pico in research question

Capstone and PICO Project Toolkit

• Starting a Project: Overview
• Developing a Research Question
• Selecting Databases
• Expanding a Search
• Refining/Narrowing a Search
• Saving Searches
• Critical Appraisal & Levels of Evidence
• Citing & Managing References
• Database Tutorials
• Types of Literature Reviews
• Finding Full Text
• Term Glossary

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)?

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:

Intervention/Therapy

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)?

Prognosis/Prediction:

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)?

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)?

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)?

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?

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?
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Do you want to know whether a Cochrane Review is relevant to you?  

Look for the PICO.  

PICO stands for four different potential components of a health question used in Cochrane Review research: 

• What are the characteristics of the patient or population (demographics, risk factors, pre-existing conditions, etc)? 
• What is the condition or disease of interest?
• What is the intervention under consideration for this patient or population? 
• What is the alternative to the intervention (e.g. placebo, different drug, surgery)? 
• What are the included outcomes (e.g. quality of life, change in clinical status, morbidity, adverse effects, complications)? 

These components give you the specific who, what, when, where and how, of an evidence-based health-care research question.  

The PICO model is widely used and taught in evidence-based health care as a strategy for defining Review criteria, formulating questions and search strategies, and for characterizing included studies or meta-analyses.  

There are three different sorts of PICOs within Cochrane Reviews: 

• Review PICOs - Used to decide which studies to include in a Review. You can find this documented in the Methods section of the Review 
• Comparison PICOs – One Review may have multiple comparisons, which group different parts of the Review PICO in different ways, to answer more specific questions.  
• Included Study PICOs – Each included study has its own PICO which may include additional PICO components, such as other outcomes, that the Review is not interested in. 

See more on using PICO in the Cochrane Handbook for Systematic Reviews of Interventions . 

Find out more about the Cochrane PICO linked data project .

How can I use PICO on the Cochrane Library? 

Pico summaries on cochrane reviews and cochrane clinical answers.

For Cochrane intervention reviews , we display included PICO terms below the Abstract.  

This gives an at-a-glance summary of Population, Intervention, Comparison, Outcome for the review as annotated by Cochrane Community experts.  

With one click on a PICO term, users can see search results for reviews with the same included PICO term. There is also prominent Help material giving clear guidance on using PICOs, linking to the relevant section of the Cochrane Handbook.  

On the Review Information pages, MeSH and PICOs are now grouped together for easy discoverability. 

For Cochrane Clinical Answers , we display PICO terms for the Cochrane review from which the Answer is derived below the Answer.  

Read more at Cochrane.org | Find Exactly the Evidence You Need: At-a-Glance PICO Summaries

PICO summaries on search results 

For Intervention Reviews, included PICOs are also displayed on search results.  

Get started with PICO Search on Wiley Customer Success Hub  

Browse by PICO 

You can browse Cochrane content using themed groups of included PICOs from the Cochrane Library and Biblioteca Cochrane homepages.  

Users can discover Cochrane content using themed groups of included PICOs curated and maintained by Cochrane experts. With one click, users can see all available search results for categories with included PICOs. 

In addition, there is clear contextual help for those new to PICOs, with clear guidance on using PICOs and links to the relevant section of the Cochrane Handbook. 

Search by PICO  

PICO search allows you to use those same terms to find Reviews most relevant to your PICO questions. 

For example, the term "Diabetes Mellitus" is cited in Cochrane Reviews in some cases as a Population term, and in other cases as an Outcome term. PICO search allows you to search on the PICO context that you are interested in. 

Read more on PICO search on Cochrane Library    

Read more on PICO Search help

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Systematic Reviews & Evidence Synthesis Methods

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PICOT Tutorials

What is PICOT - A Tutorial

Using PICOT to Formulate Your Literature Search

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Developing Your Question

Developing your research question is one of the most important steps in the review process. At this stage in the process, you and your team have identified a knowledge gap in your field and are aiming to answer a specific question, such as

• If X is prescribed, then Y will happen to patients?

OR assess an intervention

• How does X affect Y?

OR synthesize the existing evidence 

• What is the nature of X? ​

​​Whatever your aim, formulating a clear, well-defined research question of appropriate scope is key to a successful review. The research question will be the foundation of your review and from it your research team will identify 2-5 possible search concepts. These search concepts will later be used to build your search strategy. 

PICOT Questions

Formulating a research question takes time and your team may go through different versions until settling on the right research question.  A research question framework can help structure your systematic review question.  

PICO/T is an acronym which stands for

• P        Population/Problem
• I         Intervention/Exposure
• C        Comparison
• O       Outcome
• T       Time

Each PICO includes at least a P, I, and an O, and some include a C or a T. Below are some sample PICO/T questions to help you use the framework to your advantage. 

For an intervention/therapy

In _______(P), what is the effect of _______(I) on ______(O) compared with 

_______(C) within ________ (T)?

For etiology

Are ____ (P) who have _______ (I) at ___ (Increased/decreased) risk for/of_______ (O) compared with ______ (P) with/without ______ (C) over _____ (T)?

Diagnosis or diagnostic test

Are (is) _________ (I) more accurate in diagnosing ________ (P) compared with ______ (C) for _______ (O)?

For ________ (P) does the use of ______ (I) reduce the future risk of ________ (O) compared with _________ (C)?

Prognosis/Predictions

Does __________ (I) influence ________ (O) in patients who have _______ (P) over ______ (T)?

How do ________ (P) diagnosed with _______ (I) perceive ______ (O) during _____ (T)?

Melnyk B., & Fineout-Overholt E. (2010). Evidence-based practice in nursing & healthcare. New York: Lippincott Williams & Wilkins.

