2.1 Study Design

The overall study design was a collaborative approach in which researchers engaged in collaboration with experts by lived experience (hereafter referred to as ‘experts’) to prioritise and guide future research. A community-based participatory action research approach was applied, in which knowledge is generated through a process that places people with lived experience in the centre as experts [24]. Throughout the process, experts were considered as research partners in the team and were employed as research assistants at the university where the project was conducted. The term experts by lived experience was chosen to emphasise the expertise and knowledge based on unique and personal experiences, while also underscoring their role as active partners in shaping the research agenda. We acknowledge that other terms (e.g., public contributors or research partners) may be used for similar roles and tasks when conducting public involvement in research.

The core research team consisted of one coordinator who is an expert by lived experience and two Swedish-born health professional researchers (PhD and registered nurse-midwives). This core team planned and participated in consecutive workshops together with experts. Experts were employed as research assistants at the university and were paid a salary for their work, depending on the number of workshops they attended. All experts were free to decide which workshops they attended and did not have to state any reason for non-attendance.

2.2 Sampling and Workshop Attendants

A total of eight experts were recruited through purposeful, snowball and advertisement sampling to reach diversity, utilising the established networks of the research team. The experts represented diverse sexual orientations and gender identities (e.g., trans/gender non-conforming persons, lesbian women and gay men). All were adults in their 20s, 30s and 40s, originating from countries in Africa, Asia and Europe. Additionally, two consultants (licensed clinical psychologists, reimbursed for their work) were involved in targeted consultations about clinical considerations [25].

2.3 Workshop Sessions

A series of eight sequential workshops were conducted during 5 months in 2023 with the purpose of addressing the research questions. The number of workshops was determined through the research questions. The duration of each workshop was 5 h. All workshops began with a joint lunch, and refreshments were served during breaks. Focus areas for each workshop were inspired by the Template for Intervention Description and Replication (TIDieR) checklist [26]. Having determined the focus areas, the specific activities conducted during the workshops were inspired by the Iriss co-production project planner [27]. The workshops were exploratory and inductive, in which experts and researchers engaged in mutual discussions. The core research team moderated discussions and asked follow-up questions. Please see Table 1 and Appendix 1 for a presentation of the focus areas and activities of each of the eight workshops.

Field notes were taken by members of the core research team. No sensitive information about individual experts was collected during workshops. The co-produced material was stored in locked storage according to local routines at the host university. Following each workshop, the core research team had open-ended reflective meetings, collaborated to summarise the findings and planned for subsequent workshops. After concluding the final workshop, the core research team held joint meetings to summarise the overall findings, scrutinise the work and draft a report presenting the findings. The report was formatted according to the Guidance for Reporting Involvement of Patients and the Public (GRIPP2) checklist, please see Appendix 2 [28].

3.1 Which Psychosocial Challenges Should be Prioritised in Research?

The experts called attention to numerous psychosocial challenges experienced by the target population while residing in Sweden, structured in four categories with eight prioritised areas (Table 2). A range of mental health burdens were considered highly prioritised, with loneliness and social exclusion being the most prioritised areas for future research to address. According to the experts, loneliness can be exacerbated by difficulties transitioning into the new society, living in asylum accommodations and encountering multi-layered discrimination in society. Additionally, experts pointed out difficulties accessing health and social services, a lack of competence among those involved in the asylum process, and challenges finding housing and employment. Workshops highlighted the need for a range of support interventions, structured into four categories (Table 3). Support from peers in group settings and from peer mentors, informational support and capacity-building to secure employment and safe housing were emphasised as prioritised interventions in need of further attention.

3.2 Which Recruitment Strategies Should be Utilised to Reach Potential Participants, in Research and When Delivering Support Interventions?

Workshop activities revealed routes through which sexual and gender minority forced migrants could be approached for participation in research, including in-person (e.g., via non-governmental organisations and entertainment venues) and online (e.g., via social media platforms and dating sites) methods. Mainly, these routes involved community-based convenience or purposeful sampling through advertisements and snowball sampling through word-of-mouth. Experts also raised potential barriers for recruitment, which encompassed language barriers, issues of trust, geographical distances and financial constraints.

3.3 What Outcomes Are Relevant and Should be Prioritised When Evaluating Peer Support Interventions?

The experts highlighted a range of possible outcomes and benefits of participating in peer support interventions from a general perspective. Peer support was considered to have a potential to improve the following mental health and well-being outcomes: (1) feeling accepted and included, (2) loneliness, (3) emotional relief, (4) empowerment, (5) self-acceptance, (6) self-esteem, (7) happiness and hopefulness, (8) sleep quality, (9) feeling stigmatised, (10) symptoms of post-traumatic stress, (11) quality of life, (12) sense of safety and (13) experiencing mutual trust. Experts also believed that hospital admissions could be reduced when participating in a peer support intervention. A potential positive effect on information and capacity development outcomes was also expressed, including: (1) new opportunities for societal establishment (e.g., attaining education and employment, dating, language skills, expanding legal circumstances and developing social networking) and (2) enhanced knowledge (e.g., learning about health and health services, non-governmental organisations, integration issues, host country society and societal norms, sexuality, gender identity and expression, and social services). Additionally, peer support was considered to have a potential positive impact on access to basic subsistence (e.g., improving access to clothing, food, housing, the Internet, physical activities, organisation memberships and transportation).

