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23 February 2021
Jo Kesten, Research Fellow, NIHR Health Protection Research Unit in Behavioural Science and Evaluation at the University of Bristol and NIHR ARC West, describes her experiences working with street sex workers on the DUSSK study.
As a qualitative researcher I have a lot of experience recruiting people for interviews and focus groups. How I recruit depends on the resources available and the approach that best suits the participant group. This typically ranges from written invitations via emails, flyers, posters and social media advertisements to word-of-mouth and direct approaches from gatekeepers within existing organisations. Rarely do I approach potential participants in person. That is until the Drug Use in Street Sex Workers (DUSSK) study.
The study, led by Dr Nikki Jeal whose research built the foundations for DUSSK, was a collaboration with:
We investigated whether creating a drug treatment group solely for street sex workers, staffed by women and held at One25, in a sex worker only environment, would remove the stigma experienced by these women in mixed drug treatment groups. The aim was to see whether a tailored service could enable them to engage with treatment more effectively.
A key component of the study was to test the feasibility of offering trauma treatment. AWP specialist trauma unit staff screened women for post-traumatic stress disorder (PTSD) once their drug use was more stable. Those diagnosed with PTSD were then offered trauma treatment, which is not usually easily available to street sex workers.
Given the considerable challenges we faced recruiting women to the study, it was important for us to devise a strategy that was both sensitive to the women’s needs and achievable in practice. After extensive planning, which included involving street sex workers themselves through the study’s patient and public involvement (PPI) group, we developed a range of recruitment strategies.
Firstly, awareness-raising (resembling night-club flyers but laid out according to a ‘who, what, when, where, why’ format) were left in organisations and services that women were known to use. Women who picked up a flyer could phone the researcher or leave an answerphone message out of hours.
Secondly, I was one of three researchers who attended One25 at least twice a week, to approach potential participants with a flyer and talk briefly about the research before screening them for eligibility. The PPI group recommended this approach. They highlighted the issues street sex workers have with time and appointments, recommending this as the best solution for them.
Thirdly, participants were also recruited by word-of-mouth through the peer group.
One25 is a warm, caring environment; the affection staff have for the women who use the service is immediately apparent. I was welcomed into the team and joined briefings before and after each drop-in session where I approached women. The briefings were vital, allowing me to get to know the staff and what the session would involve, and to share experiences afterwards. Support and friendship from staff helped alleviate my initial anxiety about approaching the women.
Spending time at One25 over a prolonged period was important as it takes time for the women who use the service to feel comfortable talking to and trusting new people. Recruiting within One25 also gave me more credibility among the women. I got involved with making hot drinks (including the infamous ‘hug in a mug’ hot chocolate) and serving food when I wasn’t speaking to women about the study. This was an important means of building a relationship with the women and giving back to One25 who generously supported the study. However, at times it was difficult to strike the right balance between blending in and distinguishing my role from other members of staff and volunteers.
One of the key challenges I faced was judging when to approach a woman to talk about the study. I must admit, the first few occasions made my heart race and gave me a slight feeling of being a salesperson. Over time, as I built a rapport with the women and learnt key signs of how they might be feeling that day, I relaxed into the role and gained confidence.
We had to find out whether the women met our inclusion criteria in relation to their drug use and sex work. This was not always easy. These are very personal details which some women were reluctant to discuss, especially if they hadn’t met me before. We also had to be careful about how much information we disclosed because we didn’t want to say who was eligible before going through the screening questionnaire, in case this influenced their responses. This meant carefully managing women’s expectations and at times managing their disappointment if they didn’t fit the criteria. The presence of One25 staff was again valuable for supporting our explanation of the study and signposting to additional support.
As a team of three visiting One25 separately, we inevitably approached the same women more than once. There were also times when I knowingly approached the same woman more than once. Mostly, this was acceptable as it gave potential participants more than one opportunity to participate.
Overall, the experience of recruiting for DUSSK was an enormous learning curve and highly rewarding. Witnessing the work of One25 first-hand was inspiring. The experience highlighted the importance of choosing the recruitment strategy carefully from the outset to meet the needs of the participant group, gaining familiarity with the research setting and its operation and building a good rapport with potential participants.
Find out more about the feasibility study and read the BMJ Open paper.
Jo Kesten describes her experiences working on the DUSSK study.