Ghezzi-Kopel, Kate. (2019, September 16). Developing your research question. (research guide). Retrieved from  https://guides.library.cornell.edu/systematic_reviews/research_question

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• Forming Focused Questions with PICO

Forming Focused Questions with PICO: About PICO

Created by health science librarians.

What does PICO stand for?

The pico framework, get help with your pico.

• PICO's Limitations
• PICO Examples
• Other Question Frameworks

Additional letters (for PICOT, PICOS, PICOTS, PICOTTS)

• T ype of study

This guide introduces the PICO question framework for evidence-based practice. It explores PICO’s history, purpose, and limitations. This guide also introduces other question frameworks and provides example questions from across many health professions.

PICO and Its History

PICO is an acronym used to remember the key components of a clinical question. Physicians first developed the PICO framework in evidence-based medicine as a way to address knowledge gaps during patient encounters. Questions could arise around a patient’s diagnosis, prognosis, and therapy, as well as around prevention strategies and patient education. Since then, PICO has become the most widely used question framework for evidence-based practice.

The Purpose of PICO

PICO is useful in academic and clinical settings. It can help you:

• form a question that focuses on the most important issue for a patient or a population
• identify key terms to use in a search for evidence
• select results that directly relate to the situation

PICO has some limitations. The framework privileges interventions, experimental research, and dominant voices.

PICO's Limitations

• Example PICO questions Use this worksheet from Sonoma State University to help you structure your PICO question. (Word doc)
• Asking the Well-Built Clinical Question This guide walks you through the steps of EBP from PICO development to appraisal. Developed by UNC and Duke.

Other guides and tools:

• Asking Focused Questions PICO guide from the Centre for Evidence-Based Medicine (CEBM)
• Formulating Answerable Questions Practice developing your PICO questions here.
• Next: PICO's Limitations >>
• Last Updated: May 14, 2024 12:49 PM
• URL: https://guides.lib.unc.edu/pico

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Background vs. Foreground

Pico examples, asking different types of questions, pico resources & worksheet.

• Evidence Appraisal
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Evidence based practice requires that clinicians make use of the best research they can find to help them in decision-making. To find that research efficiently, the clinician must ask a well-designed clinical question with all the elements that will lead to finding relevant research literature.

The first step in doing this is to determine the type of question: background or foreground. The type of question helps to determine the resource to access to answer the question.

Background questions ask for general knowledge about a condition or thing.

• Broaden the scope - "The Forest"
• Provides basics for a a greater grasp of concepts
• Typically found in textbooks, guidelines, point-of-care monographs, encyclopedias, or topic reviews
• A question root (who, what, when, etc.) with a verb
• A disorder, test, treatment, or other aspect of healthcare

The background question is usually asked because of the need for basic information. It is not normally asked because of a need to make a clinical decision about a specific patient.

Foreground questions ask for specific knowledge to inform clinical decisions or actions.

• Focused in scope - "The Trees"
• Requires a grasp of basic concepts to fully comprehend
• Typically found in journals and conference proceedings
• Have 3 or 4 essential components (see PICO below)

PICO is a mnemonic used to describe the four elements of a good clinical foreground question:

P = Population/Patient/Problem - How would I describe the problem or a group of patients similar to mine?

I = Intervention - What main intervention, prognostic factor or exposure am I considering?

C = Comparison - Is there an alternative to compare with the intervention?

O = Outcome - What do I hope to accomplish, measure, improve or affect?

 Fill in the blanks with information from your clinical scenario: THERAPY In_______________, what is the effect of ________________on _______________ compared with _________________?

PREVENTION For ___________ does the use of _________________ reduce the future risk of ____________ compared with ______________? DIAGNOSIS OR DIAGNOSTIC TEST Are (Is) ________________ more accurate in diagnosing _______________ compared with ____________? PROGNOSIS Does ____________ influence ______________ in patients who have _____________? ETIOLOGY Are ______________ who have _______________ at ______________ risk for/of ____________ compared with _____________ with/without______________? MEANING How do _______________ diagnosed with _______________ perceive __________________? Melnyk, B. M., & Fineout-Overholt, E. (2011). Evidence-based practice in nursing & healthcare: A guide to best practice . Philadelphia: Wolters Kluwer/Lippincott Williams & Wilkins.

• PubMed PICO Tool
• TRIP Database PICO Builder
• PICO Worksheet
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PICO: The Secret Ingredient to Clinical Research: What is PICO?

• Getting to the Basics of Research
• What is PICO?
• Putting PICO to Action During Medical Scholarship
• Putting PICO to Action During Clerkship
• Additional LibGuides to Know

PICO is a tool used to focus your research. Focusing your research is important whether you are a clinician serving a specific patient need or conducting a research study. Framing your research into four main components is key to conducting a strong, efficient, and effective search.

Now, let's expand on what pico stands for:.

How is PICO helpful?

Have you ever struggled with getting started on your research project, focusing your topic, finding relevant search terms, or retrieving just the right amount of search results? PICO helps with that!

Through forming a pico question, you will have an easier time:, focusing your topic - the four primary components of pico pushes you to think beyond the patient or problem. this is especially helpful when you are conducting a research study and must develop a topic yourself. in a clinical setting, many times, you have a patient with a distinct health concern, potential intervention and/or comparison, and a desired outcome. pico is formed with very little ease. however, when you are developing a research study of your own, you must consider all of the primary components that make up the "big picture." pico can help frame your scenario-building process, finding relevant search terms - finding search terms can be a process all on its own. pico's breakdown allows you to pull out your primary research concepts into a few simple terms. this puts you on the right path next, you will want to find alternative terms. check out the tab "additional libguides to know" to learn ways of finding term alternatives., retrieving the right amount of search results - ever conduct a search and feel overwhelmed by a huge number of results what about when you retrieve zero both happen. both scenarios are frustrating. you are not alone. pico will help you narrow your results to avoid those pages and pages of resources while, most times, remaining broad enough to still find a good handful or two of sources filled with relevant information. this is also where having those alternative search terms is of great importance knowing various ways to say the same thing will help you find more resources  focused  on your topic. .