In addition to the potential outcomes leading to health improvements, experts also highlighted 10 potential risks of peer support interventions. These included: (1) not meeting expectations among participants, (2) participants and supporters not being resilient enough to cope with the information exchanged, (3) unequal service provision and not being able to accommodate all needs, (4) some participants may feel insecure when interacting with peers, (5) lack of respect among participants, (6) gossip and disclosure of sensitive information, (7) racism towards some participants, (8) envy among participants, (9) trust issues and (10) inappropriate information provided during sessions.

3.4 How Should Peer Support Interventions for These Migrants be Structured and Delivered?

Potential advantages and disadvantages related to the modality of peer support and the need for training of peer supporters were summarised (Table 4). Overarchingly, in-person peer support was considered to be associated with more advantages and fewer disadvantages than digital support. In-person support led by trained supporters was considered a safer and confidential option. Identified criteria for trained peer supporters included being able to show compassion through lived experience, having adequate communication skills and adhering to work ethics. Based on discussions and ranking procedures, seven activities within peer support interventions were identified, the most prioritised being capacity-development in language skills and securing employment, followed in descending order by activities focusing on mental health and relaxation, cooking, dating, and games and sports. Please see Appendix 3 for an expanded presentation of the identified activities. Requirements for all types of peer support interventions were: ensuring safe settings at an accessible place when arranging in-person activities, participants have access to technical equipment when arranging digital activities and participants and supporters have basic levels of language proficiency and digital literacy when needed.

4.1 Principal Findings

The overall aim of this study was to prioritise and guide future research developing and testing tailored peer support interventions. Given the higher morbidity and mortality in less privileged groups within society [29, 30], there is a pressing need to undertake targeted actions that counteract socially produced inequities impacting underserved populations [4, 12]. We engaged in collaboration with experts by lived experience through public contribution in research, which has the potential to increase the relevance and quality of research and thus can help in reducing research waste [1, 4]. Few efforts have been made to engage with underserved populations to co-produce research [6, 8], and there is an acknowledged lack of diversity within prior research utilising public involvement [9, 10]. Our study brings new insights into collaboration to prioritise and guide future research addressing the health and well-being of sexual and gender minority forced migrants, which is an underserved population. Based on our findings, we recommend that researchers prioritise intervention development that involves support from peers in group settings and from peer mentors, informational support and capacity-building.

Our study focused on tailored peer support interventions for sexual and gender minority forced migrants. Despite significant health burdens and societal disadvantages in the host country [15-17], few research efforts have been made to develop and evaluate support interventions for this target population [31]. Our study complements prior qualitative studies about support needs and preferences, providing valuable insights about prioritisation for future peer support research. In line with our findings, previous research illustrates that sexual and gender minority forced migrants desire and engage in peer support following their arrival [17]. As indicated by our findings, peer support can involve important emotional, informational and practical support between laypersons sharing similar experiences or identities [32, 33]. Peer support has been suggested to be an effective intervention for underserved populations [34] and can involve various beneficial effects on health and well-being both in sexual and gender minority populations [31, 35], as well as among forced migrants [36, 37]. We identified a range of potential positive effects, the highest ranked among our experts being reduced loneliness and social exclusion. Researchers conducting peer support intervention research for the target population should draw inspiration from our list of outcomes when considering the evaluation of their intervention. We recommend more research on peer support interventions for this population.

From a wider perspective, the recruitment strategies suggested by our experts may help researchers when planning research addressing the health and well-being of underserved and marginalised populations. Research addressing underserved and marginalised populations deserves special methodological considerations, including how to achieve successful participant recruitment [38]. Studies have highlighted various barriers to participation in research among sexual and gender minority individuals and forced migrants, including logistical challenges, potential mistrust, lack of awareness, language barriers, and concerns about confidentiality and financial incentives [39, 40]. This study revealed community-based recruitment as a potentially pragmatic approach when conducting research to develop and test support interventions for sexual and gender minority forced migrants. Community-based recruitment has been highlighted as a potential strategy for effective recruitment of sexual and gender minority individuals [41]. More research is needed about the feasibility of different recruitment strategies to successfully reach and enrol seldom heard groups, and specifically, sexual and gender minority forced migrants.

4.2 Methodological Considerations

There are methodological limitations that readers need to consider when interpreting our findings. We collaborated with eight experts by lived experience throughout eight workshops, to guide and plan future research addressing the health and well-being of sexual and gender minority forced migrants. The experts were recruited using purposeful sampling and utilising the networks among the researchers and project collaborators. While the experts represented diverse identities and backgrounds, we acknowledge that the findings should be viewed as exploratory, and we encourage additional efforts to plan and prioritise future research. We believe that we reached diversity among our experts and that the exploratory approach applied during the workshops increased our opportunities to reach novel findings. Nevertheless, utilising eight experts is a limitation. We encourage more research utilising public involvement of sexual and gender minority forced migrants.

Some challenges were encountered when conducting this study process. Significant time and effort were needed to plan the workshops, and while several people were involved in the planning, it was nevertheless challenging to plan accordingly. Researchers who want to undertake similar studies need to ensure that sufficient resources are allocated in the planning phase. Moreover, the workshops required substantial administrative tasks like arranging refreshments, locales, materials and communication with the human resources department. This needs careful consideration when planning similar public contribution efforts. Another crucial aspect was the need for funding to conduct the research and reimburse the experts by lived experience. Our public contribution efforts were highly successful in helping us plan and prioritise future research. We encourage research funders to continue supporting research utilising public contributions to prioritise and co-design future research.