Arwen Emmanuelle Bunce, MA

The flexibility, in-depth exploration, and openness to new ideas that are the hallmark of qualitative research benefit implementation research by providing a rich, nuanced understanding of the process under study. However, traditional qualitative approaches to data collection and analysis can be difficult to transfer to the realities of often fast-moving team-based research within the health care system, as well as burdensome to busy health care practitioners. Arwen has worked to adapt traditional anthropological methods to gathering and analyzing data to fit the needs of health services research in evolving health care systems and the realities of implementation research, both of which often involve numerous, geographically dispersed health care settings. She has led teams, taught clinical and informatics colleagues, and published on the real-world use of methods such as rapid qualitative assessment, ethnographic process evaluation, and realist evaluation in primary care/community settings. Her work has contributed to the development and use of rigorous, pragmatic, minimally disruptive approaches to investigating the complexities and interrelationships that underlie intervention outcomes.

• Bunce A, Middendorf M, Hoopes M, Donovan J, Gold R. Designing and implementing an electronic health record-embedded card study to survey providers: Methods and considerations. Annals of Family Medicine. 20(4). July-August 2022. PMCID: PMC9328703
• Bunce A, Gruss I, Davis J, Cohen D, Oakley J, Gold R. Lessons learned about the effective operationalization of champions as an implementation strategy: results from a qualitative process evaluation of a pragmatic trial. Implementation Science. 15(87). 2020. PMCID: PMC7528604
• Bunce AE, Gold R, Davis JV, McMullen CK, Jaworski V, Mercer M, Nelson C. Ethnographic process evaluation in primary care: explaining the complexity of implementation. BMC Health Serv Res 2014 Dec 5;14(1):607. PMCID: PMC4265455
• Guest G, Bunce A, Johnson L. How many interviews are enough? An experiment with data saturation and variability. Field Methods. 18(1): 59-82. 2006.

While primary care clinicians strive to provide person-centered care, there remains a multitude of unanswered questions about the best approaches to collecting, documenting, and acting on patient-specific contextual information, including social drivers of health. Arwen has designed and led the qualitative portions of multiple grants studying the interdependent factors that impact perception of and openness to routinized social risk screening in community health centers, as well as the feasibility, implementation, and use of EHR-based tools for supporting this work. This research has focused on using social risk screening to optimize the provision of contextualized, patient-centered care.

• Bunce A, Morrissey M, et al. Finding Meaning: A realist-informed perspective on social risk screening and relationships as mechanisms of change. Frontiers in Health Services. October 2023. https://doi.org/10.3389/frhs.2023.1282292
• Bunce A, Donovan J, Hoopes M, Gottlieb L, Krancari M, Gold R. Patient-reported social risks and provider decision-making: Results of a Clinician Survey in Primary Care Community Health Centers. Annals of Family Medicine. 2023 Mar-Apr;21(2):143-150. doi: 10.1370/afm.2953
• Gruss I, Bunce A, et al. Initiating and implementing social determinants of health data collection in community health centers. Population Health Management. 24(1): 52-58. 2021. PMCID: PMC7875127
• Gold R, Bunce A, et al. Adoption of Social Determinants of Health EHR Tools by Community Health Centers. Annals of Family Medicine 16(5): 399-407. September/October 2018. PMCID: PMC6131002

Health information technology (HIT) is part of the complex sociotechnical interactions that form the daily work of health care. The study of the adoption and use of HIT thus requires consideration of the complexities of both health care and HIT, and how the two interact. Ethnography, with its emphasis on exploring the “how” and “why” behind quantitative results, can provide deep insight into the web of factors underlying study findings, improving their credibility and transferability. Arwen has been involved in a series of studies investigating the acceptability and use of clinical decision support (CDS), first as a member of a purely qualitative team studying the impact of CDS on providers and staff at community hospitals around the country, then branching out to consider the perspectives of those working to create and market the CDS, and finally leading the qualitative components of mixed methods research into CDS-based interventions in community health clinics. Her work has contributed to the ability to meaningfully incorporate the lived experience of relevant stakeholders (often clinicians and staff) into each step of the research process, increasing the integrity and usability of findings.