• How to use PICO
• More In- Depth PICO Tutorial

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• Last Updated: Aug 29, 2023 10:29 AM
• URL: https://rowanmed.libguides.com/PICO

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Systematic Search for Systematic Review

• Formulate Research Question Using PICO
• Introduction
• Find Systematic Reviews (SR)
• Databases Selection for Conducting SR
• Step 1. Set Preferences in EndNote
• Step 2. Create Groups in EndNote
• Step 3. Export Search Results from Databases to EndNote
• Step 4. Add Name of Database to References
• Step 5. Remove Duplicate Records
• Step 6. Share References with Teammates
• Step 7. Find Full Text Articles
• [Optional] Export References to Excel
• Related Library Workshops & Courses
• FAQs on Literature Search for Conducting SR

Worksheets for Documenting & Reporting Search Process

Here are some resources for you to document and report your search process in a systematic review. 

• Workbook for documenting systematic search
• PRISMA Flow Diagram A flow diagram to depict the flow of information through the different phases of a systematic review. It maps out the number of records identified, included and excluded, and the reasons for exclusions.

Understanding SR

• What are systematic reviews? (Cochrane)
• Intro to Systematic Reviews & Meta-Analyses
• Using PICO to formulate a search question   (CEBM)
• Turning search terms into a search   (CEBM)
• Turning your search strategy into results: PubMed demonstration   (CEBM)

Understanding study design

• What is a randomised trial?
• Epidemiology Study Types: Randomized Control Trial
• Epidemiology Study Types: Cohort and Case-Control
• Cohort, Case-Control, Meta-Analysis, Cross-sectional Study Designs & Definition 

Copyright Disclaimer

Except where otherwise noted, the content of this guide is licensed under a  CC BY-NC 4.0 License .

A systematic review aims to answer a specific research (clinical) question. A well-formulated question will guide many aspects of the review process, including determining eligibility criteria, searching for studies, collecting data from included studies, and presenting findings ( Cochrane Handbook , Sec. 5.1.1).

To define a  researchable  question, the most commonly used structure is  PICO , which specifies the type of P atient or P opulation, type of I nterventions (and C omparisons if there is any), and the type of O utcomes that are of interest. 

The table below gives an example on how a research question is framed using the PICO structure. You may also use the PICO components to write the objective and title of your review, and later to structure your inclusion and exclusion criteria for study selection. This ensures that the whole review process is guided by your research question. 

Type of Question and Study Design

While formulating your research question, it's also important to consider the  type of question  you are asking because this will affect the type of studies (or study design ) to be included in your review.

Each type of question defines its type of studies in order to provide the best evidence. For example, to answer a therapeutic question, you need to include as many Randomized Controlled Trials (RCTs) as possible, because RCTs are considered to have the highest  level of evidence  (least bias) for solving a therapeutic problem. 

The table below suggests the best designs for specific type of question. The Level of Evidence pyramid, which is widely adopted in the medical research area, shows a hierarchy of the quality of medical research evidence in different type of studies ( Level of Evidence (2011), Oxford Centre for Evidence-based Medicine, CEBM ).

Usually, the study design of a research work will be clearly indicated either in its title or abstract, especially for RCT. Some databases also allow to search or refine results to one or a few study designs, which helps you locate as many as possible the relevant studies. If you are not sure the study design of a research work, refer to this brief guide for spotting study designs  (by CEBM).

Learn to Build a Good Clinical Question

Learn to build a good clinical question  from this  EBP Tutorial: Module 1:  "Introduction to Evidence-Based Practice"

It is provided by Duke University and University of North Carolina at Chapel Hill, USA.

PICO Framework and the Question Statement The above named section  in the Library guide:  Evidence-Based Practice in Health , provided by the University of Canberra Library, explains the PICO framework with examples and in various question types.

Documenting Your Search Process

Systematic review requires a detailed and structured reporting of the search strategy and selection criteria used in the review. Therefore we strongly advise you to document your search process from the very beginning. You may use this workbook  to help you with the documentation.

The documentation should include:

• Research concepts in PICO structure and research question ,
• Type of studies you intend to include, and
• Inclusion and exclusion criteria in PICO structure

and the whole search process, including:

• Databases searched (hosting platforms) , including journals and other sources covered in handsearching
• Date of search
• Search strategy , including keywords and subject headings used, the combination of searches (usually copy-paste from database search page)
• Filters used in initial search or refine results, including year coverage, type of studies, age, etc.
• Number of results retrieved after each search and refinement in each database
• Total number of results from all databases searched
• Duplicates identified from all results
• Number of results with full text

Eventually, you will need to include the information above when you start writing your review. A highly recommended structure for reporting the search process is the PRISMA Flow Diagram . You may also use PRISMA Flow Diagram Generator to generate a diagram in a different format (based on your input). 

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Evidence-Based Practice: PICO

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Focusing Clinical Questions

A clinical question needs to be directly relevant to the patient or problem at hand and phrased in such a way as to facilitate the search for an answer. PICO makes this process easier. It is a mnemonic for the important parts of a well-built clinical question. It also helps formulate the search strategy by identifying the key concepts that need to be in the article that can answer the question.

PICO or PICOTT:

PATIENT OR PROBLEM How would you describe a group of patients similar to yours? What are the most important characteristics of the patient?

INTERVENTION, EXPOSURE, PROGNOSTIC FACTOR What main intervention, exposure, or prognostic factor are you considering? What do you want to do with this patient?

COMPARISON What is the main alternative being considered, if any?

OUTCOME What are you trying to accomplish, measure, improve or affect?

