The Public Health Research (PHR) Programme would like to draw researchers’ attention to the commissioning brief below, which was first advertised in Spring 2023. This is a brief that we have previously advertised as a commissioned funding opportunity. We are still interested in receiving applications in this research area, as it remains a priority in our portfolio. However, please note that the commissioning brief, along with the underpinning literature searches, has not been updated since originally written.
Research question
- What interventions improve health outcomes for sex workers?
The PHR Programme recognises that sex workers are a diverse population with a broad range of lived experience and differing healthcare needs. By calling for new research the PHR Programme is not wanting to normalise the structural factors that might undermine sex workers’ health and wellbeing and safety. Neither is it devaluing or disregarding the decisions exercised by people entering or exiting sex work.
For this call, street-based sex work, off-street sex work, direct sex work (in person, sexual contact) and indirect sex work (non-contact or virtual/online services) is within remit.
Migrant sex workers are covered by this research brief. Sex work undertaken by people who have been trafficked to the UK for the purposes of sexual exploitation is out of remit. Interventions to support children who are victims of sex exploitation is out of remit. Research in these areas can be submitted through the researcher-led route available on the funding opportunities webpage.
In the UK, sex work is associated with a range of adverse health outcomes. Sex workers can be at disproportionate risk of poor physical and mental health. Social, economic, environmental and legal factors are fundamental causes of these health harms. The legal status of activities related to sex work means that some sex workers have to work in unsafe environments. This can increase exposure and vulnerability to health risks, and as such is a key factor influencing health outcomes.
Street-based sex workers in particular can carry a high burden of unmet health needs and can experience extreme health and social inequalities. This is compounded by the occupation-related stigma that sex workers can face which marginalise and exclude communities. Some sex workers encounter intersecting or multiple stigmas, for example, people who are from gender or sexual minority populations. The changing nature of sex work means that increasingly, work is undertaken in off-street and online environments using digital platforms for engagement.
Sex work is a primary source of income for some people in most countries. For many sex workers, a decision to undertake sex work is made in challenging circumstances, as a result of constrained choices and often due to having low or insufficient income. Women comprise the majority of sex workers yet there is a significant minority of male and trans sex workers. Most people buying sexual services are men.
Not all sex work is experienced in the same way. The type of sex work undertaken and the entry and exit points into the work varies significantly. Therefore, it is important to recognise that this diverse range of sex work sits on a continuum of occupational experiences.
All sex workers have the right to lead healthy and socially inclusive lives with easy and equitable access to health services, care and support. In spite of this and the high level of health needs many sex workers face, sex workers encounter significant barriers to health and care. There is often a lack of services tailored to sex worker needs, stigma or legal implications to identifying as a sex worker, and a lack of awareness regarding available services.
There has been little interventional research in this area. A recent systematic review found that since 2004, there have been only 20 studies of interventions to improve health outcomes for sex worker populations across all high-income countries.
The PHR Programme is predominantly interested in the evaluation of interventions operating at a population level rather than at an individual level, which should address health inequalities and the wider determinants of health. The PHR Programme recognises that this call is broad and encourages researchers to work with specific populations of sex workers to undertake research. The PHR programme recognises that sex worker populations can overlap with other inclusion health populations, such as people who are homeless or people within the criminal justice system.
The PHR Programme is interested in evaluations of interventions that are focused on populations where the burden of poor health is highest. Approaches that are sensitive and responsive to risk, harm and power imbalance, and uphold the safety, rights and dignity of sex workers should be prioritised.
Examples of research areas of interest include (but are not limited to):
- Research of sex worker populations underserved by research on health outcomes and where there are gaps in the literature. For example, sex workers from rural or regional populations, LGBTQ+ sex workers, migrant sex workers, male sex workers, off-street sex workers and sex workers using new and digital platforms to engage in wider and more contemporary areas of sex work.
- Research evaluating interventions that provide support to improve mental health and emotional wellbeing.
- Studies of programmes that are aimed at preventing and reducing social exclusion and stigma.