• Gold R, Bunce A, Davis J, Nelson J, Cowburn S, Oakley J, Carney S, Horberg M, Dearing J, Melgar G, Bulkley J. Seabrook J, Cloutier H. I didn’t know you could do that: A pilot assessment of EHR optimization training. Implementation Science. ACI Open. 5:e27-e35 2021.
• Gold R, Bunce A, Cowburn S, Davis J, Nelson J, Nelson C, Hicks E, Cohen D, Horberg M, Melgar G, Dearing J, Seabrook J, Mossman N, Bulkley J. Does Increased Implementation Support Improve Community Clinics’ Guideline-Concordant Care? Results of a Mixed Methods, Pragmatic Comparative Effectiveness Trial. Implementation Science. Implementation Science. 14(100). 2019. PMCID: PMC6894475.
• Bunce A, Gold R, Davis JV, Mercer M, Jaworski V, Hollombe C, Nelson C. 'Salt in the wound': Safety net clinician perspectives on performance feedback derived from EHR data. J Ambul Care Manage. 40(1): 26-35. 2017. PMCID: PMC5137808
• Gold R, Bunce A, Cowburn S, Davis J, Hollombe C, Nelson C, Puro J, Muench J, Hill C, Jaworski V, Mercer M, Howard C, Perrin N, DeVoe J. Cardiovascular care guideline implementation in community health centers in Oregon: a mixed-methods analysis of real-world barriers and challenges. BMC Health Services Research 17:253. 2017. PMCID: PMC5382420

How best to ensure adequate access to health care, particularly for vulnerable patients, has been the subject of much debate and experimentation over the years. An individual’s ability to access care for themselves and their family is influenced by a complex set of factors ranging from health care delivery system-level issues to patient-level factors. Arwen has worked on studies attempting to understand the role of immigration status in access to care, both from the immigrant perspective (interviews with immigrants from around the world and of all legal statuses, including undocumented) and from the standpoint of federal measurement and documentation of immigration status (exploring the methodological issues relating to definitions and assessment of legal status for the U.S. Census Bureau). In subsequent work, she provided qualitative methods expertise to research teams exploring the impact, from the perspective of the individuals and families, of programs designed to increase access to primary care for uninsured patients.

• DeVoe JE, Westfall N, Crocker S, Eigner D, Selph S, Bunce A, Wallace L. Why do some eligible families forego public insurance for their children? A qualitative analysis. Fam Med 2012 Jan; 44(1):39-46. PMCID: PMC4407493
• Saultz JW, Heineman J, Seltzer R, Bunce A, Spires L, DeVoe J. Uninsured patient opinions about a reduced-fee retainer program at academic health center clinics. J Am Board Fam Med 2011 May-Jun; 24(3):304-12. PMCID: PMC4151114
• Loue S, Faust M, Bunce A. The effect of immigration and welfare reform legislation on immigrants' access to health care, Cuyahoga, and Lorain Counties. J Immigr Health 2000 Jan; 2(1):23-30.
• Loue S, Bunce A. The assessment of immigration status in health research. Vital Health Stat 2 1999 Sep; (127):1-115.

Morbidity and mortality rates remain high in many resource-poor countries, despite ongoing attempts to address the issue(s). While reasons for these poor outcomes are multifaceted, one perspective that is often missing from well-intended programs is that of those whose behavior is targeted. As a qualitative research specialist with a large international health organization (Family Health International), Arwen worked closely with in- country teams to improve their qualitative data collection skills—how to ask open-ended questions and follow up appropriately, how to establish rapport while maintaining neutrality, how to approach sensitive topics with respect—with the goal of incorporating the perspective of those most intimately affected in the design, refinement and scale-up of health interventions. In this role, she also helped design the evaluations, created data collection guides and training materials, and often had primary responsibility for the qualitative analysis. In addition, she spent a year working with Doctors Without Border/MSF, where she was responsible for designing, conducting, analyzing and reporting on an evaluation of a five-year water and sanitation program; lessons learned were shared across the organization.

• Bunce A, Guest G, Searing H, Frajzyngier V, Riwa P, Kanama J, Achwal I. Factors affecting vasectomy acceptability in Tanzania. Int Fam Plan Perspect 2007 Mar; 33(1):13-21.
• Chillag K, Guest G, Bunce A, Johnson L Kilmarx PH, Smith DK. Talking about sex in Botswana: social desirability bias and possible implications for HIV prevention research. Afr J AIDS Res 2006; 5(2): 123- 131.
• Tolley E, Eng E, Kohli R, Bentley M, Mehendale S, Bunce A, Severy L. Examining the context of microbicide acceptability among married women and men in India. Culture, Health and Sexuality 2006 July- August; 8(4):351-369.
• Guest G, Bunce A, Johnson L, Akumatey B, Adeokun L. Fear, hope and social desirability bias among women at high risk for HIV in West Africa. J Fam Plann Reprod Health Care 2005 Oct; 31(4):285-7.