Using the Candidacy Framework to Explore Access to NHS Healthcare for Street Sex Workers in Sheffield: An Ethnography and Art-Based Research Project

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

Sex workers experience profound social stigma that extends beyond healthcare access to encompass systematic denial of bodily autonomy, exposure to violence, and pervasive social inequality. These intersecting forms of oppression relegate sex workers to an extraordinarily marginalized position—economically, socially, and politically disenfranchised. While the authors provide valuable insights into barriers preventing adequate healthcare access for this population, the study would benefit substantially from a more comprehensive approach that addresses empowerment through education and rights-based awareness. Specifically, the research lacks explicit attention to how sex workers might be educated about their fundamental rights to mental and physical health, and how such empowerment could serve as a preventive strategy against the barriers identified. Incorporating frameworks for health literacy, rights education, and empowerment alongside the candidacy framework would render this manuscript more holistic and transformative in its potential impact..

Author Response

Please see attached file of tabulated comments in response to the reviewer.

Author Response File: Author Response.pdf

Reviewer 2 Report

Comments and Suggestions for Authors

This is an interesting paper for its focus on a population often marginalized in health systems design and research, as well as for its creative and appropriate use of multiple methods of qualitative data collection coupled with a clear theoretical framework for interpretation. The findings are clearly presented and linked to some useful implications for practice. In particular, the cautionary note for digitization of access is timely, and the take-away message that SSWs are excluded rather than disengaged is one to consider in rethinking care not only for this population but as a potentially relevant framing for many systemically marginalized groups.

There are a number of suggested edits and clarifications that I think would strengthen the paper. They are addressable without reanalysis of data, I believe.

• The most significant/necessary question/clarification I have relates to the methods of consent. The paper states that there was an inclusion criterion that SSWs "must have sufficient capacity to consent and participate"; at the same time, the paper justifies not having an exact count of people in the study in reference to ethnographic/participatory traditional methods and norms. These two statements seem slightly at odds. How did SSWs consent, or did they? Who assessed if they had "sufficient capacity" and did this assessment result in some SSWs being excluded? How did they know their data would be included in the study? Did the primary author have conversations with them about consent? Were some activities (like scrapbooking) explicitly consented, while observations were not? I am not trying to "catch" the authors out on consent issues, just to have clarity on how they negotiated what sound like different frameworks  for thinking about what consent and research participation mean.
• Line 166 - given that a specific interpretive framework appears to have been applied fairly deductively (though selected because it fit well after an attempt at a more inductive thematic analysis proved unfruitful), it sounds inconsistent to me to name the results as "emerging" themes. I suggest either taking that word out or explaining how the already established interpretive framework can be defined in this case as emergent. 
• Line 176: What does it mean that results were "verified" by two of the authors? I would suggest instead describing what method was used to ensure agreement on the findings (which is a little different from the suggestion that these results are "verified," word suggesting measurement against a standard or predefined entity). Did co-authors review and discuss coding and come to consensus, for example, or something else?  
• I found this sentence (around line 450) a little confusing:  "The scrapbook method may have enhanced participation by reducing perceived commitment and formality, while occasionally encouraging participants to make practical choices about their health and evolve into actions without waiting for formal data collection completion." What "practical choices about their health" were made while scrapbooking and are being referenced, and what "actions" - are we talking about the decision to be in the study, or to seek care in some way? Also, do the authors mean that this was a low-barrier way to participate in data collection? It is still "formal data collection" if the data were used in the study - did the SSWs understand this, that their conversations while scrapbooking were going to be part of a study? This relates also/again to questions about methods and consent.
• Minor typos/clarifications:
  • Line 89: "SWs are more likely to use drugs..." - more likely than whom?
  • line 121 has a typo - "whop" for "who"  
  • lines 181-182 have a switch from first person ('my") to third ("her") person pronouns, these should be reconciled. In this section on positionality, what  might be the influence of the positionality of the co-authors who "verified" the analysis?
  • Line 367 - if possible, it would be ideal to have some citations for the more "negative" literature referenced here.

Author Response

Please see attached tabulated response to reviewer comments.

Author Response File: Author Response.pdf

Reviewer 3 Report

Comments and Suggestions for Authors

This article is on a great subject matter. But unfortunately, it has some serious issues in its methodology, results and discussion. These concerns need great attention. 