- Studies that take an inclusion health approach to service provision to address multiple, overlapping risk factors (provided that the research retains a sufficient focus on sex workers as the key population of interest).
- Studies of integrated, holistic or whole person interventions. These might include, for example, interventions facilitating access to health services that also represent an opportunity to address debt or housing issues.
- Evaluations of collaborative, multilevel, multicomponent or multiagency programmes.
- Evaluations of interventions for sex workers where the primary focus of the intervention is aimed at tackling wider determinants of health. For example, interventions to alleviate poverty, interventions that provide financial assistance, interventions to provide housing support.
- Research on interventions to prevent violence against sex workers and to prevent and reduce negative health impacts of violence. Forms of violence include, for example, sexual and physical assault, stalking, hate crimes, image abuse and visual violence and sexual exploitation.
- Studies evaluating the health impacts of interventions that focus on safety and protection for sex workers, for example, interventions relating to the nature of police enforcement.
- Evaluations of interventions to prevent and reduce the negative health impacts of statutory contributory issues where sex workers can be at disproportionate risk, such as, eviction proceedings, care proceedings, deportation.
- Research on interventions that aim to improve the health and wellbeing of sex workers through access to work-related programmes that are routinely available to other occupational groups.
- Research on education programmes for sex workers on, for example, employment or legal rights.
- Evaluations of interventions to prevent and reduce the health harms arising from multiple risk factors that can be associated with sex work.
- Evaluations of interventions focussed on the uptake of routinely available screening and testing (the effectiveness of screening and testing programmes themselves is out of remit).
- Evaluations of interventions to provide access to reproductive health for sex workers.
- Studies evaluating the effects of increased online testing for sexually transmitted infections.
- Evaluations of the health and wellbeing impacts of interventions where there is a focus on exiting sex work.
- Evaluations of service-based interventions that aim to improve relevance to sex worker needs including, for example, those relating to gender/sexual minority identity, language, service delivery format, accessibility for sex workers new to working in the geographical location of the service.
- New research to develop the evidence base on peer health initiatives.
- Research that evaluates interventions that increase sexual autonomy for sex workers.
- Evaluations of population-level education programmes and interventions addressing, for example, the reduction of stigma or the prevention of discrimination when seeking other employment.
- Studies of interventions that are focused on patterns and cycles of intergenerational sex work.
The Public Health Research Programme recognises that for some proposals, underpinning or development work to understand epidemiology and inform the evaluation of interventions might be beneficial. The Programme is willing to consider applications that include a maximum six month period of underpinning or development work. Please contact the PHR Programme before applying to discuss further.
A range of study designs and outcome measures can be used. Researchers will need to identify and justify the most suitable methodological approach. Researchers will also need to specify key outcomes and how these will be measured in the short, medium, and long term. Primary outcomes must be health-related. However, the PHR Programme will accept proxy measures for health as long as the link to health is justified. Therefore, primary outcomes could include, for example, a reduction in violence.
Understanding the value of public health interventions - whether the outcomes justify their use of resources - is integral to the PHR Programme, where resources relating to different economic sectors and budgets are potentially relevant. The main outcomes for economic evaluation are expected to include health (including health-related quality of life) and the impact on health inequalities as a minimum, with consideration of broader outcomes welcomed. Different approaches to economic evaluation are encouraged as long as they assess the value and distributive impact of interventions. Applications that do not include an economic component should provide appropriate justification.
Researchers should ensure that their application demonstrates how people with lived experience of sex work are involved in the design of the intervention and the evaluation. Researchers should also demonstrate how they intend to involve sex workers, sex worker-led organisations and/or organisations working to improve the health and wellbeing and safety of sex workers. Researchers might do this by involving key stakeholders as costed members of the research team.
Researchers should demonstrate the relevance of their proposed research to sex workers, their families and support networks, to sex worker-led organisations, other relevant service providers and to local decision-makers. Researchers are expected to be aware of other studies and ensure their proposed research is complementary.
For further information on submitting an application to the PHR Programme, please refer to the supporting information for applicants submitting Stage 1 and Stage 2 applications.