Effectiveness of peer counselling in addressing psychological distress and exposure to violence among sexual and gender minorities in Nepal: a study protocol for a randomized controlled trial

BACKGROUND: The burden of social stressors (discrimination, prejudice, violence, and stigmatization) is disproportionately high among LGBTIQA + (Lesbian, Gay, Bisexual, Transgender, Intersex, Queer and Asexual) individuals. These stressors negatively influence the overall well-being of this population which in turn affects their health-seeking behaviours, including the disclosure of psychosocial concerns to health workers. Peer-led mental health interventions have therefore been identified as a potentially suitable and acceptable approach for this population. This protocol presents the SAATHI (Support, Advocacy, and Awareness for Trauma, Healing and Inclusion) study. The study will assess the feasibility, acceptability, and effectiveness of peer counselling, safety planning, and group-based sessions in reducing exposure to violence and psychological distress among LGBTIQA + individuals in Nepal. METHODS: We will conduct a three-arm randomized controlled trial with a 1:1:1 allocation ratio. At least 1062 LGBTIQA + participants will be enrolled. Eligibility criteria include age 18-55 years, a history of violence in the past 12 months, and a score of ≥ 3 on the General Health Questionnaire, indicating psychological distress. Participants in the intervention arms will receive six 90-min peer-led counselling sessions and one of the arms will receive monthly peer-led group sessions for shared reflection and support. Follow-up assessments will occur at 7 weeks, 18 weeks, and 12 months post-baseline. A qualitative process evaluation will be conducted of the intervention delivery. The primary outcomes are psychological distress and exposure to violence. The secondary outcomes include post-traumatic stress disorder, participant-reported psychological outcomes, daily functioning, self-esteem, self-compassion, perceived social support, use of personal safety strategies, and satisfaction with community resources. We will analyse quantitative data using intention-to-treat principles. For the qualitative data, our approach will be reflexive thematic analysis, which is grounded in a critical realist/contextualist ontology. DISCUSSION: This study ultimately aims to reduce health disparities and improve the health and well-being of LGBTIQA + individuals. If effective, the SAATHI intervention has potential to be sustainable through empowered peer-led networks and scalable in low- and middle-income countries due to its low-cost, community-implemented design. TRIAL REGISTRATION: ClinicalTrials.gov NCT06979193. Registered on 20 May 2025, https://clinicaltrials.gov/study/NCT06979193.