1. It appears that the research has not properly utilized/"understood" ethnographic research approach. In ethnography, one must collect "thick description" (Clifford Geertz 1973). This approach encourages to anonymize traceable data of the interlocutors but never suggests not to mention their exact number. So, the following claim is banal: "In line with ethnographic and participatory approaches, this study does not provide a definitive count of participants involved." (Line 121-22). Please explain if the theoretical sampling was employed. 
2. What has been reported as "participant observation" so the authors are invited to critically engage with the relevant literature on "participant observation", "observation" and "observant participation".
3. The following also needs to be elaborated: How the "fieldnotes" help the authors to decipher the obtained data?
4. Please consult DeWalt and DeWalt "Participant Observation". 
5. The thematic analysis (Braun and Clarke 2006) doesn't fit well to the current research design but their recent "reflexive thematic analysis" (Braun and Clarke 2019, 2021). 
6. The following quote is also banal as TA is a way to analyze data and it would not help "adequately capture the dynamic and processual nature of healthcare access as a journey or negotiation."
7. That means, both the data collection and data analysis procedures are substantially weak hence raise serious concerns regarding the reliability, validity of this research. This entire section should be rewritten with an appropriate rationalization.   
8. In the results, it is suggested that every interlocutor should be introduced prior to mentioning their main quote. E.g.,  pseudonym, age, gender, or any other relevant identity. This will help the reader to understand the context of every quote. 
9. In the discussion section, the authors need to engage with the relevant literature. At the moment, the section appears as "simple" narrative. For instance, from line 360 to 407, there is no any relevant reference is cited. This section should triangulate: data, literature and analysis/interpretation.  

Author Response

Please see attached tabulated response to reviewer comments.

Author Response File: Author Response.pdf

Round 2

Reviewer 3 Report

Comments and Suggestions for Authors

Dear authors, 

thank you for making a significant amount of efforts in bringing the required changes. However, some of previous comments are still valid. For instance: 

1.  Every interlocutor should be introduced prior to mentioning their main quote. E.g., pseudonym, age, gender, or any other relevant identity. This will help the reader to
   understand the context of every quote. Bring in more verbatim or quotes of the interlocutors in the results section to make it more ethnographic. With these quotes in the Results section, the paper lacks ethnographic rigor. 
2. I would still encourage to use RTA of Braun and Clarke 2019/2021 as it goes will with the ethnographic research, if it is indeed an ethnographic study. Authors are encouraged to think about "ethnographic approach" through out their paper. It appears, they might have a conducted a qualitative research not an ethnography. Some further questions can be dealt with: how rapport was built with the interlocutors; which language was used; who translated and transcribed these data? 
3. Precisely, the methods and results section requires great attention; otherwise, the paper remains lacking ethnographic rigor. 

Author Response

Response to Reviewer 3 Comments

We thank the reviewer for their careful reading of our manuscript and their constructive feedback. We have given serious consideration to each comment and respond in detail below. We believe the revisions strengthen the paper while maintaining the integrity of our methodological approach, which was deliberately designed for this highly marginalised population.

Comment 1: Interlocutor introductions and verbatim quotes

Reviewer comment: "Every interlocutor should be introduced prior to mentioning their main quote. E.g., pseudonym, age, gender, or any other relevant identity. This will help the reader to understand the context of every quote. Bring in more verbatim or quotes of the interlocutors in the results section to make it more ethnographic."

Response:

We appreciate the reviewer’s attention to ethnographic conventions regarding participant introductions. We wish to explain our deliberate methodological decision not to collect demographic details, and to offer an alternative approach to contextualising quotes that maintains ethnographic richness while protecting this highly vulnerable population.

Why we did not collect demographic data:

The decision not to collect participant demographics (age, ethnicity, pseudonyms linked to individual profiles, duration of involvement in sex work) was made collaboratively with SWWOP staff during study design, based on their extensive knowledge of the women’s needs and concerns. This was not an oversight but a principled ethical and methodological choice, for several interconnected reasons:

1. Institutional harm and surveillance: Many women accessing SWWOP have experienced significant harm from institutions—including healthcare, social services, police, and immigration—and associate data collection with surveillance, control, and potential negative consequences. Staff advised that requesting demographic information would likely reduce engagement and could cause distress, replicating the institutional dynamics that contribute to these women’s marginalisation.
2. Previous research failures: Previous research teams working with SWWOP using traditional interview methods with demographic collection were unable to recruit any participants. Our methodology succeeded precisely because it did not impose conventional research norms onto a population harmed by such norms.
3. Ethical primacy: We prioritised participant safety and willingness to engage over methodological conventions designed for less marginalised populations. This aligns with inclusive health research methodologies that recognise the need to adapt approaches for populations systematically excluded from traditional research paradigms (Mitchell et al., 2023; Fryer et al., 2024).
4. The data would not exist otherwise: The richness and authenticity of participants’ accounts—shared in an environment of trust and safety—would have been inaccessible had we imposed conventional demographic collection requirements.

Our proposed solution – contextualisation without demographics:

We accept the reviewer’s point that quotes benefit from contextualisation and have revised the Results section to provide ethnographic context for quotes without demographic identifiers. We have introduced participants through:

• Circumstances of the conversation (e.g., “during a quiet moment at the drop-in centre”)
• Relevant experiential context where volunteered by the participant (e.g., “a woman who described having been involved in street work for many years”)
• Data source (e.g., “in the scrapbook, one woman wrote...” or “during an informal conversation while preparing food parcels”)

This approach provides the contextual grounding the reviewer seeks while respecting the ethical constraints of our research context.

Additional verbatim quotes:

We are unable to share verbatim quotes other than those shared in the scrapbook as we did not collect recorded interviews or interactions.

Additions to the manuscript:

We have added a new paragraph to the Methods section (Section 2.1) explicitly explaining and defending our decision not to collect demographic data. We have also revised the Limitations section to reframe this as a principled methodological choice rather than simply a limitation.