Type of Question Therapy / Diagnosis / Harm / Prognosis / Prevention

Type of Study Systematic review / RCT / cohort study / case-control

• The well-built clinical question: a key to evidence-based decisions Richardson, WS. et al. ACP Journal Club, v123:A12, Nov-Dec, 1995.

Types of Questions

Primary Question Types

• Therapy: how to select treatments to offer our patients that do more good than harm and that are worth the efforts and costs of using them.
• Diagnostic tests : how to select and interpret diagnostic tests, in order to confirm or exclude a diagnosis, based on considering their precision, accuracy, acceptability, expense, safety, etc.
• Prognosis : how to estimate a patient's likely clinical course over time due to factors other than interventions
• Harm / Etiology: how to identify causes for disease (including its iatrogenic forms).

Other Question Types

• Clinical findings: how to properly gather and interpret findings from the history and physical examination.
• Clinical manifestations of disease: knowing how often and when a disease causes its clinical manifestations and how to use this knowledge in classifying our patients' illnesses.
• Differential diagnosis: when considering the possible causes of our  patient’s clinical problem, how to select those that are likely, serious and responsive to treatment.
• Prevention: how to reduce the chance of disease by identifying and modifying risk factors and how to diagnose disease early by screening.
• Qualitative:  how to empathize with our patients’ situations, appreciate the meaning they find in the experience and >understand how this meaning influences their healing.

From: Sackett, DL. Evidence-based medicine: how to practice and teach EBM .

Clinical Question + Study Design

The type of question will often dictate the best study design to address the question. In the absence of the best study design, move down the hierarchy of evidence:

*it is not always ethical to randomize people to a known harmful exposure. However, some RCTs do contain information on adverse events, side effects, etc. that could be helpful in answering certain clinical questions regarding harms. 

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How to Conduct a Literature Review (Health Sciences and Beyond)

• What is a Literature Review?

The Research Questions

• Selection Criteria
• Database Search
• Documenting Your Search
• Organize Key Findings
• Reference Management

Background vs. Foreground Questions

You may need to find answers to background questions (i.e. about general knowledge) before seeking answers to foreground questions (i.e. about specific knowledge, such as information that might inform a clinical decision).

The research questions on this page are for foreground questions.

A well-formulated research question:

• starts your entire search process
• provides focus for your searches
• guides the selection of literature sources

Question formats are helpful tools researchers can use to structure a question that will facilitate a focused search. Such formats include: PICO , PEO , SPIDER , and  COSMIN . Other formats can be found here .  

The  PICO  format is commonly used in evidence-based clinical practice.  This format creates a "well-built" question that identifies four concepts: (1) the P atient problem or P opulation, (2) the I ntervention, (3) the C omparison (if there is one), and (4) the O utcome(s) .

Example : In adults with recurrent furunculosis (skin boils), do prophylactic antibiotics, compared to no treatment, reduce the recurrence rate?  ( Cochrane Library Tutorial, 2005 )

The  PEO  question format is useful for qualitative research questions. Questions based on this format identify three concepts: (1) P opulation, (2) E xposure, and (3) O utcome(s) .

Example:  In infants, is there an association between exposure to soy milk and the subsequent development of peanut allergy ( Levine, Ioannidis, Haines, & Guyatt, 2014 )?

The  SPIDER  question format was adapted from the PICO tool to search for qualitative and mixed-methods research.  Questions based on this format identify the following concepts: (1) S ample, (2) P henomenon of I nterest, (3) D esign, (4) E valuation, and (5) R esearch type .

Example:  What are young parents’ experiences of attending antenatal education? 

Search for ( S  AND  P of I   AND ( D  OR  E ) AND  R ) ( Cooke, Smith, & Booth, 2012 ).

The COSMIN  ( CO nsensus-based  S tandards for the selection of health status M easurement IN struments ) format is used for systematic review of measurement properties.  Questions based on this format identify (1) the construct or the name(s) of the outcome measurement instrument(s) of interest,  (2) the target population, (3) the type of measurement instrument of interest, and (4) the measurement properties on which the review focuses.

Visit the COSMIN website to view the COSMIN manual and checklist.

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Clinical Questions: PICO and PEO Research

• 4 minute read

Table of Contents

When you’re beginning the clinical research process, one of your first decisions will be around framing your clinical question. That, in turn, will depend on if your research is quantitative, or based on numerical data, or qualitative research based on non-numerical data. A PICO clinical question is tied to quantitative data, whereas a PEO question relates to qualitative data.

Let’s take a look at both of these clinical question formats.

What is a PICO Question?

As mentioned above, a PICO research question is used when quantitative data is involved. PICO stands for:

• P – Population, Patient and/or Problem: How do you describe the patients, people or the problem that you’re looking at?
• I – Intervention: What are you considering for an intervention, exposure or factor?
• C – Comparison: Do you have something to compare to the intervention, exposure or factor that you’re considering?
• O – Outcome: What are you hoping to measure, improve, affect or accomplish?

So, essentially, your PICO question will answer the above aspects. This type of clinical question is most often used when the research is investigating evidence-based medicine or other interventions. However, the PICO question format can also be used for non-clinical settings, such as psychological interventions for school-age children, and how they relate to academic achievement.

How to Write a PICO Question

It can sometimes be a challenge to write PICO Questions, as they can be very complex. Since we are looking at evidence-based conclusions, great thought has to be put into formulating a PICO research question. Once the question has been written and clarified, it can help the researcher determine what type of study model will work best to answer the question. So, in a very real way, asking the question properly helps you select what type of study you’ll be conducting.

Fortunately, once you are comfortable with the elements of a PICO question, it almost becomes a plug and play model. For example, if you are looking at questions around prognosis, you might structure your PICO question like this:

Would ________________ (I) affect or influence _________________________ (O) with patients or people who have ___________________________________________________ (P) compared to __________________________(C)?

