Peer Counselling to Reduce Psychological Distress and Exposure to Violence Among Sexual and Gender Minorities

Not Applicable

Recruiting

• Conditions: Mental Health; Psychological Distress; Secondary Violence Reduction; Discrimination; Sexual and Gender Minorities; Minority Groups; Homosexuality; Domestic Violence; Gender Based Violence

• Registration Number: NCT06979193
• Lead Sponsor: Public Health and Environment Research Centre (PERC), Nepal

Brief Summary

Lesbian, Gay, Bisexual, Transgender, Intersex, Queer, Asexual, and other sexually or gender diverse (LGBTIQA+) communities in many countries face high levels of mental health problems compared to the general population. This is often due to discrimination, being excluded, abuse, and unfair treatment. In many low- and middle-income countries, including Nepal, the mental health needs of LGBTIQA+ people are not met, and the violence they experience is often ignored because they are seen as breaking gender norms. The low number of trained mental health specialists in a country like Nepal imply that any short-term effort to alleviate the mental health problems among LGBTIQA+ must rely on other type of support workers such as peers. There is growing evidence that help from community members-such as counselling given by non-professionals-can improve mental well-being. Considering that discrimination of LGBTIQA+ is common also within the health services, this study will look at whether peer counselling-support provided by trained LGBTIQA+ community members-can work well in Nepal. We have improved a counselling program called 'Problem Management Plus' (PM+), developed by the World Health Organization, by adding new parts that focus on reducing the risk of some of the contributing causes of mental distress, namely violence, marginalisation and loneliness. The added components include safety planning, counselling that builds confidence and strength, and goal setting strategies to help study participants use the skills they learn and reach the desired impact. In addition, peer-led monthly group meetings will be conducted to enhance social cohesion, strengthen interpersonal networks, and reduce feeling of loneliness. The study uses a community based participatory research approach, meaning LGBTIQA+ people are invited to give inputs throughout the study from study design to being involved as peer advocates to deliver the counselling. The trial will recruit at least 960 LGBTIQA+ individuals aged 18 to 55 years living in seven districts of Nepal. Study participants will be randomly allocated to one of three arms: one arm receiving individual augmented PM+ counselling with six weekly sessions; one arm receiving the individual augmented PM+ counselling followed by 11 monthly group sessions; and one control arm. There will be a one year follow-up to examine whether the peer support helps improve mental health and reduce exposure to violence among LGBTIQA+ people. The study findings will help guide programmes to improve the mental health of LGBTIQA+ in other low- and middle-income countries where they also experience discrimination, exclusion, and violence.

Detailed Description

Sexual and gender minorities, including Lesbian, Gay, Bisexual, Transgender, Intersex, Queer, Asexual and other sexually or gender diverse (LGBTIQA+) individuals, disproportionately experience social stressors such as discriminatory attitudes, violence, prejudice, and stigmatization. This environment leads to negative health outcomes, including physical ailments and risky health-related behaviors (e.g., smoking, drug abuse, and inconsistent condom usage), as well as mental health problems, ultimately impacting the overall well-being of these vulnerable groups. LGBTIQA+ individuals often anticipate rejection and discrimination from the majority population, which leads to constant vigilance, identity concealment, and self-stigma. These factors negatively affect self-acceptance and exacerbate psychological distress. Despite the high burden of violence and mental illness, LGBTIQA+ individuals tend to use health services less frequently than the majority population in many countries. This is due to fears of discrimination also from health professionals and prior experiences of disrespectful treatment and poor communication. To meet the violence prevention and mental health needs of LGBTIQA+ individuals in low- and middle-income countries (LMICs) and reduce health inequalities, culturally relevant, low-cost interventions that do not require highly trained professionals are needed.

The overall objective of this trial is to evaluate the effectiveness of a multicomponent intervention (SAATHI) in reducing exposure to violence and psychological distress among LGBTIQA+ people in Nepal. This project utilizes a mixed-method research design, and the trial had been preceded by formative research with qualitative interviews and focus group discussions with key stakeholders to evaluate the feasibility and acceptability of the intervention package. The three-armed randomized controlled trial will be implemented in seven districts across two provinces in Nepal. A qualitative process evaluation will be conducted during the intervention delivery.

We will enroll at least 960 LGBTIQA+ participants in the trial. The inclusion criteria are: age 18-55 years, history of surviving violence in the previous 12 months, and a score of ≥3 on the General Health Questionnaire indicating psychological distress.

The participants allocated to the two intervention arms will receive six weekly 90-minute counseling sessions covering multiple topics. The counselling aims to mitigate the psychological effects of trauma and moderate the impacts of a stressful, coercive, and threatening environment by altering individuals' appraisal of stressful events, modify coping patterns, and promote self-regulation, self-esteem, and positive feelings about LGBTIQA+ identity. In one of the intervention arms the participants will also be invited to 11 monthly group sessions after the individual counselling to enhance social support and social cohesiveness. The counselling and the group sessions will be offered by peer advocates who have received a 10-day training in counselling and group facilitation.

