Forming Focused Questions with PICO: PICO's Limitations

While PICO can be a convenient acronym for building clinical questions, the framework has several limitations. This page lists these limitations and suggests ways to address them.

PICO primarily centers on intervention (or therapy) clinical questions. It can be less suitable for other question types.

• Use this worksheet (Word document) from Sonoma State University to help you structure your non-therapy PICO question.
• Read more about this limitation in the research published by Xiaoli Huang, MLS, Jimmy Lin, Ph.D., and Dina Demner-Fushman, M.D., Ph.D. in their article titled "Evaluation of PICO as a Knowledge Representation for Clinical Questions."

PICO privileges research that is experimental or observational in nature. It does not account for complexities like considering feasibility, context, and sociocultural acceptability.

• To broaden beyond the PICO elements, consider other question frameworks.
• Read more about this limitation in the research published by Andrew Booth, Jane Noyes, Kate Flemming, Graham Moore, Özge Tunçalp, and Elham Shakibazadehin their article titled "Formulating Questions to Explore Complex Interventions within Qualitative Evidence Synthesis."

PICO is a tool used in evidence-based practice (EBP), which is an integration of clinician expertise, patient preferences and values, and the best available research evidence. EBP defines evidence according to a pyramid with randomized controlled trials recognized as the highest level of primary evidence. This hierarchy of evidence can exclude the voices of minority populations and the interests of those in non-dominant populations. Thus, EBP, while seemingly objective, often reflects White voices and assumptions of the majority. Therefore, the use of PICO to frame literature searches may prove successful for questions with dominant populations and result in evidence gaps for non-dominant populations.

• To expand literature searches to include more voices, search databases that reflect a global perspective.
  • Global Index Medicus (provided by the Worth Health Organization and free to use)
  • Global Health (provided by EBSCOhost and available to UNC affiliates)
• Expand beyond peer reviewed journal literature to include dissertations, reports, blogs, social media, websites, and others.
• Experiment with broadening your PICO elements, such as by including a larger population.
• Contact a health sciences librarian for additional support.