Another example of a PICO research question might include an inquiry into prevention:

With ___________________ (P) does the practice or use of ________________________ (I) reduce or prevent risk of __________________________(O), compared with __________________________(C)?

What is a PEO Question?

A PEO research question focuses on non-numerical data, or qualitative research. Here, relationships and associations are explored. For example, a PEO question can try to explore whether there is a correlation between taking baby aspirin and a lowered risk of heart attacks.

PEO stands for:

• Population: Who are you studying? Infants? Males who are between the ages of 55 and 60? Adolescent females?
• Exposure: What is your population exposed to? Baby aspirin? Soy supplements? Peanuts?
• Outcome: What is the result of the exposure on your population? Lowered risk for heart attacks? Food allergies? Increased menstrual cramps?

How to Write a PEO Question

Writing a PEO question isn’t generally as complex as writing a PICO question, since you’re only looking at what population, what they’re exposed to, and what your expected outcome is. For example, if you’re looking at food allergies in infants, your PEO question might look like this:

In infants between the age of 6 to 9 months (P), is there an association between exposure to micro-doses of common food allergens (E) and reduced childhood food allergies? (O)

Similar questions can be explored this way:

In or with ___________________ (P), will ________________________(E) result in _________________________ (O)?

Using PICO and PEO Research Questions for Literature Reviews of Searching

Just as you might utilize PICO and PEO question formatting for designing your research, you can also tap into their formats when you’re looking for previous studies on your topic of interest. For example, if you are looking for information on dietary interventions and type 2 diabetes reversal, you can use keywords related to the formulation of a research question:

P: Individuals with type 2 diabetes E: Mediterranean Diet O: Reversal of type 2 diabetes

To find research related to the above question, you would pull out keywords, like:

“type 2 diabetes,” “reversal” and “Mediterranean Diet”

Clinical Question Formats

There are a wide variety of clinical question formats, in addition to PICO and PEO. These can include PICO(T), which adds a “time-frame” ingredient, and (P)PICO if your population is more complex, like white males, age 50-55.

The bottom line is that an effective clinical research question needs to be relevant to the patient or problem, and worded in a way that it’s easy for those looking for your research to find it. If you’re designing a research project, starting with an effective and well-written clinical research question is a critical first step.

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Evidence-Based Practice

• Introduction to EBP
• PICO(T) for Clinical Questions

Creating a Clinical Question: PICO / PICOTS

Picot example.

• Qualitative Questions This link opens in a new window
• 3. Appraise
• Study Design
• Resources about EBP

PICO  is an acronym that can help you create a well-built clinical question by identifying the key aspects of a complex patient presentation. 

• Patient or Population or Problem  The disease or condition you are investigating, and the particular demographic you are wanting to learn about (if applicable)
• I ntervention or Indicator  Primary treatment option
• Comparison or Control  Comparison treatment (if applicable)
• Outcome What you you expect to see?
• Timeline**:  Time it takes to demonstrate a clinical outcome or how long patients are observed.
• Study Type:  What kind of study would best answer this question (i.e., RCT, Case Series, etc.). Rather than using keywords in your search strategy, you can often use filters to limit to specific study types / designs. ** Note that the timeframe does not always show up in the abstract. If you aren't getting enough results, you may need to remove this from your search, and just eliminate results that don't fit your preferred timeframe in the Prisma screening section.

Patient or Problem = hypertension

KEYWORDS: hypertension, high blood pressure, hypertensive

Intervention = telemonitoring blood pressure

KEYWORDS: telemonitor, telemedicine, MeSH term is “Blood Pressure Monitoring, Ambulatory”

Comparison = n/a

Outcome = improve blood pressure

MeSH term is “Blood Pressure” (but if you are using terms for “telemonitoring blood pressure ,” this is unnecessary).

Timeframe = within one year

one year, twelve months (searching for timeframes can be tricky -- this won't find studies that were  less  than 12 months! If your results are too limited, you can try removing this from your search).

Potential search strategy:

or if you search everything in a single line:

Want to see an example in action? Check out the video below.

PICOT example begins at the 3:00 mark.

"Table 1" is from:

Gallagher Ford, L., & Melnyk, B. M. (2019). The Underappreciated and Misunderstood PICOT Question: A Critical Step in the EBP Process. Worldviews on Evidence-Based Nursing, 16(6), 422–423. https://doi.org/10.1111/wvn.12408

• PICO Tutorial from University of Washington
• Johns Hopkins EBP Question Development Tool Worksheet to help EBP teams develop an question that will answer a clinical, administrative, or knowledge problem.
• PICOT Worksheet This worksheet will help you build a PICOT question and identify keywords for your searchable question.
• Pubmed Clinical Queries This tool uses predefined filters to help you quickly refine PubMed searches on clinical or disease-specific topics.
• The Underappreciated and Misunderstood PICOT Question: A Critical Step in the EBP Process
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Evidence-Based Practice in Health Care: The PICO Framework

• What is the PICO Framework?
• Evidence-Based Practice

What is the PICO Framework and How Do I Use It?

Composing your pico question, pico elements may change according to the question's domain.

• PICO Case Studies
• Researching Your PICO
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Practitioners of evidence-based practice (EBP) often use a special framework called PICO to form clinical questions and facilitate the literature search (evidence). The PICO Process or Framework makes defining a clinical question and seeking a solution easier, and .

A clinical question needs to be directly relevant to the patient or problem at hand. It needs to be phrased in a way that facilitates the search for an answer. Without a well-focused question, it can be difficult and time-consuming to identify appropriate resources and search for relevant evidence. 

PICO is a mnemonic (a memory tool) for the important parts of a well-built clinical question.  PICO stands for:

• P atient or P opulation
• I ntervention
• C omparison or C ontrol

This table shows a basic outline of how the PICO Process can help you define an evidence-based care plan.

