions.
Justification of conducting research study
4. Formulation of study question.

9. Foreground Question
• Focused question about specific problem.
• Resources:
– Primary (original) research.
– Secondary research such as “systematic review”.

10. What type of question?

11. What type of question?

12. Focused search

13. Good study question
1. Related to the problem.
2. Facilitate searching for a precise answer.

14. PICO format
P  Patient or problem being addressed.
I  Intervention or exposure being considered.
C  Comparison, when relevant.
O  Outcome of interest.

15. Stillwell et al. AJN March 2010 Vol. 110, No. 3

16. Architecture of a focused question:
a 4-part review question
• Patient:
– Disease or condition
– Stage, Severity
– Demographic characteristics (age, gender, etc.)
• Intervention:
– Type of intervention or exposure
– Dose, duration, timing, route, etc.

17. Architecture of a focused question:
a 4-part review question
• Comparison:
– Absence of risk or treatment
– Placebo or alternative therapy
• Outcome:
– Risk or protective
– Dichotomous or continuous
– Type: mortality, morbidity, quality of life, etc.
• Time period (PICOT)

18. Formulation of a therapy question
Is Zinc effective in treating cold?
In children with common cold, is oral Zinc effective in
reducing the duration of symptoms, as compared to placebo?
Intervention Outcome
InterventionPatient/problem
Outcome Comparison

19. Formulation of an etiology question
Is smoking a risk factor for tuberculosis?
Are people who smoke regularly at a greater risk of developing
pulmonary tuberculosis as compared to those who do not smoke?
Exposure Outcome
ExposurePatient
Outcome Comparison

20. Formulation of a diagnosis question
Is Positron Emission Tomography (PET) a good test for coronary disease?
Is PET a more sensitive and specific test in diagnosing coronary
artery disease as compared to coronary angiography?
Test (intervention) Outcome
PatientOutcome
Comparison
Test (intervention)

21. How a focused question helps in searching
for studies
Patient
or Problem
Intervention &
comparison
Outcome
PICO
Studies most likely to address the question

22. Case Scenario
• 6 years old boy, who has been having
recurrent ear infection, presents with fever
and right ear pain. The mother expresses
concerns because her child has been on
Amoxicillin for the past few weeks.

23. Questions
– Among children, how common is ear infection?
– Is Amoxicillin effective?
– Is there any better treatment?
– What is the consequence (harm) of long-term
antibiotic use?
– What is the outcome of recurrent ear infection?

24. Case Scenario
• How to formulate a research study question
related to this scenario?

25. Once a review question is defined
• Search the literature and see if a similar study has
been done already!
• If a similar study has been done, see if there some
way you can improve on it
• If a high-quality research study already exists,
consider an alternative question!

26. Stillwell et al. AJN March 2010 Vol. 110, No. 3

27. A Research Scenario 1
• Study question: Does eating affect student
intellectual ability.
• 100 students underwent an exam after eating
lunch.
• 50% failed the exam.
• You conclude that eating worsen students
intellectual ability.

28. A Research Scenario 2
• Study question: Is drug X effective against
influenza.
• 100 influenza patients treated with drug X.
• 50% became asymptomatic in next day.
• You conclude that drug X is a very effective
treatment for influenza.