Comment 2: Reflexive Thematic Analysis and ethnographic approach

Reviewer comment: "I would still encourage to use RTA of Braun and Clarke 2019/2021 as it goes well with the ethnographic research, if it is indeed an ethnographic study. Authors are encouraged to think about ‘ethnographic approach’ throughout their paper. It appears, they might have conducted a qualitative research not an ethnography. Some further questions can be dealt with: how rapport was built with the interlocutors; which language was used; who translated and transcribed these data?"

Response:

We thank the reviewer for this suggestion and have made substantial revisions to address these points.

Adoption of Reflexive Thematic Analysis:

We have revised Section 2.3 (Analysis) to explicitly adopt Braun and Clarke’s Reflexive Thematic Analysis (2019/21). The revised section now describes our analytical process through their six-phase framework: (1) familiarisation with the data, (2) generating initial codes, (3) generating initial themes, (4) reviewing themes, (5) defining and naming themes, and (6) writing up. We have added citations to Braun and Clarke (2019/21).

RTA was selected for its epistemological flexibility and alignment with ethnographic research, which recognises meaning as contextually produced through the researcher’s interpretive engagement with data. The candidacy framework is retained as an organising lens within this analytical approach.

Clarification of ethnographic approach:

We acknowledge the reviewer’s question about whether this constitutes ethnography or qualitative research more broadly. We position this study as employing an ethnographic approach rather than claiming to be a full ethnography in the classical anthropological sense. Our approach was ethnographic in that it involved:

• Prolonged engagement in the field setting (six months)
• Participant observation as a primary method
• Attention to context, setting, and social dynamics
• Researcher immersion and relationship-building
• Reflexive attention to the researcher’s positionality

However, we recognise that traditional ethnography typically involves longer fieldwork periods and more comprehensive cultural description. We have revised the manuscript to use the term “ethnographic approach” consistently and have clarified this positioning in the Methods section. This study is perhaps best understood as pragmatic, inclusive health services research that draws on ethnographic methods to engage a population excluded by conventional research designs.

New section on rapport, language, and transcription:

We have added a new subsection to the Methods addressing the reviewer’s specific questions:

Rapport building: Rapport was established through CB’s sustained presence at SWWOP over the six-month fieldwork period. Trust-building was gradual and relational, developed through consistent attendance, participation in daily activities alongside women, and demonstration of genuine interest in their wellbeing beyond research aims. CB’s pre-existing volunteer role provided a foundation, though building research-specific trust required ongoing negotiation and transparency about dual roles.

Language: All fieldwork was conducted in English, the primary language used at SWWOP. No translation was required. CB attended closely to participants’ own terminology and phrasing, incorporating their language into field notes to preserve authentic voice.

Transcription: Field notes were written by CB during or immediately following each observation period. Voice notes recorded after sessions were transcribed verbatim by CB within 48 hours. Scrapbook contributions were photographed and transcribed by CB. All transcription was conducted by CB, ensuring consistency and maintaining immersion in the data.

Comment 3: Methods and Results require attention for ethnographic rigour

Reviewer comment: "Precisely, the methods and results section requires great attention; otherwise, the paper remains lacking ethnographic rigor."

Response:

We have undertaken substantial revisions to both sections as detailed above. In summary:

Methods section revisions:

• Adoption of Braun and Clarke’s RTA (2019, 2021) with explicit description of the six-phase process
• New subsection on rapport-building, language, and transcription
• New paragraph explaining and defending the deliberate non-collection of demographic data
• Clarification of “ethnographic approach” positioning
• Enhanced reflexivity discussion

Results section revisions:

• Contextual introductions added before all quotes (without demographic identifiers, as explained above)
• Additional verbatim quotes incorporated throughout
• Greater attention to setting and circumstances of data collection

Limitations section revision:

• Reframed non-collection of demographics as principled methodological choice rather than simple limitation

Concluding remarks

We hope the reviewer finds these revisions satisfactory. We have worked to strengthen the ethnographic rigour of the paper while being transparent about the constraints and choices that shaped our methodology. We believe the revised manuscript demonstrates that rigorous, meaningful research with highly marginalised populations sometimes requires adaptation of conventional approaches—and that such adaptation, when principled and transparent, does not diminish but rather enables authentic engagement with voices that would otherwise remain unheard.

This research was designed by frontline healthcare staff working within an established trusted relationship with this community. The methodology was co-designed with SWWOP staff who know these women intimately. We position this work as pragmatic, inclusive health services research that employs an ethnographic approach to amplify the voices of women systematically excluded from both healthcare and research.

We remain grateful for the opportunity to revise and strengthen this work.

Additional references added:

Braun, V., & Clarke, V. (2019). Reflecting on reflexive thematic analysis. Qualitative Research in Sport, Exercise and Health, 11(4), 589-597.

Braun, V., & Clarke, V. (2021). One size fits all? What counts as quality practice in (reflexive) thematic analysis? Qualitative Research in Psychology, 18(3), 328-352.