When forming your question using  PICO , keep the following points in mind:

• Your  P atient is a member of a population as well as a person with (or at risk of) a health problem. So, in addition to age and gender, you may also need to consider ethnicity, socioeconomic status or other demographic variables.
• A  C omparison is not always present in a  PICO  analysis.
• O utcomes should be measurable as the best evidence comes from rigorous studies with statistically significant findings.
• An  O utcome ideally measures clinical wellbeing or quality of life, and not alternates such as laboratory test results.

This guide about the PICO framework has been adapted from the original at the website of the University of Canberra Library.

Once you have clearly identified the main elements of your question using the  PICO  framework, it is easy to write your question statement.  The following table provides some examples.

Here are a basic and a more advanced document about how to use the PICO framework or formula. The first one has some excellent examples of fully formed PICO questions. The PDF link is a template for working your way through forming the elements of your question.

• What is the PICO Process?
• 7 Steps to the Perfect PICO Search
• Template for Asking PICO Questions

PICO Elements May Change According to the Question's Domain

When forming your question using the  PICO  framework, it is useful to think about what type of question it is you are asking, (therapy, prevention, diagnosis, prognosis, etiology ). The table below illustrates ways in which  P roblems,  I nterventions,  C omparisons and  O utcomes vary according to the type or domain of your question.

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Nursing research guide.

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• Qualitative & Quantitative Data
• Evidence-Based Practice
• Types of Study Designs
• Types of Reviews
• Searching Tips
• Books, Images, & More
• Open Educational Resources (OER)
• Finding Guidelines
• PICO Questions
• News, Blogs, & More
• CIting, Writing, & Publishing

Example Sources:

• UNC-Chapel Hill Health Sciences Library PICO Examples

What is PICO?

• P: Population, patient, or problem
• I: Intervention or indicator
• C: Comparison or control

PICO  is a formula used to develop a researchable clinical question. 

The purpose of a PICO question is to help breakdown a research question into smaller parts, making the evaluation of evidence more straightforward.

P:  Population, patient, or problem

I:  Intervention or indicator

C:  Comparison or control

O:  Outcome

Note: Not every question will have a time frame or a comparison. Outcomes should be a measure of clinical well-being/quality of life.

P: Population, patient, or problem

Who is the patient or population? (Think demographics: age, sex, gender, race).

What problem or disease or situation are you facing?

I: Intervention or indicator

What do you plan to do for your patient? (medications, diagnostic tests, therapies, procedures)

What intervention is implemented to help make a difference to your patient/population?

C: Comparison or control

What other interventions should be considered? What can we compare our research too?

Is there a control group you would like to compare your intervention with?

O: Outcome

What is the desired or effective outcome of the intervention compared to the control?

Forming Focused Question with PICO: Case Study

Case: patient education.

• You are a nurse working in a busy inpatient medical surgical unit. The patients on your unit are admitted for a wide variety of conditions: renal, GI, dermatologic, etc.
• All patients admitted that are chronic smokers are given brief counseling by an RN and a self-help brochure about smoking cessation, but no follow up counseling after that.
• You hear your coworkers complaining that they feel like they are wasting their time because they think the patients will resume smoking after discharge.
• You decide you want to find out if this minimal contact intervention works in the long term.

P: Consider when choosing your Patient/Problem/Population

• What are the most important characteristics?
• Relevant demographic factors
• The setting

I: Consider for your Intervention

• What is the main intervention, treatment, diagnostic test, procedure, or exposure?
• Think of dosage, frequency, duration, and mode of delivery

C: Consider for your Comparison

• Inactive control intervention: Placebo, standard care, no treatment
• Active control intervention: A different drug, dose, or kind of therapy

O: Consider for your Outcome

• Be specific and make it measurable
• It can be something objective or subjective

PICO: Putting It Together

Your full PICO question is:

"Among hospitalized chronic smokers, does a brief educational nursing intervention lead to long term smoking cessation [when compared with no intervention]?"

PICO Question Examples

• Infection Control
• Labor & Delivery

Patients on coronary artery bypass graft (CABG) waiting lists often experience anxiety and depression and your nurse manager wants to know if it would be a good idea to reach out to these patients with presurgical home visits and follow-up calls from a specialist cardiac nurse.

P: patients on CABG waiting lists I: program consisting of presurgical home visit and follow-up calls form a specialist cardiac nurse C: no intervention O: decreased patient anxiety and depression  

For patients on CABG waiting lists, does an intervention program consisting of presurgical home visits and follow-up calls from a specialist cardiac nurse lead to decreased patient anxiety and depression [when compared with no intervention]?

You work in the Big City Hospital ICU. Your mechanically ventilated patients sometimes contract nosocomial pneumonia, which leads to costly complications. You want to know if raising the head of the bed lowers the chance of the patient contracting pneumonia compared to letting the patient lie flat on their back.

P: mechanically ventilated ICU patients I: semi-fowlers position C: supine position O: lower incidence of nosocomial pneumonia In mechanically ventilated ICU patients, does positioning the patient in semi-fowlers result in a lower incidence of nosocomial pneumonia when compared to the supine position?

In the past few years, your hospital has installed antibacterial foam dispensers on all the nursing units. You’ve had nurses asking you if the foam is just as effective as washing their hands with water and soap.

P: hospital nurses I: using antibacterial foam C: hand washing with soap and water O: decreased bacteria count In hospital nurses, does antibacterial foam decrease bacteria count on hands as much as hand washing with soap and water?

You’re a new nurse on a labor and delivery unit. You’ve noticed that most women give birth in the lithotomy position at the encouragement of their doctors. However, you’re sure you heard in nursing school that other positions are less likely to lead to deliveries with forceps or a vacuum...or did you? You want to find some literature to back up your claim.

