munity treatment settings enhances adoption of clinical techniques and interventions and increases generalization of research findings.

Bickman also recognized that clinical environments are challenging settings for research. Reduced statistical control and rival hypotheses can complicate interpretation of results. Discussion of results with clinicians and clients may be a critical step in the development of a full understanding of the findings and the articulation of subtle but real influences on the observed outcomes. A cadre of clinicians and data collectors is often required to implement investigations, so teamwork is essential to success and the management of the research process and personnel can be as important as the collection and analysis of data. The investigator must also be willing and able to negotiate access and procedures with a full range of stakeholders: clients, clinicians, administrators, policymakers, and funding agencies. Chilo Madrid's ten questions (Box 4.2) illustrate the importance of this negotiation.

Ownership of the data and publication of the findings are issues that often generate controversy. Investigators should recognize that the participating treatment programs have a stake in the data and have claims to the findings. Investigators who make data available to the clinicians for treatment planning and evaluation and invite participation in data interpretation and publication may be encouraged to continue investigations. Those who demand autonomy and control, on the other hand, are likely to find inhibited access to programs and patients. Finally, the complexity of the research initiatives means that investigations that involve clinical settings may require a substantial investment of time and money. Funding should include incentives for patient participants (if primary data collection is required) and for treatment agencies that permit access. These influences and tensions have been apparent in the development of health services research.

Health services research is a multidisciplinary field of inquiry, both basic and applied, that examines the use, costs, quality, accessibility, delivery, organization, financing, and outcomes of health care services to increase knowledge and understanding of the structure, processes and effects of health services for individuals and populations.

Health Services Research: Workforce and Educational Issues, IOM (1995), p. 3.



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