The trial participants will be followed up for one year to assess changes in exposure to violence and mental health status. The primary outcome will be GHQ-12 score. The effectiveness analysis will be based on intention-to-treat principles. The intervention effects on outcomes will be assessed using mean differences for continuous outcomes and risk ratios and absolute risk differences for binary variables.

The qualitative analysis of data from the formative research and intervention delivery will be based on Reflexive Thematic Analysis, grounded in critical realist/contextualist ontology, where interviewees' experiences are understood as lived realities produced and existing within broader social contexts.

By addressing mental health distress, discrimination and violence through a culturally sensitive and community-driven approach, this study aims to contribute to the reduction of health disparities and the improvement of health and well-being among LGBTIQA+ individuals in Nepal.

Study Timeline

• Study First Submitted: 2025-05-12
• Study First Submitted QC: 2025-05-12
• Study First Posted: 2025-05-18
• Study Start: 2025-05-20
• Status Verified: 2025-09
• Last Update Submitted: 2025-09-12
• Last Update Posted: 2025-09-18
• Primary Completion: 2026-12-31
• Study Completion: 2027-04-30

Recruitment & Eligibility

• Status: RECRUITING
• Sex: All
• Target Recruitment: 960

Inclusion Criteria

• Self-identify as a member of the LGBTIQA+ community
• Aged 18 to 55 years
• Have a history of exposure to any form of violence (physical, sexual, or psychological) within the past 12 months
• Exhibit psychological distress, defined as a score of more than or equal to 3 on the General Health Questionnaire (GHQ-12)

Exclusion Criteria

• Express current suicidal ideation or plans to end their life
• Meet diagnostic criteria for substance use disorders, including alcohol or drug dependence
• Have severe functional impairment due to a mental, neurological, or developmental disorder (e.g., severe intellectual disability, dementia, or psychosis)
• Decline or are unable to provide informed consent
• Intend to relocate from the study districts or move outside the country within the next few months

Study & Design

• Study Type: INTERVENTIONAL
• Study Design: PARALLEL

Primary Outcome Measures

Name	Time	Method
General Health Questionnaire (GHQ-12)	Baseline Assessment; Follow up 1 at one-week post-counselling (7 weeks after baseline); Follow up 2 at 12 weeks post-counselling (18 weeks after baseline); Follow up 3 at 47 weeks after PM+ counselling completion (53 weeks after baseline assessment).	The General Health Questionnaire (GHQ-12) will be used to assess psychological distress among study participants. The GHQ-12 consists of 12-items and, when scored using the Likert method, resulting in a total score ranging from 0 to 36, with higher scores indicate greater levels of psychological distress. Participants will be asked to reflect on their experiences over the past two weeks. The mean score will be used as a measure of mental distress.
Experience of violence	Baseline Assessment; Follow up 1 at one-week post-counselling (7 weeks after baseline); Follow up 2 at 12 weeks post-counselling (18 weeks after baseline); Follow up 3 at 47 weeks after PM+ counselling completion (53 weeks after baseline assessment).	Experience of violence will be measured using a modified version of WHO multi-country questionnaire on women's health and domestic violence. The adapted tool assesses the prevalence and type of violence experienced by study participants at different time points. This will be measured as a binary variable with the value 1 if a participant has experienced any type of violence in the specified recall period, and 0 if they have not experienced any recent violence.; The following categories are included in the definition of violence: controlling behaviors, psychological violence, physical violence, and sexual violence. The recall period for experience of violence at baseline will be the past 12 months. Changes in the experience of violence at follow-up assessments will be measured relative to baseline.