P: laboring women delivering in a hospital I: positions other than the lithotomy position C: lithotomy position O: decreased incidence of assisted deliveries In laboring women delivering in the hospital, do positions other than lithotomy position lead to a decreased incidence of assisted deliveries?

You’re the nurse manager of a NICU unit. One concern of parents of infants receiving tube feedings is being able to successfully breastfeed their child upon discharge. One of your staff nurses asks if it would be helpful to give the infants cup feedings instead of tube feedings during their NICU stay.

P: Infants in the NICU I: cup feeding throughout the hospital stay C: tube feedings throughout the hospital stay O: greater reported success with breastfeeding post-discharge In infants in the NICU, will cup feeding throughout the hospital stay lead to greater success with breastfeeding post-discharge when compared to tube feedings?

You work with patients with advanced cancer and have been taught to suggest pain diaries for your patients as a form of pain management. You’ve been wondering for a while now if these diaries actually improve pain control or make pain worse by making patients more aware of their pain.

P: patients with advanced cancer I: keeping a pain journal C: no intervention O: lower reported pain scores In patients with advanced cancer, does keeping a pain journal result in lower reported pain scores when compared to no intervention?

You work in a pediatrician’s office and give patients their routine vaccinations. The younger children are often fearful of needles, and some of the RNs use toys to distract the patients. You want to know if this technique actually has an effect on the children's pain response.

P: young children I: distraction techniques during immunization C: no intervention O: lower pain scores rated by the Faces pain scale In young children, do distraction techniques during immunization administration using toys result in lower pain scores when compared to no intervention?

You work on an inpatient psychiatric unit. One of your patients with chronic schizophrenia, Joe, normally mumbles to himself, but will occasionally speak to others when residents play games together. Noticing this, you say to a coworker that maybe social skills group training sessions would bring out Joe’s conversational skills. Your coworker shakes her head and says "I don’t think so. Joe is in and out of this hospital, he’s a lost cause."

P: Inpatient chronic schizophrenia patients I: social skills group training sessions C: standard care O: increased conversational skills as evidenced by greater number of interactions with peers In inpatient chronic schizophrenia patients, do social skills group training sessions increase conversational skills when compared to standard care?

A diabetic patient from a nursing home has recently been admitted with a stage III pressure ulcers on his heels. The unit nurses have called you in for a wound consult. You have to choose between standard moist wound therapy and using a wound vac.

P: elderly diabetic with stage III foot ulcers I: negative pressure wound therapy C: standard moist wound therapy O: improved wound healing as measured by pressure ulcer grading system guidelines In elderly diabetic patients with stage III foot ulcers, does negative pressure wound therapy lead to improved wound healing when compared to standard moist wound therapy?

The main concern for most of your patients coming out of anesthesia in your PACU is pain. You want to explore nursing interventions you can use on top of medication administration to decrease pain. One coworker mentions trying to make the PACU feel less clinical by playing soft music to relax patients.

P: PACU patients I: soft music as an adjunct to standard care C: standard care alone O: lower reported pain scores In PACU patients, will playing soft music in the PACU as an adjunct to standard care result in lower reported pain scores when compared to standard care alone?

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PICO Research Questions: Formulating a PICO Question

• Getting Started

Formulating a PICO Question

• PICO in the Databases
• Levels of Evidence
• Online Resources
• Breaking Down PICO
• Background & Foreground Questions
• Inclusion & Exclusion

How do I Break Down a PICO Question?

You first need to come up with a question that includes all of the PICO components and break those down for searching the database.

For example:  In non-ambulatory patients, (P) does turning the patient (I) compared to pressure mattresses (C ) reduce the risk of pressure ulcers? (O)

To search for evidence-based articles related to your PICO question, identify the keywords for each PICO element.

• P  – Patient, non-ambulatory
• I  – turning
• C  – pressure mattress
• O  – pressure ulcer

Turn these keywords into  subject descriptors  or  MeSH/CINAHL subject headings  to use in your database searches.

Ask background questions   and foreground questions.

• Typically found in textbooks, encyclopedia, or reviews.
• Not normally asked when clinical decisions are needed to be made about a patient.
• Typically found in journals and conference proceedings.
• Require a grasp of the basic concepts from background questions

Think about inclusion and exclusion criteria to help you select and set boundaries for your searching.

• Certain types of studies.
• Certain geographic locations.
• Published within last 5 years.
• Comparison of certain treatments.
• Use of wrong types of studies.
• Published more than 5 years ago.
• Published in another language (depending on if you can read the language or are looking for articles only pertaining to the U.S.).
• << Previous: Getting Started
• Next: PICO in the Databases >>
• Last Updated: Feb 13, 2024 2:25 PM
• URL: https://library.madonna.edu/pico

EBP Learning Module

Ask the Question

Formulating a question using pico.

Often our need for information is not formulated as a question to begin with - but if you don't ask a question, it is probably fair to say you will not get an answer! Asking the right question is an important start to finding the information needed to inform clinical practice.

Structuring the question is the first step. Vague, broad, poorly framed questions will most likely result in lost time and an inability to locate useful evidence. In comparison, asking a specific and focused question enables the development of relevant keywords and an effective search strategy.

Most questions can be broken down into three or four components that describe the population, the intervention or treatment (and sometimes an alternative treatment), and the outcome you want to investigate. This is known as the PICO method, and it is widely used by health researchers, healthcare professionals, and related collaborations such as those in The Cochrane Library, to construct searchable questions that give relevant and precise results.

The table below shows how the PICO method is used.

The acronym is sometimes given as PICOT where T stands for time, type of study, or test; or PECOT where E stands for the exposure group, C for the control group and T for time, type of study, or test.

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Evidence Based Practice

• 1. Ask: PICO(T) Question
• 2. Align: Levels of Evidence
• 3a. Acquire: Resource Types
• 3b. Acquire: Searching
• 4. Appraise
• Primary vs. Secondary Sources
• Qualitative and Quantitative Sources
• Managing References

Ask: Write a focused clinical question

Use the PICOT format to break down your question into smaller parts and identify keywords:

• The Well-Built, Patient-Oriented Clinical Question Use this worksheet to break down the parts of your PICO question.

PICO Question Template Examples

It can be helpful to classify your question based on the clinical domain(s) it falls under.  

See below for definitions, PICO templates, and example questions from the primary clinical domains: intervention , diagnosis , etiology , prevention , prognosis/prediction , quality of life/meaning , and therapy .

Intervention

Questions addressing the treatment of an illness or disability.

In _________ (P), how does _________ (I) compared to _________(C) affect _______(O) within _______ (T)? In _______(P), what is the effect of _______(I) on ______(O) compared with _______(C) within ________ (T)?

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

Are (is) _________ (I) more accurate in diagnosing ________ (P) compared with ______ (C) for _______ (O)? In ________ (P) are/is ________(I) compared with ________(C) more accurate in diagnosing ________(O)?  

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

Are ____ (P) who have _______ (I) at ___ (Increased/decreased) risk for/of_______ (O) compared with ______ (P) with/without ______ (C) over _____ (T)?

Are ______(P) who have ______(I) compared with those without _______(C) at ________ risk for/of _______ (O) over ________(T)?

Questions on how to reduce the chance of disease by identifying and modifying risk factors and how to diagnose disease early by screening.

For ________ (P) does the use of ______ (I) reduce the future risk of ________ (O) compared with _________ (C)?

Prognosis/Prediction

Questions addressing the prediction of the course of a disease.

Does __________ (I) influence ________ (O) in patients who have _______ (P) over ______ (T)? In _______ (P), how does ________ (I) compared to ________ (C) influence _________ (O) over _________ (T)?

Quality of Life/Meaning

Questions addressing how one experiences a phenomenon.

How do ________ (P) diagnosed with _______ (I) perceive ______ (O) during _____ (T)?

Questions around how to select treatments to offer our patients that do more good than harm and that are worth the efforts and costs of using them.

In _______(P), what is the effect of _______(I) on ______(O) compared with _______(C) within ________ (T)?

Source1 Source2 Source3  

Click "Next" below to start your research.

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WHO guideline on preventive chemotherapy for public health control of strongyloidiasis [Internet]. Geneva: World Health Organization; 2024.

WHO guideline on preventive chemotherapy for public health control of strongyloidiasis [Internet].

Annex 4 pico questions and grade summary tables, a4.1. efficacy of ivermectin against strongyloides stercoralis infection, pico question.

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GRADE summary table of the findings

CI: confidence interval; GRADE: Grading of Recommendations, Assessment, Development and Evaluation NA: not applicable.

A relative risk greater than one is a higher cure rate against the comparator, while a relative risk less than one is a lower cure rate. The absolute effect estimates refer to the number of persons with infection that are cured.

The GRADE ratings are based on guideline member and methodologist judgements using pre-defined criteria specific to the guideline. Thus, ratings may differ from those in published literature.

A4.2. Impact of mass drug administration with ivermectin on strongyloidiasis

CI: confidence interval; PC: preventive chemotherapy.

A4.3. Safety of ivermectin used in large scale and in particular the risk for non-infected to be treated

A4.4. Modelling and cost-effectiveness analysis

We followed recent GRADE guidance to evaluate certainty of evidence for modelling studies with a qualitative appraisal of the modelling evidence in this study ( 1 , 2 ).

A4.4.1. Risk of bias

We assessed the risk of bias of model outputs by considering the credibility of the model itself (e.g. structure, performance on calibration and validation) and the certainty of evidence for each model input (e.g. infection incidence, disseminated disease incidence; for economic model outputs, resource use, utility values and baseline risks of outcomes). In our evaluation, there is some risk of bias for the key model inputs of incidence of disseminated strongyloidiasis and disability weight for chronic infection. Given the lack of longitudinal data, model validation was not formally undertaken, but the findings broadly align with observational studies.

A4.4.2. Inconsistency

We assessed consistency in the model inputs ascertained from the literature. Overall model inputs were consistent. Further, the model consistently demonstrated the cost–effectiveness of mass drug administration (MDA) with ivermectin across a range of epidemiological settings and sensitivity analyses. This increased confidence in the modelled reductions in infection prevalence and disability-adjusted life years (DALYs) post-MDA with ivermectin.

A4.4.3. Imprecision

We considered the point estimates and the variability from the results of the modelling study. The modelling study did include information about the output variability and the key findings on cost–effectiveness were precise overall.

A4.4.4. Indirectness

We evaluated the indirectness of the modelling evidence, based on whether the modelling input data were discrepant with the ideal target model’s input or the modelling outputs were discrepant with the intended population, intervention(s), time horizon, analytic perspective and/or outcome(s), and/or did not accurately reflect the decision question at hand. Overall, the Guideline Development Group did not identify issues with indirectness.

A4.4.5. Publication bias

Risk of publication bias was not relevant when assessing this modelling evidence because this is a single model that was constructed de novo. Publication bias may be possible for model inputs.

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• Cite this Page WHO guideline on preventive chemotherapy for public health control of strongyloidiasis [Internet]. Geneva: World Health Organization; 2024. Annex 4, PICO questions and GRADE summary tables.
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• Efficacy of ivermectin against Strongyloides stercoralis infection
• Impact of mass drug administration with ivermectin on strongyloidiasis
• Safety of ivermectin used in large scale and in particular the risk for non-infected to be treated
• Modelling and cost-effectiveness analysis

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