Secondary Outcome Measures

Name	Time	Method
Post-Traumatic Stress Disorder Symptoms (PCL-5)	Baseline Assessment; Follow up 1 at one-week post-counselling (7 weeks after baseline); Follow up 2 at 12 weeks post-counselling (18 weeks after baseline)	Post-Traumatic Stress Disorder (PTSD) Symptoms will be measured using PTSD checklist for DSM-5 (PCL-5), which is a 20-item self-report measure used to assess the presence and severity of PTSD in the previous week, based on DSM-5 diagnostic criteria. We will compare the mean scores in each arm.
Daily functioning (WHODAS 2.0- 12-item version)	Baseline Assessment; Follow up 1 at one-week post-counselling (7 weeks after baseline); Follow up 2 at 12 weeks post-counselling (18 weeks after baseline)	The WHO Disability Assessment Schedule (WHODAS 2.0) a 12-items measure will be used to assess functional impairment across six domains of life over the past 30 days. These include cognition, mobility, self-care, getting along with people, life activities, and participation in society. The total score ranges between 0 to 48 and a higher score indicates a greater difficulty in functioning. We will compare the mean scores in each arm.
Modified Collective Self-Esteem Scale	Baseline Assessment; Follow up 1 at one-week post-counselling (7 weeks after baseline); Follow up 2 at 12 weeks post-counselling (18 weeks after baseline); Follow up 3 at 47 weeks after PM+ counselling completion (53 weeks after baseline assessment).	Modified Collective Self-Esteem Scale will be used to assess participants' attitudes, feelings, and perceptions related to their membership in the LGBTIQA+ community. This tool measures sense of personal worth within the group, public perceptions of the group, the importance of group membership to personal identity, and the individual's sense of contribution and belonging. The total score ranges from 16 to 112 and higher total scores indicate more positive collective self-esteem related to the sexual and gender minority group membership. We will compare the mean scores in each arm.
Neff's Self-Compassion Scale (Short- form)	Baseline Assessment; Follow up 1 at one-week post-counselling (7 weeks after baseline); Follow up 2 at 12 weeks post-counselling (18 weeks after baseline); Follow up 3 at 47 weeks after PM+ counselling completion (53 weeks after baseline assessment).	The Neff's Self-Compassion Scale (short form) will be used to assess participants' capacity for self-compassion, particularly how they respond to themselves during times of failure, difficulty, or emotional distress. This scale measures components such as self-kindness, self-judgement, common humanity, isolation and mindfulness. The total score ranges from 12 to 60 and a higher total score reflects greater self-compassion. We will compare the mean scores in each arm.
MOS Modified Social Support Survey- Five Item Version (MSSS-5)	Baseline Assessment; Follow up 1 at one-week post-counselling (7 weeks after baseline); Follow up 2 at 12 weeks post-counselling (18 weeks after baseline).	The MOS Modified Social Support Survey will be used to assess participants' perceived social support. MSSS-5 includes five items that measures the availability of various types of support such as emotional/informational, tangible, affectionate, and positive social interaction. Participants rate each item on a 5-point Likert scale (1=none of the item, 5=all the time) reflecting the frequency of available support in the past 4 weeks. The total scores ranges from 5 to 25 with higher scores indicating greater perceived social support. We will compare the mean scores in each arm.
Modified Safety Planning Checklist	Baseline Assessment; Follow up 1 at one-week post-counselling (7 weeks after baseline); Follow up 2 at 12 weeks post-counselling (18 weeks after baseline); Follow up 3 at 47 weeks after PM+ counselling completion (53 weeks after baseline assessment).	Modified Safety Planning Checklist will be used to assess participants' use of personal safety strategies in response to potential violence. This tool covers practical activities such as securing a safe place to stay, keeping essential documents or things (e.g., certificates, medicines etc.), preparing an emergency safety plan, using safety codes with trusted contacts, and keeping contact to emergency communication and contact lists.
Use of Community Resources	Baseline Assessment; Follow up 1 at one-week post-counselling (7 weeks after baseline); Follow up 2 at 12 weeks post-counselling (18 weeks after baseline); Follow up 3 at 47 weeks after PM+ counselling completion (53 weeks after baseline assessment).	This tool will be used to measure participants' use of community-based services for violence prevention and support. It captures both formal and informal support systems utilized by the participants (yes vs. no) across different time periods (from the past month as baseline to the past 12 months at the last follow-up) and assesses their level of satisfaction rated on a 5-point Likert scale (1=Not satisfied at all, 5= Very satisfied) with each available local support service in the community.
Psychological Outcomes	Intervention arm: Pre-counseling, during sessions 2-5, Follow-up 1 at one-week post-counseling and Follow-up 2 at 12 weeks after post-counseling. Enhanced usual care arm: Baseline, Follow-up 1 at 7 weeks, and Follow-up 2 at 18 weeks post-baseline.	The Psychological Outcomes Profile (PSYCHLOPS) is a participant-reported outcome measure to evaluate perceived psychological change over time. It consists of four items that assess problems, functioning, and overall well-being. Each item is rated on a 6-point ordinal scale (0-5), with a total score range of 0-20; higher scores indicate greater psychological distress. One additional item assesses suicidal ideation and is used solely for safety monitoring. Participants also provide narrative responses related to their current concerns, which will be analyzed qualitatively. The tool includes a post-intervention item assessing perceived change (rated from "feeling much better" to "feeling much worse"). Quantitative scores will be analyzed using mean change from baseline between study arms. Qualitative responses will be thematically analyzed to identify common themes and concerns.

Trial Locations

Locations (12)

SAATHI Program Chitwan site; 🇳🇵 Chitwan, Bagmati, Nepal

SAATHI Program Kathmandu and Lalitpur site; 🇳🇵 Kathmandu, Bagmati, Nepal

SAATHI Program Makwanpur site; 🇳🇵 Makwanpur, Bagmati, Nepal

SAATHI Program Dhanusha site; 🇳🇵 Dhanusha, Madhesh, Nepal

SAATHI Program Parsa site; 🇳🇵 Parsa, Madhesh, Nepal

SAATHI Program Sarlahi site; 🇳🇵 Sarlahi, Madhesh, Nepal

SAATHI Program Chitwan site; 🇳🇵 Chitwan, Bagmati, Nepal

SAATHI Program Kathmandu and Lalitpur site; 🇳🇵 Kathmandu, Bagmati, Nepal

SAATHI Program Makwanpur site; 🇳🇵 Makwanpur, Bagmati, Nepal

SAATHI Program Dhanusha site; 🇳🇵 Dhanusha, Madhesh, Nepal

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